Jeppson Peter C, Balgobin Sunil, Rahn David D, Matteson Kristen A, Dieter Alexis A, Ellington David R, Aschkenazi Sarit O, Grimes Cara, Mamik Mamta M, Balk Ethan M, Murphy Miles
University of New Mexico, Albuquerque, New Mexico; the University of Texas Southwestern Medical Center, Dallas, Texas; Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; the University of North Carolina, Chapel Hill, North Carolina; the University of Alabama at Birmingham, Birmingham, Alabama; ProHealth, Waukesha Memorial Hospital, Waukesha, Wisconsin; Columbia University Medical Center and Icahn School of Medicine at Mount Sinai, New York, New York; the Center for Evidence Based Medicine, Brown University School of Public Health, Providence, Rhode Island; and the Institute for Female Pelvic Medicine and Reconstructive Surgery, North Wales, Pennsylvania.
Obstet Gynecol. 2017 May;129(5):877-886. doi: 10.1097/AOG.0000000000001995.
To create evidence-based clinical practice guidelines based on a systematic review of published literature regarding the risks and benefits of available preoperative, intraoperative, and postoperative technical steps and interventions at the time of vaginal hysterectomy for benign indications.
We systematically searched the literature to identify studies that compared technical steps or interventions during the preoperative, intraoperative, and postoperative periods surrounding vaginal hysterectomy. We searched MEDLINE, Cochrane Central Register of Controlled Trials, Health Technology Assessments, and ClinicalTrials.gov from their inception until April 10, 2016, using the MeSH term "Hysterectomy, Vaginal" and associated text words. We included comparative studies, single-group studies, and systematic reviews published in English.
We double-screened 4,250 abstracts, identifying 60 eligible studies. Discrepancies were adjudicated by a third reviewer. We followed standard systematic review methodology and the Grades for Recommendation, Assessment, Development and Evaluation approach to evaluate the evidence and generate guideline recommendations.
TABULATION, INTEGRATION, AND RESULTS: Because of limited literature, only 16 perioperative risks, technical steps, and interventions were identified: obesity, large uteri, prior surgery, gonadotropin-releasing hormone agonists, vaginal antisepsis, bilateral salpingo-oophorectomy, morcellation, apical closure, uterine sealers, hemostatic injectants, hot cone, retractor, cystoscopy, vaginal packing, bladder management, and accustimulation. We organized and reported these as four domains: patient selection, preoperative, intraoperative, and postoperative. We did not identify any patient characteristics precluding a vaginal approach; chlorhexidine or povidone is appropriate for vaginal antisepsis; vasopressin decreases blood loss by 130 cc; tissue-sealing devices decrease blood loss by 44 cc and operative time by 15 minutes with uncertain complication implications; vertical cuff closure results in 1-cm increased vaginal length; either peritoneum or epithelium can be used for colpotomy closure; and routine vaginal packing is not advised.
Minimal data exist to guide surgeons with respect to planning and performing a vaginal hysterectomy. This study identifies available information and future areas for investigation.
基于对已发表文献的系统评价，制定基于证据的临床实践指南，这些文献涉及良性指征阴道子宫切除术术前、术中和术后可用技术步骤及干预措施的风险和益处。
我们系统检索文献，以识别比较阴道子宫切除术围手术期术前、术中和术后技术步骤或干预措施的研究。我们使用医学主题词“阴道子宫切除术”及相关文本词，从MEDLINE、Cochrane对照试验中央注册库、卫生技术评估和ClinicalTrials.gov建库至2016年4月10日进行检索。我们纳入以英文发表的比较研究、单组研究和系统评价。
我们对4250篇摘要进行双盲筛选，确定60项符合条件的研究。分歧由第三位评审员裁决。我们遵循标准的系统评价方法以及推荐分级、评估、制定与评价方法来评估证据并生成指南推荐。
列表、整合与结果：由于文献有限，仅识别出16项围手术期风险、技术步骤和干预措施：肥胖、子宫较大、既往手术史、促性腺激素释放激素激动剂、阴道消毒、双侧输卵管卵巢切除术、碎切术、顶端闭合、子宫封闭剂、止血注射剂、热凝器、牵开器、膀胱镜检查、阴道填塞、膀胱管理和穴位刺激。我们将这些内容组织并报告为四个领域：患者选择、术前、术中和术后。我们未发现任何排除阴道入路的患者特征；洗必泰或聚维酮适用于阴道消毒；血管加压素可减少130毫升失血；组织封闭装置可减少44毫升失血并缩短手术时间15分钟，但并发症影响尚不确定；垂直袖套闭合可使阴道长度增加1厘米；阴道切开术闭合可使用腹膜或上皮；不建议常规进行阴道填塞。
指导外科医生进行阴道子宫切除术规划和操作的数据极少。本研究识别了现有信息及未来的研究领域。
