The assessment of surgical quality is complex and an adequate case-mix correction is missing in currently applied quality indicators. The purpose of this study is to give an overview of all studies mentioning statistically significant associations between patient characteristics and surgical outcomes for laparoscopic hysterectomy (LH). Additionally we identified a set of potential case-mix characteristics for LH. This systematic review was conducted according to the MOOSE guidelines. We searched PubMed and EMBASE from 1(st) of January 2000 up to the 1(st) of August 2015.All articles describing statistical significant associations between patient characteristics and adverse outcomes of LH for benign indications were included. As primary outcomes were included blood loss, operative time, conversion and complications. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale (NO-QAS). The included articles were summed per predictor and surgical outcome. Three sets of case-mix characteristics were determined, stratified by different levels of evidence. Eighty-five of 1.549 identified studies were considered eligible. Uterine weight and BMI are the most mentioned predictors (respectively 83 and 45 times described in the papers) of high quality studies. For longer operative time and higher blood loss uterine weight ≥ 250-300g and ≥ 500g and BMI ≥30 kg/m² dominate as predictors. Previous operations, adhesions and higher age are also considered as predictors for longer operative time. For complications and conversions, the patient characteristics vary widely and uterine weight, BMI, previous operations, adhesions and age predominated. Studies of high methodological quality indicated uterine weight and BMI as relevant case-mix characteristics for all surgical outcomes. For future development of quality indicators of LH and in order to compare surgical outcomes adequately, a case-mix correction is suggested for at least uterine weight and BMI. A potential case-mix correction for adhesions and previous operations can be considered. For both surgeon and patient it is valuable to be aware of potential factors predicting adverse outcomes and to anticipate on this. Finally, to benchmark clinical outcomes at international level it is of highest importance to introduce uniform outcome definitions.
ZIEL: Um die am besten geeignete chirurgische Verfahren der Hysterektomie (Bauch-, Vaginal-oder laparoskopische) für Frauen mit gutartigen Erkrankungen zu evaluieren.
DESIGN: Systematischer Review und Meta-Analyse.
Datenquellen: Cochrane Menstruationsstörungen und Subfertilität Gruppe Trials Register, Cochrane Zentralregister Controlled Trials, Medline, Embase und Biological Abstracts.
AUSWAHL DER STUDIEN: nur randomisierte kontrollierte Studien wurden ausgewählt; Teilnehmer mussten gutartige gynäkologische Erkrankung haben; Interventionen musste mindestens eine Hysterektomie Verfahren im Vergleich mit einem anderen umfassen, und Studien mussten primären Endpunkte berichten (Zeit, um zu normalen Aktivitäten zurückkehren, intraoperative viszeralen Verletzungen, und die wichtigsten langfristigen Komplikationen) oder sekundäre Endpunkte (Betriebszeit, anderen unmittelbaren Komplikationen der Operation, Kurzzeit-Komplikationen, und die Dauer des Krankenhausaufenthaltes).
Ergebnisse: 27 Studien (insgesamt 3643 Teilnehmer) wurden eingeschlossen. Rückkehr zu normalen Aktivitäten war schneller als nach vaginaler nach abdominalen Hysterektomie (gewichtete mittlere Differenz 9,5 (95% Konfidenzintervall 6,4-12,6) Tage) und nach laparoskopischer als nach abdominalen Hysterektomie (Differenz 13,6 (11,8-15,4) Tage), aber nicht signifikant verschiedenen für die laparoskopische gegen vaginale Hysterektomie (Differenz -1,1 (-4,2 bis 2,1) Tage). Es waren mehr Harnwege Verletzungen mit der laparoskopischen als mit abdominalen Hysterektomie (Odds Ratio 2,61 (95%-Konfidenzintervall 1,22-5,60)), aber keine anderen intraoperative viszerale Verletzungen zeigte einen signifikanten Unterschied zwischen chirurgische Ansätze. Die Daten wurden für viele wichtige langfristigen Behandlungserfolg Maßnahmen, wo die Analysen wurden zu schwach, um wichtige Unterschiede zu erkennen, oder sie wurden einfach nicht in Studien berichtet vor allem fehlt.
FAZIT: Deutlich schnellere Rückkehr zu normalen Aktivitäten und andere verbesserte sekundäre Endpunkte (kürzere Dauer des Krankenhausaufenthaltes und weniger nicht näher bezeichnet Infektionen oder Fieberepisoden) legen nahe, dass vaginale Hysterektomie ist vorzuziehen, abdominale Hysterektomie, wo möglich. Wobei vaginale Hysterektomie nicht möglich ist, ist die laparoskopische Hysterektomie bevorzugt, abdominale Hysterektomie, obwohl es bringt eine höhere Chance, Blase oder Harnleiter Verletzung.
The assessment of surgical quality is complex and an adequate case-mix correction is missing in currently applied quality indicators. The purpose of this study is to give an overview of all studies mentioning statistically significant associations between patient characteristics and surgical outcomes for laparoscopic hysterectomy (LH). Additionally we identified a set of potential case-mix characteristics for LH. This systematic review was conducted according to the MOOSE guidelines. We searched PubMed and EMBASE from 1(st) of January 2000 up to the 1(st) of August 2015.All articles describing statistical significant associations between patient characteristics and adverse outcomes of LH for benign indications were included. As primary outcomes were included blood loss, operative time, conversion and complications. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale (NO-QAS). The included articles were summed per predictor and surgical outcome. Three sets of case-mix characteristics were determined, stratified by different levels of evidence. Eighty-five of 1.549 identified studies were considered eligible. Uterine weight and BMI are the most mentioned predictors (respectively 83 and 45 times described in the papers) of high quality studies. For longer operative time and higher blood loss uterine weight ≥ 250-300g and ≥ 500g and BMI ≥30 kg/m² dominate as predictors. Previous operations, adhesions and higher age are also considered as predictors for longer operative time. For complications and conversions, the patient characteristics vary widely and uterine weight, BMI, previous operations, adhesions and age predominated. Studies of high methodological quality indicated uterine weight and BMI as relevant case-mix characteristics for all surgical outcomes. For future development of quality indicators of LH and in order to compare surgical outcomes adequately, a case-mix correction is suggested for at least uterine weight and BMI. A potential case-mix correction for adhesions and previous operations can be considered. For both surgeon and patient it is valuable to be aware of potential factors predicting adverse outcomes and to anticipate on this. Finally, to benchmark clinical outcomes at international level it is of highest importance to introduce uniform outcome definitions.
