Advances on minimally invasive approach for benign total hysterectomy: a systematic review

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It can be performed through several routes, each of which has its advantages and disadvantages. We conducted this systematic review to evaluate recent advances in surgical outcomes of benign total hysterectomies by any route: vaginal (VH), laparoscopic (LH), laparoscopically assisted vaginal (LAVH), single-port (SP), and robotic-assisted laparoscopy (RH). The search was applied to the PubMed electronic database by using keywords “hysterectomy” and “uterine benign disease”, “adenomyosis”, and “myoma”. Prospective and randomized trials of the last 3 years were included. Nine studies were selected and showed that VH was superior to LH, LAVH, and RH in terms of hospital stay and operation time and had the same complication rate and lower costs. SP hysterectomy had no clear advantages over VH or conventional LH." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/6-1295/v1/iparadigms", "name": "Advances on minimally invasive approach for benign total hysterectomy:..." } } ] } Home Browse Advances on minimally invasive approach for benign total hysterectomy:... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Andres MdP, Borrelli GM and Abrão MS. Advances on minimally invasive approach for benign total hysterectomy: a systematic review [version 1; peer review: 2 approved] . F1000Research 2017, 6 (F1000 Faculty Rev):1295 ( https://doi.org/10.12688/f1000research.11523.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Review Advances on minimally invasive approach for benign total hysterectomy: a systematic review [version 1; peer review: 2 approved] Marina de Paula Andres 1 , Giuliano Moysés Borrelli 1 , Mauricio Simões Abrão https://orcid.org/0000-0003-1320-3010 1 Marina de Paula Andres 1 , Giuliano Moysés Borrelli 1 , Mauricio Simões Abrão https://orcid.org/0000-0003-1320-3010 1 PUBLISHED 01 Aug 2017 Author details Author details 1 Endometriosis Section, Gynecology Division, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Hysterectomy is one of the most commonly performed gynecologic surgeries, mainly for uterine myomas, abnormal uterine bleeding, and prolapses. It can be performed through several routes, each of which has its advantages and disadvantages. We conducted this systematic review to evaluate recent advances in surgical outcomes of benign total hysterectomies by any route: vaginal (VH), laparoscopic (LH), laparoscopically assisted vaginal (LAVH), single-port (SP), and robotic-assisted laparoscopy (RH). The search was applied to the PubMed electronic database by using keywords “hysterectomy” and “uterine benign disease”, “adenomyosis”, and “myoma”. Prospective and randomized trials of the last 3 years were included. Nine studies were selected and showed that VH was superior to LH, LAVH, and RH in terms of hospital stay and operation time and had the same complication rate and lower costs. SP hysterectomy had no clear advantages over VH or conventional LH. READ ALL READ LESS Keywords Hysterectomy, Uterine benign diseases, Uterine myoma Corresponding Author(s) Mauricio Simões Abrão ( [email protected] ) Close Corresponding author: Mauricio Simões Abrão Competing interests: The authors declare that they have no competing interests. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2017 Andres MdP et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Andres MdP, Borrelli GM and Abrão MS. Advances on minimally invasive approach for benign total hysterectomy: a systematic review [version 1; peer review: 2 approved] . F1000Research 2017, 6 (F1000 Faculty Rev):1295 ( https://doi.org/10.12688/f1000research.11523.1 ) First published: 01 Aug 2017, 6 (F1000 Faculty Rev):1295 ( https://doi.org/10.12688/f1000research.11523.1 ) Latest published: 01 Aug 2017, 6 (F1000 Faculty Rev):1295 ( https://doi.org/10.12688/f1000research.11523.1 ) Introduction Hysterectomy is one of the most commonly performed gynecologic surgeries, mostly for uterine myomas, abnormal uterine bleeding, and prolapses. It can be performed through several routes: abdominal, vaginal, laparoscopic, and—more recently—robotic-assisted laparoscopy 1 . Advantages in using minimally invasive techniques include a decrease in pain, a short hospital stay, decreased infection and blood loss, and better cosmetics. However, a significant increase in cost is observed when using devices such as robotic-assisted laparoscopy or conventional laparoscopy in comparison with vaginal or abdominal hysterectomy 2 , 3 . Several factors may influence the surgeon’s choice of approach to hysterectomy. Nulliparity, previous surgeries, and suspicion of endometriosis, for example, are usually related to an abdominal or laparoscopic approach, whereas multiparity and uterus with small size and descent are often associated with the vaginal approach. Also, the surgeon’s experience and skills will largely determine the surgical approach to hysterectomy. Because there are several approaches to hysterectomies, technological innovations are often incorporated into the arsenal for surgical treatments. As the last review performed on this topic was in 2014, we sought to conduct this review to evaluate recent advances in surgical treatment, considering the different approaches and outcomes for hysterectomies performed due to benign pathologies, which constitute the majority of indications. Methods Search strategy A thorough search of PubMed/MEDLINE was conducted on the basis of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement 4 . We used the search terms “hysterectomy” and “uterine benign disease”, “adenomyosis”, and “myoma” as keywords to recover all possible publications on this topic at the PubMed database. Strategies for our electronic search at the Medical Subject Headings (MeSH) database were the following combined MeSH terms with details: (((benign[All Fields] AND (“uterine diseases”[MeSH Terms] OR (“uterine”[All Fields] AND “diseases”[All Fields]) OR “uterine diseases”[All Fields] OR (“uterine”[All Fields] AND “disease”[All Fields]) OR “uterine disease”[All Fields])) OR (“myoma”[MeSH Terms] OR “myoma”[All Fields])) OR (“adenomyosis”[MeSH Terms] OR “adenomyosis”[All Fields])) AND (“hysterectomy”[MeSH Terms] OR “hysterectomy”[All Fields]). Two authors (MPA and GMB) independently assessed the studies for inclusion/exclusion, risk of bias, and extracted data. References of articles were also manually reviewed for other relevant articles. Selection criteria and eligibility We included all comparative trials (randomized clinical trials, case-control studies, and prospective cohorts) that assessed outcomes of total hysterectomy by any route: totally vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), laparoscopically assisted VH (LAVH), single-port hysterectomy (SP-H), and robotic hysterectomy (RH). Outcomes were the following: operation time, estimated blood loss, early post-operative pain symptoms (evaluated by visual analogic scale, or VAS), number of post-operative days in hospital, uterine weight, concomitant procedures, and minor complications (fever) and major complications (wound or vaginal cuff infection, blood transfusion, urinary tract injury, bowel injury, or need of re-operation). Data extraction One author abstracted the data into tables (MPA) and a second author (GMB) independently confirmed the accuracy of the data abstraction. Results Study selection Using the search strategy, we identified 2,276 non-duplicate titles, reviewed 97 abstracts and references, and obtained 26 full-text articles for consideration. We excluded 17 of these full-text articles for the following reasons: not comparative studies, study protocols, and articles that did not evaluate the outcomes described ( Figure 1 ). Figure 1. Flow diagram showing the selection of articles for systematic review. Characteristics of studies Nine studies were eligible for inclusion (five randomized clinical trials and four case-control studies) 3 , 5 – 12 . Four of them evaluated VH 3 , 6 – 8 ; four evaluated SP-H 9 – 12 and one was of these was robotic-assisted 12 ; and six included LH 3 , 5 , 7 – 9 , 11 , two of them with the LAVH approach 5 , 8 ( Table 1 ). Studies excluded suspicious or known malignancy, simultaneous need for prolapse surgery, known extensive intra-abdominal adhesion, and uterine volume at more than 16 to 18 weeks of gestation. Table 1. Summary of abstracted data of included studies on hysterectomy. Reference Year Study design Intervention Number Sesti et al . 5 2014 RCT VH versus LH VH versus LAVH 108 Chen et al . 6 2015 RCT Nerve sparing VH versus conventional VH 300 Lönnerfors et al . 3 2015 RCT VH versus LH 122 Bogani et al . 7 2015 Prospective cohort VH versus LH 80 Kovachev et al . 8 2016 Prospective cohort VH versus LAVH 187 Kim et al . 9 2015 RCT SP-LH versus LH 243 Song et al . 10 2015 RCT SP-LH versus SP-LAVH 76 Angioni et al . 11 2015 Case-control SP-LH versus LH 61 Paek et al . 12 2016 Case-control SP-RH versus SP-LH 125 LAVH, laparoscopically assisted vaginal hysterectomy; LH, laparoscopic hysterectomy; RCT, randomized clinical trial; RH, robotic-assisted hysterectomy; SP, single-port; VH, vaginal hysterectomy. Vaginal hysterectomy Four studies evaluated VH and compared it with LH 3 , 5 , 7 or LAVH 5 , 8 ( Table 2 ). Table 2. Surgical outcomes of vaginal hysterectomy (VH) compared with laparoscopic hysterectomy (LH) or laparoscopically assisted vaginal hysterectomy (LAVH). Characteristic Sesti et al . 5 Lönnerfors et al . 3 Bogani et al . 7 Kovachev et al . 8 VH LH LAVH VH LH VH LH VH LAVH Study design RCT RCT Prospective cohort Prospective cohort Number 36 36 36 25 36 40 40 58 129 Uterine weight, g 319.2 ± 107 309.1 ± 88 318.9 ± 100 152 (30–433) 163 (31–694) 80 (30–400) 100 (30–700) 234 ± 68 227 ± 116.5 Pain, n (%) None 17 (47) 19 (53) 5 (14) N/A N/A N/A N/A N/A N/A Mild 10 (28) 11 (30) 22 (62) Moderate 4 (11) 2 (6) 4 (11) Severe 2 (6) 3 (8) 4 (11) Very severe 3 (8) 1 (3) 1 (3) Operation time, min 70 ± 19 a 151 ± 4 a 129.6 ± 47 a 59 (29–118) 104 (54–223) 60 (30–140) 75 (20–305) 68 ± 11.1 b 126 ± 18.2 b Blood loss, mL 182.8 ± 53 a 204 ± 168 a 358.3 ± 67 a 50 b 100 b 100 b 50 b 16 ± 7 b , c 10 ± 5 b , c Minor complications, n (%) 0 0 0 0 0 N/A N/A N/A N/A Major complications, n (%) 0 1 (2.8) 2 (5.5) 5 (20) 7 (19.4) 3 (7) 1 (2) N/A N/A Conversion, n (%) 0 0 0 1 2 1 (2) 1 (2) N/A N/A Time of discharge, days 2.1 ± 1 a 3.2 ± 1.2 a 3.2 ± 1.4 a N/A N/A 2.4 ± 1.2 b 1.7 ± 1.0 b N/A N/A Concomitant procedures, n (%) N/A N/A N/A 4 (19) 27 (75) N/A N/A N/A N/A Pain score evaluated by visual analog scale (VAS) 24 hours post-operatively and was classified as absence of pain (VAS = 0), mild pain (VAS = 1–25), moderate pain (VAS = 26–50), severe pain (VAS = 51–75), and very severe pain (VAS = 76–100). Data are expressed as mean ± standard deviation or mean (range). a P <0.001. b P <0.05. c Drop of hemoglobin concentration (in grams per liter). N/A, data not available; RCT, randomized clinical trial. VH and LH were compared in a total of 213 patients. Operation time was similar in two studies 3 , 7 (59–60 versus 75–104 min) and was significantly lower for VH in one of them 5 (70 versus 151 min; P <0.001). No conversion to laparotomy was observed. Blood loss was significantly lower in the VH group than the LH group in two studies 3 , 5 (50.0–100 versus 182.8–204.0 mL) and significantly higher in one study 7 (100 versus 50 mL; P <0.05). One study 5 compared pain measured 24 hours post-operatively by using VAS between VH and LH. Pain score was classified as absence of pain (VAS = 0), mild pain (VAS = 1–25), moderate pain (VAS = 26–50), severe pain (VAS = 51–75), and very severe pain (VAS = 76–100). No difference was observed between VH and LH groups in pain intensity: none (47 versus 53%), mild (28 versus 30%), moderate (11 versus 6%), severe (6 versus 8%), and very severe (8 versus 3%). There was no difference in rates of major complications (vaginal cuff hematoma, vaginal cuff dehiscence, blood transfusion, port infection, re-admission, or re-operation) between VH and LH groups (8/101, 7.9% versus 9/112, 8.0%). No minor complications were reported. Time of discharge was heterogeneous between studies: Sesti et al . 5 reported faster discharge in the VH group (2.1 ± 1 versus 3.2 ± 1.2 days; P <0.001), whereas Bogani et al . 7 reported faster discharge in the LH group (2.4 ± 1.2 versus 1.7 ± 1.0 days; P <0.05). Two authors 5 , 8 compared a total of 159 patients submitted to VH or LAVH ( Table 2 ). Results showed that VH was superior to LAVH in operation time and duration of hospital stay and had shorter duration of procedure and faster hospital discharge. No difference was observed in post-operative pain symptoms after 24 hours 5 . Blood loss differed between studies: Sesti et al . 5 showed a greater blood loss in LAVH compared with VH, whereas Kovachev et al . 8 showed a greater blood loss in VH. Single-port laparoscopic hysterectomy Four studies 9 – 12 with a total of 505 patients evaluated single-port laparoscopic hysterectomy (SP-LH) ( Table 3 and Table 4 ). Compared with conventional multi-portal LH or LAVH, SP-LH showed no difference in blood loss, conversion, or minor or major complications. Post-operative pain was variable between studies: two of them 10 , 11 showed less pain at 18 to 24 hours after surgery in the SP-LH group (2.3–3.0 versus 3.9–4.0; P <0.05), whereas one author 9 showed no difference (3.0 versus 3.0). Furthermore, Angioni et al . 11 showed an increase in operative time (89.6 versus 67.3 min; P <0.05) in SP-LH but less post-operative pain and shorter length of hospital stay when compared with LH. However, these results were not observed by other authors 9 , 10 . Table 3. Surgical outcomes of single-port laparoscopic hysterectomy (SP-LH) compared with conventional laparoscopic hysterectomy (LH) or conventional laparoscopically assisted vaginal hysterectomy (LAVH). Characteristic Kim et al . 9 Angioni et al . 11 Song et al . 10 SP-LH LH SP-LH LH SP-LH LAVH Study design RCT Case-control RCT Number 122 121 31 30 38 38 Uterine weight, g 280 (65–1,380) 298 (60–750) 259.2 ± 44.7 a 296.8 ± 59.2 a 337.9–150.6 324.7–160.1 Pain, visual analog scale 3 (0–9) 3 (0–9) 2.3 ± 0.5 b 4.0 ± 0.9 b 3.0 ± 0.4 b 3.9 ± 0.8 b Operation time, min 80 69.5 89.6 b 67.3 b 95.8 ± 20.7 95.8 ± 20.7 Blood loss, mL 100 150 63.8 ± 12.5 56.3 ± 11.4 95.8 ± 20.7 95.8 ± 20.7 Minor complications, n (%) 0 1 (0.8) 0 0 3 (8.0) 0 Major complications, n (%) 6 (4.9) 13 (10.3) 1 (3.2) 1 (3.3) 0 0 Conversion, n (%) 5 (4) 1 (0.8) 0 0 5 (13.0) 0 Time of discharge, days 3 (2–7) 3 (2–13) 2.1 ± 0.3 b 2.6 ± 0.6 b 3 (2–5) 3 (2–5) Concomitant procedures, n (%) N/A N/A 5 (16.1) 26 (86.7) 12 (31.0) 11 (29) Pain score evaluated by visual analog scale (0–10) 18 to 24 hours after surgery. Data are expressed as mean ± standard deviation or mean (range). a P <0.05. b P <0.001. N/A, not available; RCT, randomized clinical trial. Table 4. Surgical outcomes of single-port robotic hysterectomy (SP-RH) compared with single-port laparoscopic hysterectomy (SP-LH) and robotic hysterectomy (RH) compared with vaginal hysterectomy (VH). Characteristic Paek et al . 12 Lönnerfors et al . 3 SP-RH SP-LH RH VH Study design Case-control RCT Number 25 100 61 25 Uterine weight, g 271 ± 119 249 ± 190 180 (54–1,114) 163 (31–694) Pain, visual analog scale 3 (2–4) a 4 (2–5) a N/A N/A Operation time, minutes 170.9 ± 65.5 a 88.3 ± 38.4 a 76 (43–210) 59 (29–118) Blood loss, mL 20 b 50 b 50 50 Minor complications, n (%) 0 5 (1.1) 0 0 Major complications, n (%) 0 6 (1.3) 4 (6.6) b 5 (20) b Time discharge, days 3.5 ± 0.7 3.8 ± 1.4 N/A N/A Concomitant procedures N/A N/A 27 (75) 36 (59) Pain score evaluated by visual analog scale (0–10) 12 hours after surgery. Data are expressed as mean ± standard deviation or mean (range). a P <0.001. b P <0.05. N/A, not available; RCT, randomized clinical trial. Robotic hysterectomy Two studies evaluated robotic-assisted laparoscopic hysterectomy for benign pathologies 3 , 12 . Single-port robotic hysterectomy (SP-RH) was compared with SP-LH by Paek et al . 12 in 2016 with a total of 125 patients. Results showed benefits in post-operative pain (evaluated by VAS), operation time, and blood loss in the SP-LH group compared with the SP-RH group. There was no difference in rates of minor (0% versus 1.1%) or major (0% versus 1.3%) complications between the SP-RH and SP-LH groups. Intra-operative blood loss was superior in the SP-LH group (50 versus 20 mL; P <0.05) ( Table 4 ). Lönnerfors et al . 3 included a total of 86 patients submitted to VH or RH ( Table 4 ). Concomitant procedures were performed in 4 (19.0%) of the patients in the VH group and 36 (59.0%) in the RH group ( P =0.47). There was no difference in operation time, blood loss, or conversion to laparotomy between VH or RH. No minor complications were observed. This study reported significantly less major complications (vaginal cuff hematoma, vaginal cuff dehiscence, and port infection) in RH (n=4, 6.6%) compared with VH (n=5, 20.0%; P <0.05). Discussion This systematic review evaluated nine studies from the last 3 years, looking to recent advances and surgical outcomes for total hysterectomy using minimally invasive techniques for benign diseases. Our findings reveal that the oldest technique for uterus removal using the vaginal route remains the preferable option for most indications of benign hysterectomy. Alternatively, LH brings some benefits for some specific cases. We observed that in the last 3 years all randomized and prospective trials were related to minimally invasive techniques. None of them included abdominal hysterectomy (by laparotomy) in the analyses, although this type of procedure is still frequently performed worldwide. In the present review, included studies revealed that VH showed lower operation time and shorter hospital stay compared with LH. Also, although studies have shown different results regarding blood loss during VH compared with LH and LAVH, no significant difference was observed in peri-operative complications with this technique. These results are in agreement with a meta-analysis from 2014 1 , showing that for the same uterus size and vaginal access, VH has the same clinical outcomes as LH or LAVH, has faster recovery and less costs. On the other hand, LH and LAVH offer some advantages when compared with VH, such as the possibility of abdominal exploration. Also, they are preferable in patients with suspicion of adhesions, ovarian cysts/mass, and endometriosis 5 . Single-port laparoscopic surgeries have been recently introduced in order to maximize minimally invasive advantages by reducing the number of incisions to one. In this review, we found controversial results in terms of post-operative pain and length of hospital stay between SP-LH and conventional LH or LAVH. A previous review showed no difference in return to normal activities, major complications, quality of life, and patient satisfaction in SP-LH compared with LH despite a better cosmetic result 1 . Furthermore, single-port is a challenging technique since it is made technically difficult by the clash between instruments, instability of the camera, the limited mobility of straight instruments, and the lack of instrument triangulation 12 . In this sense, robotic surgery has emerged as a feasible option for single-port surgeries, increasing surgical precision, visualization, and ergonomics 12 . We found that in comparison with conventional SP-LH, SP-RH had no advantages in operation time but was related to less post-operative pain. No differences in complication rate were observed. Similarly, there were no advantages in operation time, blood loss, or conversion in multi-portal RH compared with VH. These results are in agreement with previous studies, which showed lack of evidence of RH benefits over other conventional techniques for benign uterine conditions but did show greater costs 1 , 12 , 13 . However, there was one study, by Lim et al. 14 , that estimated the incidence and reasons for conversion to laparotomy in women submitted to LH for benign gynecologic indications. Overall, almost 7,000 women underwent an attempted LH with 3.93% (n=275) converted to laparotomy. After adjusting for intra-operative associated-factors, hysterectomy indication, and socioeconomic differences, the authors observed a decreased odds of conversion to laparotomy with the use of robotic-assisted laparoscopy compared with conventional laparoscopy (adjusted odds ratio 0.14, 95% confidence interval 0.07–0.25) with a predicted risk of conversion of 0.8% compared with 5.4% ( P <0.001) 14 . In summary, updated evidence suggests that for hysterectomy in benign conditions VH is still superior to LH, LAVH, and RH regarding hospital stay and operation time and has the same complication rate and lower costs. Pre-operatively, it is important to consider possible contraindications for the vaginal route as discussed in the present review. SP-H performed by either laparoscopy or robotic-assisted laparoscopy emerged as a novel minimally invasive technique, but according to the available data, it currently has no clear advantages compared with VH or conventional LH. This updated information, despite all of the advances in technologies and surgical equipment, brings up advantages of one of the oldest approaches for uterus removal, VH. Limitations of this review include the studies’ heterogeneity, imprecision of results of included studies, and inadequate report of outcomes. (For example, some studies did not include information regarding concomitant procedures and time of discharge; other studies did not report outcomes on pain using the VAS, making it impossible to compare them with studies that performed this evaluation.) Certainly, more prospective studies, preferably randomized clinical trials, are still required to compare all aspects of the different routes for benign hysterectomy, including new advances and technologies such as SP-RH. Competing interests The authors declare that they have no competing interests. Grant information The author(s) declared that no grants were involved in supporting this work. Faculty Opinions recommended References 1. Aarts JW, Nieboer TE, Johnson N, et al. : Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015; (8): CD003677. PubMed Abstract | Publisher Full Text | Faculty Opinions Recommendation 2. Albright BB, Witte T, Tofte AN, et al. : Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials. J Minim Invasive Gynecol. 2016; 23 (1): 18–27. PubMed Abstract | Publisher Full Text | Free Full Text | Faculty Opinions Recommendation 3. Lönnerfors C, Reynisson P, Persson J: A randomized trial comparing vaginal and laparoscopic hysterectomy vs robot-assisted hysterectomy. J Minim Invasive Gynecol. 2015; 22 (1): 78–86. PubMed Abstract | Publisher Full Text | Faculty Opinions Recommendation 4. Moher D, Shamseer L, Clarke M, et al. : Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4 (1): 1. PubMed Abstract | Publisher Full Text | Free Full Text 5. Sesti F, Cosi V, Calonzi F, et al. : Randomized comparison of total laparoscopic, laparoscopically assisted vaginal and vaginal hysterectomies for myomatous uteri. Arch Gynecol Obstet. 2014; 290 (3): 485–91. PubMed Abstract | Publisher Full Text | Faculty Opinions Recommendation 6. Chen L, Liu M, Huang X, et al. : A Modified Nerve-Sparing Panhysterectomy for Benign Uterine Diseases: Techniques and Evaluation of Postoperative Pelvic Dysfunctions. Gynecol Obstet Invest. 2015; 80 (1): 38–45. PubMed Abstract | Publisher Full Text | Faculty Opinions Recommendation 7. Bogani G, Cromi A, Uccella S, et al. : Laparoscopic versus vaginal hysterectomy for benign indications in women aged 65 years or older: propensity-matched analysis. Menopause. 2015; 22 (1): 32–5. PubMed Abstract | Publisher Full Text | Faculty Opinions Recommendation 8. Kovachev S, Ganovska A, Stankova T: [COMPARISON OF LAPAROSCOPIC ASSISTED VAGINAL HYSTERECTOMY AND VAGINAL HYSTERECTOMY FOR BENIGN DISEASES AND LESIONS OF THE FEMALE GENITAL SYSTEM]. Akush Ginekol (Sofiia). 2016; 55 Suppl 1 Pt 1 : 4–10. PubMed Abstract | Faculty Opinions Recommendation 9. Kim TJ, Shin SJ, Kim TH, et al. : Multi-institution, Prospective, Randomized Trial to Compare the Success Rates of Single-port Versus Multiport Laparoscopic Hysterectomy for the Treatment of Uterine Myoma or Adenomyosis. J Minim Invasive Gynecol. 2015; 22 (5): 785–91. PubMed Abstract | Publisher Full Text | Faculty Opinions Recommendation 10. Song T, Kim MK, Kim ML, et al. : A Randomized Comparison of Laparoendoscopic Single-Site Hysterectomies: Total Laparoscopic Hysterectomy Versus Laparoscopically Assisted Vaginal Hysterectomy. J Laparoendosc Adv Surg Tech A. 2015; 25 (7): 541–7. PubMed Abstract | Publisher Full Text | Faculty Opinions Recommendation 11. Angioni S, Pontis A, Pisanu A, et al. : Single-port Access Subtotal Laparoscopic Hysterectomy: A Prospective Case-Control Study. J Minim Invasive Gynecol. 2015; 22 (5): 807–12. PubMed Abstract | Publisher Full Text | Faculty Opinions Recommendation 12. Paek J, Lee JD, Kong TW, et al. : Robotic single-site versus laparoendoscopic single-site hysterectomy: a propensity score matching study. Surg Endosc. 2016; 30 (3): 1043–50. PubMed Abstract | Publisher Full Text | Free Full Text | Faculty Opinions Recommendation 13. Munro MG: The Surgical “Robot” in Benign Gynecology: Surgical Advance or a Set of Costly Training Wheels? J Minim Invasive Gynecol. 2016; 23 (1): 1–4. PubMed Abstract | Publisher Full Text 14. Lim CS, Mowers EL, Mahnert N, et al. : Risk Factors and Outcomes for Conversion to Laparotomy of Laparoscopic Hysterectomy in Benign Gynecology. Obstet Gynecol. 2016; 128 (6): 1295–305. PubMed Abstract | Publisher Full Text | Faculty Opinions Recommendation Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 01 Aug 2017 ADD YOUR COMMENT Comment Author details Author details 1 Endometriosis Section, Gynecology Division, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil Competing interests The authors declare that they have no competing interests. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 01 Aug 2017, 6:1295 https://doi.org/10.12688/f1000research.11523.1 Copyright © 2017 Andres MdP et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Andres MdP, Borrelli GM and Abrão MS. Advances on minimally invasive approach for benign total hysterectomy: a systematic review [version 1; peer review: 2 approved] . F1000Research 2017, 6 (F1000 Faculty Rev):1295 ( https://doi.org/10.12688/f1000research.11523.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Editorial Note on the Review Process Faculty Reviews are review articles written by the prestigious Members of Faculty Opinions . The articles are commissioned and peer reviewed before publication to ensure that the final, published version is comprehensive and accessible. The reviewers who approved the final version are listed with their names and affiliations. Reviewers who approved this article Sawsan As-Sanie , Department of Obstetrics and Gynecology, University of Michigan, USA Competing interests: No competing interests were declared. (for version 1) Francisco Carmona , Department of Gynecology, Hospital Clínic of Barcelona, Spain Competing interests: No competing interests were declared. (for version 1) Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 01 Aug 2017 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 01 Aug 17 Faculty Reviews are review articles written by the prestigious Members of Faculty Opinions . The articles are commissioned and peer reviewed before publication to ensure that the final, published version is comprehensive and accessible. The reviewers who approved the final version are listed with their names and affiliations. Sawsan As-Sanie , Department of Obstetrics and Gynecology, University of Michigan, USA Competing interests: No competing interests were declared. View more View less Francisco Carmona , Department of Gynecology, Hospital Clínic of Barcelona, Spain Competing interests: No competing interests were declared. 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