Vaginal Hysterectomy: A Network Meta-Analysis Comparing Short-Term Outcomes of Surgical Techniques and Devices

Objective: To provide available evidence comparing surgical outcomes of different vaginal hysterectomy (VH) techniques and devices. Data Sources: PubMed, Embase, and ClinicalTrials.gov databases were searched from inception to December 1, 2023, using relevant keywords. Methods of Study Selection: Studies comparing at least 2 surgical techniques and devices for VH were included. An arm-based random effect frequentist network meta-analysis was performed. All available surgical outcomes were evaluated. Tabulation, Integration, and Results: Ten randomized controlled trials and 7 observational studies were eligible reporting on 1577 women undergoing VH with different techniques and devices (50% conventional, 22.5% Ligasure, 17.3% BiClamp, and 9.2% transvaginal natural orifice transluminal endoscopic surgery [vNOTES]). All surgical techniques/devices had a comparable risk ratio (RR) in terms of intraoperative complications, but Clavien-Dindo grade III postoperative complications were significantly reduced in the vNOTES group (RR, 0.15; 95% confidence interval [CI], 0.03–0.82; I2 = 0%) compared with conventional VH. The pooled network analysis showed a lower standard mean deviation for blood loss when comparing energy-based vessel sealing technologies (Ligasure: standard mean deviation, −0.92; 95% CI, −1.47 to −0.37; BiClamp: standard mean deviation, −1.66; 95% CI, −2.77 to −0.55) with conventional VH. Total operative time, postoperative hemoglobin variation, and pain were significantly reduced only in the Ligasure group compared with conventional VH. Bilateral salpingectomy or bilateral salpingo-oophorectomy was most commonly performed in the vNOTES group (RR, 1.9; 95% CI, 1.17–3.10) compared with the conventional VH group. Conclusion: Modern surgical techniques/devices have the potential to improve anatomic exposure and to reduce morbidity of VH. This may drive resurgence of vaginal approach to hysterectomy.