DISCUSSION
When selecting the surgical approach to hysterectomy, many variables
must be taken into account. However, these variables may be valued
differently by the patient, health care provider performing the
procedure, and healthcare systems. For example, the latter may consider
procedure cost, technique availability at a locoregional level, faster
recovery time, or difficulty of surgical training for adequate technique
performance as most important variables (24). On the other hand,
physicians may consider more important variables such as required
operative time, received professional fees for performing a given
technique, as well as their own personal training among others. For
hospitals, variables such as operative time, cost or duration of
hospital stay, may be of greater importance (25). Thus, in this study we
aimed to better understand which variables are perceived as most
important by women when choosing a surgical approach to hysterectomy.
Our results indicate that for patients undergoing hysterectomy variables
such as operative time, cost of procedure, or training time required by
surgeon to properly perform each technique are of less relevance.
In fact, recommendations by the Cochrane metanalysis in 2015 indicated
that vaginal hysterectomy should be the first choice of surgical
approach to hysterectomy, since based on the analyzed studies they were
able to show that it requires shorter operative time, has lower risk of
urinary tract injury, and a faster return to daily activities (3).
Nonetheless, the former two statements are arguable since graphical data
of that same study does not show clear differences, and the presented
confidence intervals lack statistical significance for both outcomes
(3). More recently, the Sandberg metanalysis (6), which includes a
greater number and newer studies, reported that the only disadvantage of
LH compared with VH is a longer operative time, a variable that in our
study was ranked as being of low importance to our participants.
In 2017, based on the Cochrane systematic review and meta-analysis, the
ACOG recommendations indicated VH as first choice since it requires
shorter operative time and is less expensive. In our study, the variable
of procedure cost was ranked as second-to-last in importance in
questions 1 and 2, and in last place in question 3. Furthermore, in the
Sandberg meta-analysis, no significant difference in procedure cost was
found between vaginal and laparoscopic hysterectomies (6). Altogether
our results indicate that variables considered as relevant by
physicians, which the ones currently used to issue recommendations, are
not necessarily the most important to patients undergoing hysterectomy.
Upon deciding surgical approach to hysterectomy, participants in our
study ranked lower complication rates as one of the most important
aspects influencing their choice. In this regard, the ACOG and two
recent meta-analyses were unable to find significant differences in
rates of total, minor, or major complications between VH and LH, thus
indicating that this may not be a criterion on which to base selection
of surgical approach to hysterectomy (5-6,10). In fact, given these
data, the most recent guideline of the Society of Obstetricians and
Gynecologists of Canada recommends that, for benign indications,
hysterectomy should be preferably approached by vaginal or laparoscopic
approaches since these techniques present lower rates of complications
than the abdominal approach (9)
In our study, participants experiencing less pain as the most important
aspect influencing their choice of surgical approach to hysterectomy in
questions 1 and 2, and the second most important in question 3. While
the Cochrane review did not find significant differences in
postoperative pain between vaginal and laparoscopic hysterectomy, a more
recent meta-analysis shows that, compared with vaginal hysterectomy,
laparoscopic hysterectomy was associated with lower pain score and
required less analgesia (6).
Complete visualization of abdominopelvic cavity is a unique feature of
laparoscopic surgery that has been widely highlighted as it allows the
evaluation, identification, and treatment of pelvic and abdominal
diseases (16). Interestingly, in our study the complete visualization of
abdominopelvic cavity was ranked by participants as one of the most
important items in questions 1 and 2, particularly by the group of 150
women who were about to undergo hysterectomy.
Regarding sick leave, previous meta-analyses (3,5) were unable to find
significant differences in its duration and return to normal daily
activities between laparoscopic and vaginal hysterectomy, suggesting
that this may not be a feature to choose one over the other.
Nonetheless, in our study, shorter sick leave was the third most valued
feature in question 3 of our survey.
In this study, we found that a shorter hospital stay was ranked as 4th
(of 12) most important feature in question 1, and section 2 of our
questionnaire. Since 2007, our group has performed outpatient management
in over 95% of patients undergoing total laparoscopic hysterectomy, and
have not evidenced complications attributed to this approach to date. In
agreement with this, the Dedden systematic review showed that outpatient
management can be a safe approach for both vaginal and laparoscopic
hysterectomy (26).
Six advantages of each laparoscopic and abdominal hysterectomies were
listed in question 1, and interestingly, and participants ranked 6 of
the 6 advantages of laparoscopic hysterectomy as their top 6 preferred
items, strongly suggesting that women in our study would choose to
undergo a laparoscopic hysterectomy rather than an abdominal one. In
agreement with our findings, in the Kluivers study, after thoroughly
explaining the advantages and disadvantages of abdominal and
laparoscopic hysterectomy to a group of patients and a to a group of
nurses, participants were asked to choose the surgical approach of their
preference which showed that 84% of patients and 74% of nurses chose
the laparoscopic approach (26). Furthermore, the Janda study reported
that after thoroughly explaining all three surgical approaches, the
majority of women preferred laparoscopic hysterectomy (40%), followed
by vaginal (17%), and abdominal hysterectomy (5%) (14).
Because of the relevance that aesthetics may have for some women, and
based on the Yeung study (15), we thus decided to include scar size
and/or presence or absence among the most important variables to be
evaluated in section 3 of our questionnaire. While scores obtained for
this variable were usually in the middle range, thus not being the most
nor the least important, we did find it to be statistically significant
for younger women who were not undergoing hysterectomy.