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.