Cochrane - Histerectomia Total vs Subtotal

8/17/2019 Cochrane - Histerectomia Total vs Subtotal

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Total versus subtotal hysterectomy for benign gynaecologicalconditions (Review)

Lethaby A, Ivanova V, Johnson NP

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2007, Issue 2

http://www.thecochranelibrary.com

1Total versus subtotal hysterectomy for benign gynaecological conditions (Review)Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

http://www.thecochranelibrary.com/http://www.thecochranelibrary.com/


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T A B L E O F C O N T E N T S

1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .3SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .4METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .10 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Table 01. Quality of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Table 02. Summary of ndings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Comparison 01. Subtotal abdominal hysterectomy vs total abdominal hysterectomy . . . . . . . . . . . .16INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Analysis 01.01. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 01

Prevalence of perceived urinary incontinence (always or often) . . . . . . . . . . . . . . . . .

19 Analysis 01.02. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 02Prevalence of urge incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . .

20 Analysis 01.03. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 03Prevalence of stress incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . .

21 Analysis 01.04. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 04Prevalence of urinary frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22 Analysis 01.05. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 05Prevalence of constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22 Analysis 01.07. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 07Satisfaction with sex (at 2 yrs follow up) . . . . . . . . . . . . . . . . . . . . . . . . .

23 Analysis 01.08. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 08 Sexualproblems (at 2 yrs follow up) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23 Analysis 01.09. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 09

Prevalence of dyspareunia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Analysis 01.10. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 10 Change

in quality of life (SF36) after 1 year . . . . . . . . . . . . . . . . . . . . . . . . . .24 Analysis 01.13. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 13 Quality

of life - physical (after 1-2 yrs) . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Analysis 01.14. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 14 Quality

of life - mental (after 1-2 years) . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Analysis 01.15. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 15

Operating time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iTotal versus subtotal hysterectomy for benign gynaecological conditions (Review)Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd


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25 Analysis 01.16. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 16 Urinary tract injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26 Analysis 01.17. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 17 Bloodloss during surgery (mL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26 Analysis 01.18. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 18 Pain

score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Analysis 01.19. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 19Requirement for blood transfusion . . . . . . . . . . . . . . . . . . . . . . . . . .

27 Analysis 01.20. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 20 Intra-abdominal haematoma/abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28 Analysis 01.21. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 21 Woundinfection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28 Analysis 01.22. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 22 Lengthof hospital stay (days) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29 Analysis 01.23. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 23 Returnto normal activities (weeks) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29 Analysis 01.24. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 24 Febrilemorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30 Analysis 01.25. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 25Ongoing cyclical vaginal bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Analysis 01.26. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 26

Persistent pain (after discharge) . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Analysis 01.27. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 27 Bowel

obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Analysis 01.28. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 28

Prolapse (pelvic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Analysis 01.29. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome 29

Readmission rate (related to surgery) . . . . . . . . . . . . . . . . . . . . . . . . . .

iiTotal versus subtotal hysterectomy for benign gynaecological conditions (Review)Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd


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Total versus subtotal hysterectomy for benign gynaecologicalconditions (Review)

Lethaby A, Ivanova V, Johnson NP

This record should be cited as:Lethaby A, Ivanova V, Johnson NP. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004993. DOI: 10.1002/14651858.CD004993.pub2.

This version rst published online: 19 April 2006 in Issue 2, 2006.Date of most recent substantive amendment: 03 February 2006

A B S T R A C T

BackgroundHysterectomy using an abdominal approach removes either the uterus alone (subtotal hysterectomy) or both the uterus and the cervix (total hysterectomy). The latter is more common but outcomes have not been systematically compared.

ObjectivesTo assess and compare outcomes with subtotal hysterectomy versus total abdominal hysterectomyfor benign gynaecological conditions.

Search strategy We searched the Cochrane Menstrual Disorders and Subfertility Group’s specialised register of controlled trials (December 2005),Central (December 2005), Medline (1966 to December 2005), EmBase (1980 to December 2005), Biological Abstracts (1980 toDecember 2005), the National Research Register and relevant citation lists.

Selection criteria Only randomised controlled trials of women undergoing either total or subtotal hysterectomy for benign gynaelogical conditions wereincluded.

Data collection and analysisThree trials that included 733 participants were included. Independent selection of trials and data extraction were undertaken by 2reviewers and results compared.

Main resultsThere was no evidence of a difference in the rates of incontinence, constipation or measures of sexual function. In one unblinded trial, a signicantly greater proportion of women indicated that they had frequent episodes of urinary incontinence after subtotal hysterectomy when compared with total hysterectomy (OR=2.1, 1.02 to 4.3), but these results were not conrmed by the other two trials thatmeasured both stress and urge incontinence and urinary frequency. . Length of surgery and amount of blood lost during surgery weresignicantly reduced during subtotal hysterectomy when compared with total hysterectomy, but there was no evidence of a differencein the odds of transfusion. Febrile morbidity was less likely (OR=0.43, 0.25 to 0.75) and ongoing cyclical vaginal bleeding one yearafter surgery was more likely (OR=11.3, 4.1 to 31.2) after subtotal when compared with total hysterectomy. There was no evidence of a difference in the rates of other complications, recovery from surgery or readmission rates.

Authors’ conclusionsThis review has not conrmed the perception that subtotal hysterectomy offers improved outcomes for sexual, urinary or bowelfunction when compared with total abdominal hysterectomy. Surgery is shorter and intraoperative blood loss and fever are reduced but women are more likely to experience ongoing cyclical bleeding up to a year after surgery with subtotal hysterectomy compared to totalhysterectomy.



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P L A I N L A N G U A G E S U M M A R Y

When abdominal hysterectomy is required for non cancerous conditions, either the uterus alone (subtotal hysterectomy) or the uterusand the cervix (total hysterectomy) are removed. Some people have suggested that not removing the cervix (subtotal hysterectomy) would reduce the chance of sexual difculties and/or problems with passing urine or solids. This review has found no evidence of a difference between these 2 types of surgery for these outcomes. Surgery is faster with subtotal hysterectomy and there is less blood lossand fever during or just after surgery but women are more likely to have long term ongoing menstrual bleeding, when compared withtotal hysterectomy.

B A C K G R O U N D

Anatomically the uterus consists of two parts, the uterine body and the cervix. Hysterectomy is the surgical removal of the uterus.It is the most frequently-performed major surgical intervention ingynaecology. A total hysterectomyinvolvesthe removal of both theuterine body and the cervix; a subtotal hysterectomy involves theremoval of only theuterine body, leaving thecervix intact. Subtotalhysterectomy is also referred to as supracervical hysterectomy.

The rst reported elective hysterectomy was performed through a vaginal approach by Conrad Langenbeck in 1813. The rst elec-tive abdominal hysterectomy, a subtotal operation, was performedby Charles Clay of Manchester in 1863 (Sutton 1997). Subtotalabdominal hysterectomy remained the operation of choice until1929, when EH Richardson performed the rst total abdominalhysterectomy. Subsequent concerns over the potential for the de-velopment of cancer in a conserved cervix, combined with furtherimprovements in operative and anaesthetic techniques,meant thattotal hysterectomy replaced subtotal hysterectomy almost com-pletely.

One of the few ’indications’ for subtotal hysterectomy was recto-vaginal endometriosis, which would have made removal of thecervix difcult or hazardous. Withdevelopments in endometriosissurgery, it is now apparent that leaving the cervix intact is likely to leave signicant tissue with endometriosis which could causefuture symptoms. This type of endometriosis is often regarded asan relative contraindication for a subtotal hysterectomy (Nezhat1996).

On the other hand, removal of the cervix to prevent the develop-ment of cervical canceris nota justiable reasonto practice routinetotalhysterectomy. Theriskof cervical stumpcarcinomainwomen with a previously normal smear is no more than 0.3% (Storm

1992), approximately the same risk as that of vaginal carcinoma after hysterectomy for a benign condition (Lyons 1993). For fur-ther risk reduction, Semm (Semm 1991) introduced a technique which involved removing the endocervix (lining of the cervix) andtransformation zone (area of the cervix where the squamous andcolumnar cells meet). A further argument proposed in favour of subtotal hysterectomy is that it allows tightening of the cardinal/uterosacral ligaments (brous structures that support the uterusand hold it in place) and surgically securing them to the vaginal

vault (wall of the vaginal), thereby possibly reducing the risk of prolapse after a hysterectomy.

Subtotal hysterectomy requires less dissection of surrounding tis-sue than subtotal hysterectomy. There has been a suggestion itmight be associated with:

• a reduced risk of damage to the bladder and ureter (Kilkku

1981; Parys 1990);• a reduced risk of a postoperative pelvic haematoma (collection

of blood in the pelvis) (Nathorst-Boos 1992);

• a reduced risk of prolapse after surgery;

• better sexual function (Helstrom 1994);

• and less damage to neuro-anatomical structures compared tototal hysterectomy.

There is some evidence of a resurgence in the use of subtotal hys-terectomy. In Denmark, the number of total abdominal hysterec-tomy decreased by 38% and the number of subtotal hysterec-tomies increased by 458% during the years 1988 and 1998 (Gim-bel 2001). A steady rise in the use of subtotal hysterectomy hasalso been reported in the USA (Sills 1998; Sills 1998a).

This review will compare outcomes for women undergoing subto-tal versus total hysterectomy. The route of approach to hysterec-tomy is the scope of another Cochrane review (Johnson 2005).

O B J E C T I V E S

The aim of this review is to compare the efcacy and safety of subtotal versus total hysterectomy.

C R I T E R I A F O R C O N S I D E R I N GS T U D I E S F O R T H I S R E V I E W

Types of studies

Randomised controlled trials (RCTs) where subtotal is compared with total hysterectomy by any approach (laparoscopic,abdominalor vaginal).



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Types of participantsInclusion criteria: Women undergoing hysterectomy for benign gynaecological con-ditions. Subgroup analysis will be performed according to the in-dication for hysterectomy if there are sufcient trials.

Exclusion criteria: Women with gynaecological cancer.

Types of interventionSubtotal versus total hysterectomy.

Comparison of the surgical approaches to removal of the uterus,for example abdominal hysterectomy, vaginal hysterectomy andlaparoscopic hysterectomy, are the focus of another Cochrane re-view and such comparative trials will not be included in this re-view. However, subgroup analysis in this review will be performedaccording to the approach used if there are sufcient trials.

Types of outcome measuresPrimary outcomes(1) Urinary incontinence(2) Sexual function(3) Bowel function

Secondary outcomesShort term:(4) Participant’s quality of life(5) Operating time(6) Surgical injury (7) Blood loss during surgery (amount in mls)(8) Pain (prior to discharge)(9) Requirement for transfusion

(10) Pelvic haematoma (collection of blood in the pelvis)(11) Any infection(12) Length of hospital stay (13) Return to normal activitiesLong term:

(14) Fistula (abnormal opening)(15) Ongoing cyclical vaginal bleeding (16) Pelvi-abdominal pain (after discharge from hospital)(17) Pelvic oor condition (prolapse)(18) Gynaecological cancer

S E A R C H M E T H O D S F O R

I D E N T I F I C A T I O N O F S T U D I E S

See: Cochrane Menstrual Disorders and Subfertility Groupmethods used in reviews.

All reports which described (or might have described) RCTs of subtotal versus total hysterectomy.

(1) The Menstrual Disorders & Subfertility Group’s SpecialisedRegister of controlled trials was searched for any trials. See the

Review Group for more details on the make-up of the SpecialisedRegister.

(2) The following electronic databases were searched using Ovidsoftware;MEDLINE - 1966 to December 2005EMBASE - 1980 to December 2005Biological Abstracts - 1980 to December 2005

The MEDLINE, EMBASE and Biological Abstract databases were searched using the following keywords:1. Hysterectom$.tw.2. Sub-total$.tw.3. Supracervical$.tw 4. Cervix adj conserv$.tw 5. Or/2-46. 1 and 57. exp clinical trials/8. exp research design/9. clinical trial.pt.10. randomized controlled trial.pt.11. (singl$ or doubl$ or trebl$ or tripl$).tw.12. (mask$ or Blind$).tw.13. 11 and 1214. placebos/ or placebo.tw.15. 7 or 8 or 9 or 10 or 13 or 1416. 6 and 15

(3) The Cochrane Central Register of Controlled Trials(CENTRAL) on the Cochrane Library was also searched in allelds using the following words:1. Hysterectomy 2. Subtotal3. Supracervical4. 1 and 2 or 3

(4) The National Research Register (NRR), a register of ongoing and recently completed research projects funded by, or of interestto, the United Kingdom’s National Health Service, as well asentries from the Medical Research Council’s Clinical TrialsRegister, and details on reviews in progress collected by the NHSCentre for Reviews and Dissemination, were searched for any trials with the following keywords:1. Hysterectomy 2. Subtotal3. Supracervical4. 1 and 2 or 3

The Clinical Trials register, a registry of federally and privately funded US clinical trials was also searched for the same keywords.

(5) The citation lists of relevant publications, review articles,abstracts of scientic meetings and included studies were alsosearched.



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M E T H O D S O F T H E R E V I E W

Selection of trialsThe selection of trials for inclusion in the review was performedby two reviewers (VI and AL) after employing the search strategy

described previously. Differences of opinion were resolved by consensus after consultation with a third reviewer (NJ).

Trials were excluded from the review if they made comparisonsother than those specied above and these are detailed in the tableof excluded trials.

Quality assessment Included studies were assessed independently by two reviewers(VI and AL) for the following quality criteria and methodologicaldetails. This information is presented in a table describing theincluded studies and provides a context for assessing the reliability of results.

(1) Trial characteristics(a) Method of randomisation (either adequate (unpredictable);not reported; or inadequate (predictable))(b) Allocation concealment (either adequate (A), unknown (B) orinadequate (C))(c) Study design:(i) blinding (of assessor)(ii) duration of follow-up(iii) type of follow-up(d) Size of study:(i) number of women recruited(ii) number of women randomised(iii) number of women excluded(iv) number of women withdrawn and lost to follow-up(v) number of women analysed(e) Study setting (i) Single-centre or multicentre(ii) Location(iii) Timing and duration(iv) Source of funding stated or not(f) Analyses(i) Whether a power calculation was performed and adhered to(ii)Whether ’intention to treat’ analysiswasperformed by authors,possible from data but not performed by authors, not possible oruncertain(g) Criteria for hysterectomy (i) Indications specied(ii) Data broken down by indications for hysterectomy

(2) Characteristics of the study participants(a) Baseline characteristics(i) Age(ii) Parity (number of babies)(iii) Indication for hysterectomy (iv) Investigative work-up, for example pelvic ultrasound scan,endometrial sampling

(v) Previous treatments for gynaecological conditions(vi) Exclusion criteria (b) Treatment characteristics(i) Pre-operative preparation, for example pre-operative medicaltreatment

(ii) Level of training of surgeons (experience with the specicprocedures)

(3) Interventions(a)Approachtohysterectomy - abdominal, vaginal, laparo-vaginal,laparoscopic(b) Use of technique to support the vaginal vault (to preventprolapse)(c) proportion undergoing bilateral elective oophorectomy versusovarian conservation (removing vs saving the ovaries)(d) other strategies to reduce the likelihood of complications(e) Absence of co-interventions in treatment and control groups

(4) Outcomes After the publication of the protocol, the reviewers decided to listoutcomes according to their status as primary or secondary

Primary outcomes(1) Urinary function (such as incontinence and frequency)(2) Sexual function (including satisfaction)(3) Bowel function (constipation)

Secondary outcomes(4) Quality of life(5) Operating time(6) Surgical injury (7) Blood loss during surgery (amount in mls)(8) Pain (prior to discharge)(9) Requirement for transfusion(10) Pelvic haematoma (11) Any infection(12) Length of hospital stay (13) Return to normal activities(14) Fistula (15) Vaginal bleeding (16) Pelvi-abdominal pain (after discharge)(17) Pelvic oor condition (prolapse)(18) Gynaecological cancer

Data Management All data were extracted independently by at least two reviewers(AL and VI) and differences of opinion were to be resolved by consensus after consultation with a third reviewer. Consultation was not necessary. Additional information on trial methodology or actual original trial data was sought from the corresponding author of one trial which was initially published in a conferenceabstract but the information was subsequently published.

Statistical analysis



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Statisticalanalysiswas performedinaccordancewith the guidelinesfor statistical analysis developed by the Menstrual Disorders andSubfertility Group.

The outcome data were pooled in a meta-analysis where nosignicant clinical heterogeneity was apparent and there was noevidence of major skew. Statistical heterogeneity between theresults of different studies were examined by inspecting the scatterin thedata pointson thegraphsandthe overlap in their condenceintervalsand,more formally, by checking the results of chi-squaredtests. The I2 quantity was also checked for evidence of statisticalheterogeneity (Higgins 2003).

Dichotomous data were expressed as an odds ratio with 95%condenceintervalsandcombinedfor meta-analysiswithRevMansoftware using the Peto-modied Mantel-Haenszel method.For negative outcomes (for example, urinary incontinence), anincrease in the odds of a particular outcome for the experimentalgroup is displayed graphically in the meta-analyses to the right

of the centre-line and a decrease in the odds of an outcome isdisplayed graphically to the left of the centre-line. For positiveoutcomes (for example, satisfaction with treatment), an increasein odds is shown on the reverse axis. Graphs have been labelledfor ease of interpretation.

Continuous data was combined for meta-analysis with RevMansoftware using the weighted mean difference (WMD) with 95%condence interval and a xed effects model.

It was planned to perform sensitivity analyses to examine thestability of the results in relation to:(a) allocation concealment (inadequate/unclear or adequate)(b) source of data (published or unpublished)

(c) prior experience of the surgeonThere were insufcient trials to undertake these analyses.

Subgroup analysis was planned according to:(a) indication for hysterectomy (b) hysterectomy approach (abdominal, laparoscopic or vaginal)There were insufcient trials to undertake these analyses.

A search will be conducted for trials every twelve months and thereview updated if new trials are found.

D E S C R I P T I O N O F S T U D I E S

We identied ten trials that were potentially relevant to the re-view. Of these 10 studies, 3 were excluded, one because it wasnot randomised, one because it compared resource use betweentype of hysterectomy which is not an outcome in this review andone because the 2 groups being compared did not have similarcharacteristics at baseline. Ofthe 7 included studies, 4 were subse-quent publications of a primary study (mostly assessing differentoutcomes from the primary publication). Thus, 3 RCTs met ourinclusion criteria and were included in the review.

The three trials randomised a total of 733 women but they werenot all included in the analysis of every outcome. One trial wasNorth American, one Danish and the other trial was from theUnited Kingdom.

ParticipantsTwo of the studies specied that the criteria for inclusion was


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- stress incontinence (dened as an involuntary leakage of urine ac-companying physicalactivity, suchas laughing,coughing,sneezing or physical activity) (rated on a 4 point scale) - data later retrievedon the proportions of women who had incontinence weekly oralways

- urgency of wanting to pass urine (rated on a 4 point scale)- peak ow rate of urine (measured in ml/sec)- rst desire to pass urine (measured in mls)- strong desire to void (measured in mls)- maximal capacity of urine (measured in mls)

Bowel function was measured by multiple variables as follows:- proportionof participants whohadconstipation(dened as fewerthan 3 bowel movements per week)- proportion of participants who had hard stools (rated as a scoreof 2 or higher on a 6 point scale)- proportion of participants who had straining to move bowels(rated as a score of 3 or higher on a 6 point scale)- proportion of participants who used laxatives (rated as a score of 3 or higher on a 6 point scale)- proportion of participants who had urgency (rated as a score of 3 or higher on a 6 point scale)- proportion of participants who had incontinence of atus (pass-ing gas or wind) (rated as a score of 3 or higher on a 6 point scale)

Sexual function was measured (only in those who were sexually active) by a number of different variables; frequency of orgasmand multiple orgasm was measured on a 4 point scale and vaginallubrication, deep or supercial dyspareunia (painful or difcultintercourse) and sexual relationship with a partner was scored aseither present or absent.

This review has assessed the prevalence of urinary incontinenceas a whole (perceived by the women), urge incontinence, stressincontinence and urinary frequency. The other primary outcomesincluded in the review are the prevalence of constipation, satisfac-tion with sexual life and dyspareunia (after 1 year follow up) andscores (from 1 to 100, where 100 represents optimum function)at 2 years follow up for satisfaction with sex and sexual problems.

Secondary outcomes in the three trials included quality of lifescores (SF36), perioperative outcomes(during the operation), hos-pital readmission rate, post operative complications and effects onpelvic function.

M E T H O D O L O G I C A L Q U A L I T Y

See additional table, Table 01 Quality of included studies.

Study DesignThe three included trials were randomised controlled trials witha parallel group design. The duration of the study was 1 year for2 studies ( Gimbel 2003; Thakar 2002) and 2 years for the otherstudy (Learman 2003).

Randomisation/allocation concealment All three included trials had computer generated randomisation;twostudies randomised participants in blocksand twostudies usedopaque sealed envelopes. All three had adequate concealment of allocation.

Blinding Two studies were not blinded. The other study had double blind-ing(participantsandoutcome assessors) throughout the 12 monthstudy period (Thakar 2002). Although self examination by par-ticipants could break the blinding, this was strongly discouragedand the investigators considered that the women were highly mo-tivated and willing to participate in the interests of the study.

Intention to treat All three included studies reported intention to treat analyses. Onestudy had true intention to treat for the primary outcomes butminimal loss to follow up for secondary outcomes. Another study performed four analyses: ’regular’ intention to treat (based on out-

come data only for those participants whose results were known,i.e excluding exclusions from the analysis and lost to follow-up);’best case scenario’ intention to treat (analysis considered all ran-domised participants and estimated dropouts as not having theprimary undesirable outcome of interest); ’worst case scenario’ in-tention to treat (analysis considered all randomised participantsand estimated dropouts as having the primary undesirable out-come of interest); and ’carry forward’ intention to treat (analysisconsidered the last registered information on the outcome of in-terest among those dropping out as being the result at the end of the study period). Conclusions were based on the ’regular’ inten-tion to treat analysis which excluded 13.2% of participants afterrandomisation. The other study assessed perioperative outcomes

in full intention to treat analysis including the 8 participants whodid not have the procedure. Analysis of the primary outcomes wasonly undertaken where data were available.

Thus, overall dropouts from thestudies were 0%,13% anda rangeof 13 to 15% (for the primary outcomes in the Thakar trial).

Power calculation for sample size All three included studies had power calculations for sample size; 2studies had80% power andthe other had90% power to determinea difference in the primary outcome.

Source of funding One study had funding from AHRQ (Agency for HealthCare Re-searchand Quality),another wassupportedby grants from a num-ber of different trial groups, organisations and hospitals in Den-mark and the other was supported by a grant from the ResponsiveProgramme, Research and Development, National Health ServiceExecutive, London.

R E S U L T S

Sexual function



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All three trials measured outcomes relating to sexual function.There was no evidence from the meta-analyses that sexual func-tion, as measured by satisfaction with sexual life (Learman 2003),prevalence of dyspareunia (Gimbel 2003; Thakar 2002) and rateof sexual problems (Learman 2003) differed according to type of

hysterectomy at 1 or 2 years after surgery. Sexual satisfaction wasmeasured by the extent to which women perceived that they weresatised by their ability to have and enjoy sex, with or withouta partner. Data from the other 2 trials that measured ’sexual sat-isfaction’ (Gimbel 2003; Thakar 2002) could not be pooled inthe meta-analysis because the question on sexual satisfaction wasasked in a different format.

IncontinenceIn one trial (n=276), a signicantly smaller proportion of womenindicated that they had urinary incontinence (’always’ or ’often’)after total abdominal hysterectomy than after subtotal abdominalhysterectomyone yearafter surgery (OR=2.1, 1.02to 4.3)(Gimbel2003). This nding was not conrmed by the results of the othertwo trials where the prevalence of different types of incontinence were assessed at different follow up times and by more robustmethods (Learman 2003; Thakar 2002). There was no evidenceof a difference in urge incontinence or urinary frequency at 6, 12and 24 months follow up in these two trials. There was also noevidence of a difference in stress incontinence in these two trialsat 12 and 24 months follow up.

ConstipationThere was no evidence of a difference in the rates of constipationaccording to type of hysterectomy either at 6 or 12 months follow up in 2 trials (Gimbel 2003; Thakar 2002).

Quality of lifeThere was no evidence from two trials of a difference in physicalor mental function in quality of life scores (SF36) according totype of hysterectomy (Gimbel 2003; Learman 2003). There wasalso no evidence of a difference in the individual domains of theSF36 scale in another trial; in this trial the data were skewed andthe results are presented in a table (Thakar 2002).

Intraoperative outcomesThe length of time required for surgery was signicantly shorterfor subtotal hysterectomywhen compared with total hysterectomy in two trials (WMD=11.41mins, 95% CI 6.6 to 16.3) (Learman2003;Thakar 2002). The amount of blood loss during surgery was signicantly less with subtotal hysterectomy when compared with total hysterectomy in 2 trials (WMD=85.1mls, 95% CI 27.4to 142.9) (Learman 2003; Thakar 2002). However, there was noevidence ofa difference inthe odds of requiring a blood transfusionaccording to type of surgery.

ComplicationsFebrile morbidity (temperature higher than normal) was less likely after subtotal hysterectomy than total hysterectomy in all 3 trials(OR=0.43, 0.25 to 0.75). Ongoing cyclical vaginal bleeding after

one year was more likely after subtotal hysterectomy than totalhysterectomy in 3 trials (OR=11.31, 4.1 to 31.2) with 11.9% of women having subtotal hysterectomy experiencing ongoing cycli-calvaginal bleeding (0.8%for totalhysterectomy, intentionto treatresults). There wasno evidence of a difference in ongoing bleeding

at 2 years in one small trial (Learman 2003). There was no evi-dence of differences for any of the other complications measuredin the studies: urinary tract injury, pain score, wound infection,persistent pain (after discharge) or bowel obstruction and pelvicprolapse. The odds of intra-abdominal haematoma or abscess in 2trials (prevalence 1% with subtotal vs 5% with total hysterectomy)(Gimbel 2003; Thakar 2002) was just outside the pre-assignedlevel at which results were considered signicantly different (p=0.06). The odds of pelvic prolapse in 2 trials (OR=6.5, 95% CI0.77 to 54.25 - prevalence with subtotal 1.9% compared to 0% with total hysterectomy) (Gimbel 2003; Thakar 2002) was also just outside the pre-assigned level of signicance (p=0.08).

Theincludedtrials didnot have long enoughfollow uptocomparerisk of cancer in the 2 groups.

Recovery There was no evidence of a difference in the length of hospitalstay (Learman 2003; Thakar 2002) or return to normal activities(Learman 2003) according to type of hysterectomy, although thedifference in hospital stay was just outside the level of signicance(4.25 days with subtotal vs 4.75 days with total hysterectomy; p=0.07). There was also no evidence of a difference in the readmis-sion rate that was related to surgery at one (Thakar 2002) or two(Learman 2003) years follow up.

Heterogeneity There was signicant heterogeneity (I squared >70%) in the for-est plots assessing constipation, dyspareunia and ongoing cycli-cal bleeding. There was moderate heterogeneity in the length of hospital stay outcome and prevalence of febrile morbidity aftersurgery (I squared=44% and I squared=58% respectively).

Sensitivity analysisThere were too few trials in the analysis to conduct sensitivity analyses.

D I S C U S S I O N

The rationale for undertaking this review was the perception by

women that the retention of the cervix was necessary to maintainsexual pleasure and that subtotal hysterectomy may be preferableto total hysterectomy. It has been hypothesized that total hysterec-tomy may lead to damage of the pelvic nerves or pelvic supportstructures that potentially could increase the riskof urinary incon-tinence, bowel dysfunction and reduce sexual pleasure (Thakar2005). This review has not demonstrated conrmatory evidenceof subtotal hysterectomy causing less damage to neuroanatomicalstructures than total hysterectomy. The outcomes most indicative



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of such damage, including urinary, bowel and sexual dysfunctionhave shown no consistent evidence of a benet in women under-going subtotal hysterectomy. This nding is based on only 3 ran-domised trials including 733 women and so the reported conclu-sions must be considered provisional.

Sexual functionSexual response after hysterectomy has been extensively studiedin a number of observational studies but results were inconsis-tent (Kilkku 1983; Kilkku 1983a; Roussis 2004; Saini 2002;Roovers 2003). The poorer quality retrospective studies (Kilkku1983; Kilkku 1983a; Saini 2002) reported that women undergo-ing subtotal hysterectomy reported better sexual function and sat-isfaction than those undergoing total hysterectomy but two morerecent better quality prospective studies (Roussis 2004; Roovers2003) reported no differences between groups. These latter twostudies also reported that perceived sexual function appeared toimprove after hysterectomy regardless of technique.

It is clear that “sexual function” is a complex concept with many interrelated factors that are difcult to assess adequately. All of theRCTs in this review assessed the effects of surgical technique on a number of factors that are considered to be related to sexual func-tion (frequency of orgasm, dyspareunia, vaginal lubrication, andsexual satisfaction) and failed to demonstrate an unequivocal dif-ference. There was signicant heterogenity in the measurement of sexual satisfaction whichunderscores the complexityof measuring this outcome. Sexual satisfaction (the proportion of women who were satised with their sexual life, if sexually active) was measuredby questionnaire in two trials. However, the Thakar trial asked whether women had a good sexual relationship with their partnerand the Gimbel trial asked women if they were satised with their

sexual life (either with or without a partner). These were differentquestions and the authors considered that they were not similarenough for the trials to be combined in a meta-analysis. The ab-solute proportions differed between the trials indicating that it ispossible that women perceive the 2 questions differently. Anothertrial measured sexual satisfaction as a continuous score and there was no evidence of a difference between groups of women. Sim-ilarly, the absolute proportions of women with dyspareunia dif-fered between the trials. TheGimbel trial askedwomen whetherornot they had dyspareunia and the Thakar trial distinguised “deep”from “supercial” dyspareunia. Only the data for deep dyspareu-nia were extracted and included in the meta-analysis.

The evidence appears to be clearer with regard to other prognosticfactors that had an effect on postoperative sexual function: preop-erative satisfaction with sexual life,good relationship with partner,chronic disease and hormone replacement therapy (Gimbel 2003;Helstrom 1994).

Urinary functionFour retrospective observational studies (Kilkku 1981; Kilkku1985; Neumann 2004; Roovers 2001) and one systematic review (Brown 2000) have also assessed theeffectsof type ofhysterectomy

on various measures of urinary function after surgery. Resultswereinconsistent in the observational studies and the systematic review conrmed most of the results of the RCTs in this review. There was no evidence of a difference in urge or stress incontinence orurinary frequency according to type of hysterectomy, even though

urge incontinence is the type of urinary incontinence recognisedas being most closely associated with neuroanatomical aetiology.TheBrown systematic reviewhowever did suggest that, forwomenaged more than 60 years, urinary incontinence after hysterectomy is about 60% higher than for women in same age group whohave not undergone hysterectomy. This has not been conrmedby other studies, in particular the RCTs in this review which mea-sured incontinence at baseline and post surgery and found im-proved urinary function. It is possible that the conditions thatmay lead to hysterectomy adversely affect lower urinary tract functionand surgery provides a benet. The outcomes measured here weremeasures of women’s perception of urinary symptoms rather thanurodynamic investigation since the association between clinical

symptoms and urodynamic ndings is poor (Abrams 1983).

It was considered plausible that subtotal hysterectomy mightprotect against urinary incontinence when compared with totalhysterectomy because of protection from damage to the pelvicnerves or pelvic support structures. Paradoxically, one of the nonblinded RCTs measured overall incontinence (“often or always”)12 months after surgery and reported a signicant difference infavour of total hysterectomy (Gimbel 2003). However, the otherRCTs, oneof which hadmore specic methodology formeasuring separate typesof incontinence as well as urinary frequency, did notsupport this result (Learman 2003; Thakar 2002). The Thakartrial wasblinded andwomen’s perceptions of whetherthey suffered

various measures of incontinence was conrmed by physiologicalinvestigations, conforming to the standards of the InternationalContinence Society (Abrams 1988).

Bowel functionBowel symptoms include constipation, feeling of incompleteevac-uation, fecal incontinence, atus incontinence, difculty empty-ing the rectum and painful defecation. One retrospective study not included in the review has reported an increased prevalence of disturbed bowel function within one month of hysterectomy that waned over time but no differences according to type of surgery (van Dam 1997). In this review, there was signicant heterogene-ity, possibly the result of differentmethods of measuring constipa-

tion and possibly different baseline distributions in the 2 includedtrials. In the Thakar trial, constipation was dened as fewer than3 bowel motions per week. In the Gimbel trial, prevalence of con-stipation was sought from a validated questionnaire but no de-nition was provided in the publication. This review has found noevidence that type of hysterectomy has any effect on constipationrates after surgery.

Quality of life



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Quality of life measures after surgery did not appear to vary ac-cording to type of hysterectomy. In 3 of the studies, quality of life improved signicantly from baseline regardless of type of hys-terectomy. This nding has been reported in another Cochranesystematic review evaluating the effect of hysterectomy for benign

disease on women’s wellbeing (Lethaby 2000).Intraoperative and postoperative outcomes A signicant benet of subtotal, as compared to total, hysterec-tomy wasreducedoperating time andreducedbloodloss,althoughno differences were reported in the requirement for blood trans-fusion. The data were underpowered to detect a difference in ratesof urinary tract injury, but it was interesting that, in this smallseries, more urinary tract injuries occurred in women undergoing total hysterectomy (1.9%) than in women undergoing subtotalhysterectomy (0.5%) (p=0.24). There was signicantly less febrilemorbidity after subtotal hysterectomy. There was no evidence of a difference in other outcomes such as risk of urinary tract infec-tion, wound infection, bowel obstruction, persistent pain or painscore. The risk of intra-abdominal haematoma (pooling of bloodinside the abdomen) was just outside the chosen level of statisticalsignicance in favour of subtotal hysterectomy, p=0.06. Lengthof hospital stay was also just outside the chosen level of statisticalsignicance in favour of subtotal hysterectomy (OR=0.26, 95%CI 0.06 to 1.08), p=0.07), but there was signicant heterogeneity in the analysis and a wide and imprecise condence interval. Thispossibly could be explained by the likelihood of different hospitalpolicies since the trials were conducted in different countries, theUSA and UK. Shorter hospitalisation was reported for both typesof hysterectomy in the USA when compared with the UK. There was no evidence of any difference in return of normal activitiesafter surgery. Likelihood of readmission to hospital also did notdiffer according to type of surgery; statistical heterogeneity in theanalysis reected the different length of follow up in the includedtrials. It is clear that subtotal hysterectomy is considered less dif-cult and faster surgery and is less invasive for women in terms of postoperative febrile morbidity.

Ongoing cyclical bleeding Ongoing bleeding wasexperienced by 6.8% and 19.9% of womenone year after subtotal hysterectomy in 2 trials but no difference was detected in ITT analyses in the third small trial, although mostof the women in the total hysterectomy group had not undergonesurgery (6.6% subtotal versus 4.8% total). There was signicantheterogeneity in the analysis but this can be explained by the mix-

ing of non ITT and ITT analyses. The bleeding rate of 20% wasreported in an analysis in the Gimbel trial where a proportion of women had been lost to follow up. One of the authors speculatedthat formal reverse conization during subtotal hysterectomy mightminimise the complication of cyclical bleeding(Thakar 2002).

Pelvic prolapseThere was no evidence in this review of a difference in the rateof pelvic prolapse following surgery by totality of hysterectomy,

although the results were just outside the pre-assigned level of sig-nicance in favour of total hysterectomy. It is possible that thefuture addition of more trial results may show a benet for totalhysterectomy for this outcome. We excluded the outcome “uterusbulging or dropping out” from the outcome analysis pending clar-

ication from the authors as to whether this was in fact cervicalprolapse. It is unclear that women who have had a hysterectomy can have a “uterus bulging or dropping out”. Exclusion of thesedata from the outcome “pelvic prolapse” reduced the heterogene-ity in the analysis.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

There appears to be a limited resurgence in rates of subtotal hys-terectomy in the Western world. This review, however, has not

conrmed the perception that subtotal hysterectomy offers im-proved outcomes for urinary, sexual and bowel function whencompared with total hysterectomy. Surgery is signicantly fasterand blood loss and postoperative febrile morbidity reduced withsubtotal hysterectomy but ongoing cyclical vaginal bleeding islikely to be increased up to a year after surgery. This informationneeds to be communicated to women requiring hysterectomy fora benign condition and this is not often routine. An American sur-vey reported that fewer than 20% of gynecologists offered womena choice between subtotal and total hysterectomy (Zekam 2003). Women can be informed about the route of hysterectomy by ref-erence to another Cochrane systematic review (Johnson 2005).

One of the rationales for total, as opposed to subtotal, hysterec-tomy is the potential risk of cervical cancer when the cervix is leftin place, although this review has not been able to assess this risk.The incidence of cervical cancer in women who have had subtotalhysterectomy is fairly rare; a study of 1,104 women having thissurgery in Denmark between 1978 and 1988, found an incidenceof 0.3% (Storm 1992). Another study of cervical cancer screening in the midwestern United States showed no differences in screen-ing rates between women who did not have hysterectomy (Eaker1998). This potential risk is not an issue for women in countriesthat have routine cervical screening programs. However, it may beprudent to advise against subtotal hysterectomy in women with a history of high grade cervical lesions, a fear of developing cervicalcancer, or cervical cancer screening that is not up to date or un-likely to occur regularly in the future.

Implications for research

Although this review has not conrmed the presumed superiority of subtotal hysterectomy for preserving urinary, sexual and bowelfunction, the conclusions are based on only 3 RCTs, two of which were unblinded, with less than 1000 women in total. There aredifculties in adequately measuring these complex outcomes and



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more research would be welcome to conrm the provisional con-clusions of this review. Larger double blinded randomised con-trolled trials with adequate assessment tools are needed becausemany of the important outcomes are subjective.One of the expected disadvantages of total hysterectomy, an in-

crease in postoperative vaginal vault prolapse has not been con-rmed in this review and it is possible that the trials were under-powered to adequately assess this outcome. Prolapse may appearyears after hysterectomy and studies with long term follow up areneededto assesswhethercervical preservationresults inbetter sup-port of the vaginal vault.

P O T E N T I A L C O N F L I C T O FI N T E R E S T

None known.

A C K N O W L E D G E M E N T S

We would like to thank the editorial group of the Cochrane Men-strual Disorders and Subfertility Group for their help and guid-ance with this review: Shauna Sylvester, Review Group Coordina-tor and Lisa McComb Williams, past Trials Search Coordinator.

S O U R C E S O F S U P P O R T

External sources of support

• No sources of support supplied

Internal sources of support • Department of Obstetrics and Gynaecology, University of

Auckland NEW ZEALAND

R E F E R E N C E S

References to studies included in this review

Gimbel 2003 {published data only}∗ Gimbel H, Zobbe V, Andersen BA, Filtenborg T, Gluud C, Tabor A. Randomised controlled trial of total compared with subtotal hys-

terectomy with one-year follow up results. BJOG 2003;110 :1088–1098.

Zobbe V, Gimbel H, Andersen BA, Filtenborg T, Jakobsen K,Sorensen HC, et al. Sexuality after total vs. subtotal hysterectomy. Acta Obstet Gynecol Scand 2004;83:191–196.

Learman 2003 {published data only}Kupperman M, SummittJnr RL,Varner E, McNeely SG,Goodman-Gruen D, Learman LA,et al.Sexual functioning aftertotal compared

with supracervical hysterectomy: a randomized trial. Obstet Gynecol 2005;105:1309–1318.

∗ Learman LA, Summitt RL, Varner RE, McNeeley SG, Goodman-Gruen D, Richter HE, et al. A randomized comparison of total or

supracervical hysterectomy: surgical complications and clinical out-comes. Obstet Gynecol 2003;102(3):453–462.

Thakar 2002 {published data only}∗ Thakar R, Ayers S, Clarkson P, Stanton S, Mayonda I. Outcomesafter total versus subtotal abdominal hysterectomy. NEJM 2002;347(17):1318–1325.

Thakar R, Ayers S, Gerogakapolou A, Clarkson P, Stanton S,Manyonda I. Hysterectomy improves quality of life and decreases



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psychiatric symptoms: a prospective and randomised comparison of total versus subtotal hysterectomy. BJOG 2004;111 (10):1115–20.

References to studies excluded from this review Lalos 1986

Lalos O, Bjerle P. Bladder wall mechanics andmicturition before and

after subtotal and total hysterectomy. Eur J Obstet Gynecol Reprod Biol 1986;21:143–150.

Lyons 1993Lyons TL. Laparoscopic supracervical hysterectomy. Journal of Re- productive Medicine 1993;38(10):763–767.

Showstack 2004Showstack J, Kuppermann M, Lin F, Vittinghoff E, VarnerRE, Sum-mit RL. Resource use for total and supracervical hysterectomies: re-sults of a randomised trial. Obstet Gynecol 2004;103(5):834–841.

Additional references Abrams 1983

Abrams P. The clinical contribution of urodynamics. Urodynamics .Springer-Verlag, 1983.

Abrams 1988 Abrams P, Blaivas JG, Stanton SL, Anderson JT. The standardisationof terminology of lower urinary tract function. Scand J Urol Nephrol Suppl 1988;114 :5–19.

Brown 2000Brown JS, Sawaya G, Thom DH, Grady. Hysterectomy and urinary incontinence: a systematic review. Lancet 2000;356:535–538.

Eaker 1998Eaker ED, Vierkant RA, Konitzer KA, Remington PL. Cervical can-cer screeningamong women withand without hysterectomies. Obstet Gynecol 1998;14:551–555.

Gimbel 2001Gimbel H, Settines A, Tabor A. Hysterectomy on benign indicationin Denmark 1988-1998. Acta Obstet Gynecol Scand 2001;80:267–272.

Helstrom 1994Helstrom L. Sexuality after hysterectomy: A model based on quanti-tative and qualitative analysis of 104 women before and after subto-tal hysterectomy. Journal of Psychosomatic Obstetrics & Gynaecology 1994;15:219–29.

Higgins 2003Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring in-consistency in meta-analyses. BMJ 2003;327:557–60.

Johnson 2005 Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R.Surgical approach to hysterectomy for benign gynaecological disease

(Cochrane Review). In: The Cochrane Library , 1, 2005. Chichester,UK: John Wiley & Sons, Ltd.Kaser 1985

Kaser O, Ikle FA, HirschHA. Atlas of Gynecological Surgery . 4th Edi-tion. Stuttgart; New York: Georg Thieme Verlag; Thieme-Stratton,1985.

Kilkku 1981Kilkku P, Hirvonen T, Gronroos M. Supracervical uterine amputa-tion versushysterectomy: The effects on urinary symptoms with spe-

cial reference to pollakiuria, nocturia and dysuria. Maturitas 1981;3:197–204.

Kilkku 1983Kilkku P, Gronroos M, Hirvonen T, Rauramo L. Supravaginal uter-ine amputation vs hysterectomy. Effects on libido and orgasm. Acta Obstet Gynecol Scand 1983;62:147–152.

Kilkku 1983a Kilkku P. Supravaginaluterine amputationvs hysterectomy: effect oncoital frequency and dyspareunia. Acta Obstet Gynecol Scand 1983;62:141–145.

Kilkku 1985Kilkku P. Supravaginal uterine amputation versus hysterectomy withreference to subjective bladder symptoms and incontinence. Acta Obstet Gynecol Scand 1985;64(5):375–379.

Lethaby 2000Lethaby A, Shepperd S, Cooke I,Farquhar C. Endometrial resectionand ablation versus hysterectomy for heavy menstrual bleeding. In:TheCochraneLibrary , 2, 2000. Chichester, UK:JohnWileyand Sons,Ltd.

Lyons 1993LyonsTL. Laparoscopic supracervical hysterectomy. A comparisonof morbidity and mortality results with laparoscopically assistedvaginalhysterectomy. Journal of Reproductive Medicine 1993;38(10):763–7.

Nathorst-Boos 1992Nathorst-Boos J, Fuchs T, von Schoultz B. Consumer’s attitude tohysterectomy: the experience of 678 women. Acta Obstetrica et Gy-necologica Scandinavica 1992;71:230–4.

Neumann 2004Neumann G, Olesen PG, HansenV, Lauszus FF, Ljungstrom B, Ras-mussen KL. The short-term prevalenceof de novourinary symptomsafter different modes of hysterectomy. Int Urogynecol J 2004;15:14–19.

Nezhat 1996Nezhat CH, Nezhat F, Roemisch M, Seidman DS, Nezhat C. La-paroscopic trachelectomy for persistent pelvic pain and endometrio-sis after supracervical hysterectomy. Fertility and Sterility 1996;66:925–8.

Parys 1990Parys BT, Haylen BT, HuttonJL, ParsonsKF. Urodynamic evaluationof lower urinary tract function in relation to total hysterectomy. Aus-tralia and New Zealand Journal of Obstetrics and Gynaecology 1990;30(2):161–5.

Roovers 2001Roovers J-PWR, vander Bom JG,van der Vaart CH, Fousert DMM,Heintz PM. Does mode of hysterectomy inuence micturition anddefecation?. Acta Obstet Gynecol Scand 2001;80:945–951.

Roovers 2003Roovers J-PWR, van der Bom JG, van der Vaart CH, Heintz PM.Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and totalhysterectomy. BMJ 2003;327:774–778.

Roussis 2004Roussis NP, Waltrous L, Kerr A, Robertazzi R, Cabbad MD. Sexualresponse in the patient after hysterectomy: total abdominal versus



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supracervical versus vaginal procedure. Am J Obstet Gynecol 2004;190:1427–1428.

Saini 2002Saini J, Kuczynski E, Gretz III HF, Sills ES. Supracervical hysterec-tomy versus total abdominal hysterectomy: perceived effects on sex-

ual function. BMC Women’s Health 2002;2:1.

Semm 1991Semm K. Hysterectomy via laparotomy or pelviscopy. A new CASHmethod without colpotomy [Hysterektomie per laparotomiam oderper pelviskopiam. Ein neuer Weg ohne Kolpotomie durch CASH].Geburtshilfe und Frauenheilkunde 1991;51(12):996–1003.

Sills 1998Sills ES, Saini J. Supracervical and total abdominal hysterectomy trends in New York State: 1990-1996. J Urban Health 1998;1998 :903–910.

Sills 1998a

Sills ES, Saini J, Steiner CA, McGee M, Gretz HF. Abdominal hys-terectomy practice pattersn in the United States. Int J Gynecol Obstet 1998;63:277–283.

Storm 1992Storm HH, Clemmensen IH, Manders T, Brinton LA. Supravaginaluterine amputation in Denmark 1978-1988 and risk of cancer. Gy-necologic Oncology 1992;45(2):198–201.

Sutton 1997Sutton C. Hysterectomy: a historical perspective. Ballieres Clinical Obstetrics & Gynaecology 1997;11:1–22.

Thakar 2005Thakar R, Sultan AH. Hysterectomy and pelvic organ dysfunction.Best Practice and Research Clinical Obstetrics and Gynaecology 2005;19(3):403–18.

van Dam 1997van Dam JH, Gosselink MJ, Drogendijk AC, Hop WCJ, Schouten WR. Changes in bowelfunctionafterhysterectomy.DisColonRectum1997;40:1342–1347.

Zekam 2003Zekam N, Oyelese Y, Goodwin K, Colin C, Sinai I, Queenan JT.Total versus subtotal hysterectomy: a survey of gynecologists. Obstet Gynecol 2003;102:301–305.

∗ Indicates the major publication for the study

T A B L E S

Characteristics of included studies

Study Gimbel 2003Methods Randomisation method: Restricted, computer generated block randomisation

No of centres: 11Design: parallel groupBlinding: NoNo randomised 319No analysed: 277Dropout at end of follow up: 15% in subtotal group; 11% in total groupPower calculation: yesIntention to treat analysis: Authors claimed both ’regular’ ITT and per protocol analysis but 13% of ran-domised participants excluded from analysisSource of funding: Numerous trial groups/organisations and hospitals

Participants Inclusion: Women who are scheduled for hysterectomy for benign diseaseExclusion:Laparoscopic/vaginal hysterectomy; dysplasia (cervical); uterine prolapse; malignant disease; diabetes; partic-ipation in other research projects; unable to read/write Danish; former urological operation; cervix problems;psychological problems; poor mental function; neurological disease; chronic alcoholism. Age: 47 years (mean)Source: Departments of Obstetrics and Gynaecology in Denmark

Interventions (1) subtotal hysterectomy (2) total abdominal hysterectomy Follow up 1 year



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Characteristics of included studies ( Continued )

Outcomes Primary:Perceived urinary incontinenceSecondary:Quality of life (SF36); constipation; prolapse; satisfaction with sexual life; pelvic pain; vaginal bleeding;postoperative complications; dyspareunia

Notes A later publication compared the effects of interventions on sexual function (Zobbe 2003) Allocation concealment A – Adequate

Study Learman 2003

Methods Randomisation method: Computer generated random numbers sequence in blocks with sealed numberedopaque envelopesNumber of centres: 4Design: parallel groupNo randomised: 135No analysed: 135Drop out at end of follow up: 10% for subtotal hyst and 4% for total hystPower calculation: yesIntention to treat analysis: YesSource of funding: AHRQ Stratied by clinical centre

Participants Inclusion:Premenopausal womenwith symptomatic broidswhohavedecided to undergo abdominalhysterectomyOR premenopausal womenwhohave abnormalbleeding anda minimum 3 month trialof hormonalmanagement who want hysterectomy; if >/= 45 yrs, FSH 50 years; positive pregnancy test; desire for future childbearing; genital tract cancer (known or sus-pected); cervical dysplasia or carcinoma in situ; complex or atypical endometrial hyperplasia; candidate forvaginal hysterectomy; not geographically accessible for 4 yrs.

Age: 41.8 (mean)Source: University gynaecological clinics afliated with 4 universities in USA

Interventions (1) subtotal hysterectomy (2) total abdominal hysterectomy Follow up: 2 yrs

Outcomes Primary:Surgical complications and clinical outcomes: reduction in symptoms; hospital readmissions; rate of com-plications; degree of symptom improvement; activity limitationSecondary:Sexual function and health related quality of life

Notes A later publication compared the effects of the interventions on sexual function and quality of life

Allocation concealment A – Adequate

Study Thakar 2002

Methods Randomisation method:Computer generated numbers and sealed opaque envelopes opened after surgical incision made.No of centres: 2Design: parallel groupBlinding: doubleNo randomised: 279



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No analysed: 279 (only for perioperative outcomes)Dropout at end of follow up: 8% in subtotal group; 14% in total groupPower calculation for sample size: yesIntention to treat analysis: yes, but some data not available for analysis of primary outcomesSource of funding: Responsive Funding Program, Research and Development; NHS Executive; London.

Participants Inclusion: Women offered abdominal hysterectomy for a benign indicationExclusion:>60 years; suspected carcinoma; body weight >100 kg; previous pelvic surgery; known endometriosis; ab-normal cervical smears; symptomatic uterine prolapse; symptomatic urinary incontinence Age: 43-44 (mean)Source: 2 London hospitals in the UK (Jan 1996 to Apr 2000)

Interventions (1) subtotal hysterectomy (2) total abdominal hysterectomy Follow up: 1 yr

Outcomes Primary:Bowel, bladder and sexual functionSecondary:Postoperative complications; intraoperative outcomes and complications; readmission rate; changes in psy-chological outcomes and health status/quality of life

Notes A later publication comparedthe effects ofthe interventions onhealth status/quality of lifeandpsychologicaloutcomes

Allocation concealment A – Adequate

Characteristics of excluded studies

Study Reason for exclusion

Lalos 1986 Baseline characteristics were not similar between groups.

Lyons 1993 Not randomised.

Showstack 2004 Resource use for total and supracervical hysterectomy was compared. These outcomes are not relevant to the review.

A D D I T I O N A L T A B L E S

Table 01. Quality of included studies

Study IDRandomisationmethod

Allocationconcealmt Blinding

Lost to follow up

Powercalculation

Intention totreat

Gimbel 2003 Adequate Adequate None Subtotal: 15%Total: 11%

Yes No

Learman 2003 Adequate Adequate None Subtotal: 10%Total: 4%

Yes Yes

Thakar 2002 Adequate Adequate Double(participants andassessors

Subtotal: 8%Total: 13%

Yes Yes but lossto follow upfor primary outcomes



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Table 01. Quality of included studies ( Continued )

Study IDRandomisationmethod

Allocationconcealmt Blinding

Lost to follow up

Powercalculation

Intention totreat

measured at 1year

Table 02. Summary of ndings

OutcomeNo of participants Control grp risk Risk Ratio

Change inevents

Quality of evidence Comments

Urgeincontinence (12mths)

361 (2 trials) 10.4% 0.97 (0.5 to 1.9) Nil High

Stressincontinence (12mths)

370 (2 trials) 9.7% 1.13 (0.6 to 2.2) Nil High

Satisfaction withsex

129 (1 trial) - - Score: -1 (-8.9 to6.9)

High

Operating time 411 (2 trials) - - -11mins (-16.3to -6.6)

High

Blood loss during surgery

411 (2 trials) - - -85.1mLs(-142.9 to -27.4)

High

Febrile morbidity 687 (3 trials) 12.5% 0.43 (0.25 to0.75)

Nil High

Vaginal bleeding 689 (3 trials) 0.8% 11.3 (4.1 to 31.2) Nil High

Pain (at 1 yr

follow up)

679 (3 trials) 14% 0.92 (0.6 to 1.4) Nil High

Pelvic prolapse 555 (2 trials) 0% 6.5 (0.8 to 54.3) Nil High

A N A L Y S E S

Comparison 01. Subtotal abdominal hysterectomy vs total abdominal hysterectomy

Outcome titleNo. of studies

No. of participants Statistical method Effect size

01 Prevalence of perceived urinary incontinence (always or often)

Odds Ratio (Fixed) 95% CI Subtotals only

02 Prevalence of urge incontinence Odds Ratio (Fixed) 95% CI Subtotals only

03 Prevalence of stressincontinence Odds Ratio (Fixed) 95% CI Subtotals only

04 Prevalence of urinary frequency Odds Ratio (Fixed) 95% CI Subtotals only 05 Prevalence of constipation Odds Ratio (Fixed) 95% CI Subtotals only 07 Satisfaction with sex (at 2 yrs

follow up)1 129 Weighted Mean Difference (Fixed) 95% CI -1.00 [-8.87, 6.87]

08 Sexual problems (at 2 yrs follow up)

1 129 Weighted Mean Difference (Fixed) 95% CI 2.00 [-6.97, 10.97]

09 Prevalence of dyspareunia 2 452 Odds Ratio (Fixed) 95% CI 0.87 [0.46, 1.67]



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10 Change in quality of life (SF36)after 1 year

Other data No numeric data

13 Quality of life - physical (after1-2 yrs)

2 405 Standardised Mean Difference (Fixed) 95% CI -0.07 [-0.26, 0.13]

14 Quality of life - mental (after

1-2 years)

2 405 Standardised Mean Difference (Fixed) 95% CI -0.12 [-0.32, 0.07]

15 Operating time 2 411 Weighted Mean Difference (Fixed) 95% CI -11.41 [-16.25,-6.56]

16 Urinary tract injury 2 408 Odds Ratio (Fixed) 95% CI 0.33 [0.05, 2.10]17 Blood loss during surgery (mL) 2 411 Weighted Mean Difference (Fixed) 95% CI -85.11 [-142.87,

-27.35]18 Pain score Weighted Mean Difference (Fixed) 95% CI Subtotals only 19 Requirement for blood

transfusion2 411 Odds Ratio (Fixed) 95% CI 1.06 [0.45, 2.50]

20 Intra-abdominal haematoma/abscess

2 555 Odds Ratio (Fixed) 95% CI 0.26 [0.06, 1.08]

21 Wound infection 2 555 Odds Ratio (Fixed) 95% CI 0.85 [0.34, 2.09]22 Length of hospital stay (days) 2 411 Weighted Mean Difference (Fixed) 95% CI -0.32 [-0.67, 0.03]23 Return to normal activities

(weeks)1 132 Weighted Mean Difference (Fixed) 95% CI 0.10 [-0.80, 1.00]

24 Febrile morbidity 3 687 Odds Ratio (Fixed) 95% CI 0.43 [0.25, 0.75]25 Ongoing cyclical vaginal

bleeding Odds Ratio (Fixed) 95% CI Subtotals only

26 Persistent pain (after discharge) Odds Ratio (Fixed) 95% CI Subtotals only 27 Bowel obstruction 1 279 Odds Ratio (Fixed) 95% CI 0.22 [0.01, 4.55]28 Prolapse (pelvic) Odds Ratio (Fixed) 95% CI Subtotals only 29 Readmission rate (related to

surgery)Odds Ratio (Fixed) 95% CI Subtotals only

30 Prevalence of gynecologicalcancer

0 0 Odds Ratio (Fixed) 95% CI Not estimable

I N D E X T E R M S

Medical Subject Headings (MeSH)Blood Loss, Surgical; Coitus; Hysterectomy [adverse effects; ∗ methods]; Hysterectomy, Vaginal [adverse effects; methods]; Leiomyoma [∗ surgery]; Menorrhagia [∗ surgery]; Quality of Life; Randomized Controlled Trials; Urination Disorders [etiology]

MeSH check wordsFemale; Humans

C O V E R S H E E T

Title Total versus subtotal hysterectomy for benign gynaecological conditionsAuthors Lethaby A, Ivanova V, Johnson NP

Contribution of author(s) Valeria Ivanova devised the idea for the review and wrote the protocol after discussion withProf Cindy Farquhar. She selected trials for inclusion and, extracted data. Anne Lethaby commented on the protocol and nalised the protocol after peer review. Sheperformed searches for trials, selected trials for inclusion, extracted and entered data and wrote the remaining sections of the review.Neil Johnson commented on the review.



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Issue protocol rst published 2004/4

Review rst published /

Date of most recent amendment 22 February 2006

Date of most recentSUBSTANTIVE amendment

03 February 2006

What’s New Information not supplied by author

Date new studies sought butnone found

Information not supplied by author

Date new studies found but notyet included/excluded


Date new studies found andincluded/excluded


Date authors’ conclusionssection amended


Contact address Ms Anne Lethaby Section of Epidemiology and Biostatistics (Level four)School of Population HealthTamaki Campus, University of AucklandPrivate Bag 92019 AucklandNEW ZEALANDE-mail: [email protected]: +64 9 373 7599Fax: +64 9 373 7503

DOI 10.1002/14651858.CD004993.pub2

Cochrane Library number CD004993

Editorial group Cochrane Menstrual Disorders and Subfertility Group

Editorial group code HM-MENSTR



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G R A P H S A N D O T H E R T A B L E SAnalysis 01.01. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome

01 Prevalence of perceived urinary incontinence (always or often)

Review: Total versus subtotal hysterectomy for benign gynaecological conditions

Comparison: 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy

Outcome: 01 Prevalence of perceived urinary incontinence (always or often)

Study Subtotal Total Odds Ratio (Fixed) Weight Odds Ratio (Fixed)

n/N n/N 95% CI (%) 95% CI

01 At 6 months follow up

Subtotal (95% CI) 0 0 0.0 Not estimable

Total events: 0 (Subtotal), 0 (Total)

Test for heterogeneity: not applicable

Test for overall effect: not applicable


Gimbel 2003 24/136 13/140 100.0 2.09 [ 1.02, 4.31 ]

Subtotal (95% CI) 136 140 100.0 2.09 [ 1.02, 4.31 ]



Test for overall effect z=2.01 p=0.04


Subtotal (95% CI) 0 0 0.0 Not estimable



Test for overall effect: not applicable

0.1 0.2 0.5 1 2 5 10

Favours subtotal Favours total



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Analysis 01.02. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome02 Prevalence of urge incontinence



Outcome: 02 Prevalence of urge incontinence

Study Subtotal Total Odds Ratio (Fixed) Weight Odds Ratio (Fixed)n/N n/N 95% CI (%) 95% CI

01 At 6 months

Thakar 2002 15/117 11/120 100.0 1.46 [ 0.64, 3.32 ]

Subtotal (95% CI) 117 120 100.0 1.46 [ 0.64, 3.32 ]




02 At 12 months

Learman 2003 5/61 5/63 26.9 1.04 [ 0.28, 3.77 ]

Thakar 2002 13/117 14/120 73.1 0.95 [ 0.42, 2.11 ]

Subtotal (95% CI) 178 183 100.0 0.97 [ 0.49, 1.92 ]Total events: 18 (Subtotal), 19 (Total)

Test for heterogeneity chi-square=0.01 df=1 p=0.91 I² =0.0%


03 At 24 months

Learman 2003 4/61 2/64 100.0 2.18 [ 0.38, 12.33 ]

Subtotal (95% CI) 61 64 100.0 2.18 [ 0.38, 12.33 ]




0.1 0.2 0.5 1 2 5 10




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Analysis 01.03. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome03 Prevalence of stress incontinence



Outcome: 03 Prevalence of stress incontinence


01 At 6 months

Thakar 2002 9/129 7/118 100.0 1.19 [ 0.43, 3.30 ]

Subtotal (95% CI) 129 118 100.0 1.19 [ 0.43, 3.30 ]




02 At 12 months

Learman 2003 8/61 6/63 31.9 1.43 [ 0.47, 4.41 ]

Thakar 2002 12/124 12/122 68.1 0.98 [ 0.42, 2.28 ]




03 At 24 months

Learman 2003 8/61 3/64 100.0 3.07 [ 0.77, 12.16 ]

Subtotal (95% CI) 61 64 100.0 3.07 [ 0.77, 12.16 ]




0.1 0.2 0.5 1 2 5 10




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Analysis 01.04. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome04 Prevalence of urinary frequency



Outcome: 04 Prevalence of urinary frequency


01 At 6 months

Thakar 2002 27/119 21/121 100.0 1.40 [ 0.74, 2.64 ]

Subtotal (95% CI) 119 121 100.0 1.40 [ 0.74, 2.64 ]




02 At 12 months

Learman 2003 13/61 9/63 27.7 1.63 [ 0.64, 4.14 ]

Thakar 2002 28/119 24/121 72.3 1.24 [ 0.67, 2.30 ]




03 At 24 months

Learman 2003 10/61 9/64 100.0 1.20 [ 0.45, 3.19 ]

Subtotal (95% CI) 61 64 100.0 1.20 [ 0.45, 3.19 ]




0.1 0.2 0.5 1 2 5 10




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Analysis 01.05. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome05 Prevalence of constipation



Outcome: 05 Prevalence of constipation

Study Subtotal hyst Total hysterectomy Odds Ratio (Fixed) Weight Odds Ratio (Fixed)n/N n/N 95% CI (%) 95% CI

01 At 6 months

Thakar 2002 9/133 14/146 100.0 0.68 [ 0.29, 1.64 ]

Subtotal (95% CI) 133 146 100.0 0.68 [ 0.29, 1.64 ]

Total events: 9 (Subtotal hyst), 14 (Total hysterectomy)



02 At 12 months

Gimbel 2003 27/136 25/140 54.8 1.14 [ 0.62, 2.08 ]

Thakar 2002 7/133 18/146 45.2 0.40 [ 0.16, 0.98 ]

Subtotal (95% CI) 269 286 100.0 0.80 [ 0.49, 1.31 ]Total events: 34 (Subtotal hyst), 43 (Total hysterectomy)



0.1 0.2 0.5 1 2 5 10


Analysis 01.07. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome07 Satisfaction with sex (at 2 yrs follow up)



Outcome: 07 Satisfaction with sex (at 2 yrs follow up)

Study Subtotal Total Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)

N Mean(SD) N Mean(SD) 95% CI (%) 95% CI

Learman 2003 64 72.00 (26.00) 65 73.00 (19.00) 100.0 -1.00 [ -8.87, 6.87 ]

Total (95% CI) 64 65 100.0 -1.00 [ -8.87, 6.87 ]



-10.0 -5.0 0 5.0 10.0

Favours treatment Favours control



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Analysis 01.08. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome08 Sexual problems (at 2 yrs follow up)



Outcome: 08 Sexual problems (at 2 yrs follow up)

Study Subtotal Total Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)


Learman 2003 64 82.00 (26.00) 65 80.00 (26.00) 100.0 2.00 [ -6.97, 10.97 ]

Total (95% CI) 64 65 100.0 2.00 [ -6.97, 10.97 ]



-10.0 -5.0 0 5.0 10.0

Favours total Favours subtotal

Analysis 01.09. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome09 Prevalence of dyspareunia



Outcome: 09 Prevalence of dyspareunia

Study Subtotal Total Odds Ratio (Fixed) Weight Odds Ratio (Fixed)

n/N n/N 95% CI (%) 95% CI

Gimbel 2003 13/137 9/140 40.9 1.53 [ 0.63, 3.70 ]

Thakar 2002 6/91 12/84 59.1 0.42 [ 0.15, 1.19 ]

Total (95% CI) 228 224 100.0 0.87 [ 0.46, 1.67 ]




0.1 0.2 0.5 1 2 5 10


Analysis 01.10. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome10 Change in quality of life (SF36) after 1 year

Change in quality of life (SF36) after 1 yearStudy SF36 Domain Subtotal (mean (SD)) Total (mean (SD)) Stat test results

Thakar 2002 Health perceptionMental healthEnergy Physical functionRole - physicalRole - emotionalSocial function

12 (17)3.4 (14)-0.5 (14)8.7 (23)23 (47)19 (50)

10 (17)2.9 (13)0 (16)5.7 (19)21 (50)6.8 (46)15 (28)

p=0.5p=0.77p=0.79p=0.28p=0.64p=0.04p=0.39



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Change in quality of life (SF36) after 1 year (Continued )

Study SF36 Domain Subtotal (mean (SD)) Total (mean (SD)) Stat test results

Pain 18 (30)-27 (34)

-22 (34)

p=0.26

Analysis 01.13. Comparison 01 Subtotal abdominal hysterectomy vs total abdominal hysterectomy, Outcome13 Quality of life - physical (after 1-2 yrs)



Outcome: 13 Quality of life - physical (after 1-2 yrs)

Study Subtotal Total Standardised Mean Difference (Fixed) Weight Standardised Mean Difference (Fixed)


Gimbel 2003 136 52.92 (8.81) 140 53.78 (8.81) 68.1 -0.10 [ -0.33, 0.14 ]

Learman 2003 64 47.00 (10.00) 65 47.00 (9.00) 31.9 0.00 [ -0.35, 0.35 ]

Total (95% CI) 200 205 100.0 -0.07 [ -0.26, 0.13 ]


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