Article first published online: 22 DEC 2003
BJOG: An International Journal of Obstetrics & Gynaecology
Volume 109, Issue 12, page 1430, December 2002
How to Cite
(2002), Author's Reply. BJOG: An International Journal of Obstetrics & Gynaecology, 109: 1430. doi: 10.1046/j.1471-0528.2002.1007b.x
- Issue published online: 22 DEC 2003
- Article first published online: 22 DEC 2003
I read the letter from Dr Rowlands with interest. It concerns the practical aspects of our study comparing laparoscopic and total abdominal hysterectomy. The aim of the study was not to compare two techniques which would enable oophorectomy to be carried out more easily than at vaginal hysterectomy. Our aim was to compare laparoscopic hysterectomy with abdominal hysterectomy since the former was a new procedure which needed to be validated against standard best practice. Although there are a number of surgeons who perform a lot of vaginal hysterectomies in women where there is no uterine descent, it is still the case that the majority are carried out by the abdominal route, as mentioned in the introduction to the paper. If vaginal hysterectomy had been the treatment of choice in the women in our study, then this would have excluded them.
I agree that the incidence of ureteric damage of 1% does raise concerns as the damage occurred at abdominal hysterectomy and all the surgeons had considerable experience of this procedure. It suggests that the incidence is higher than many people realise or admit.
Although many surgeons have stopped using staple guns because of the cost, this was not the case when we started our study and it was the most widely used technique. I am not aware of any data which suggest that a 12-mm incision will cause more morbidity than either a 10- or 7-mm incision.
I do not think it is a cause for concern that the mean duration of laparoscopic-assisted vaginal hysterectomy was assessed during the study. The surgeons taking part were all experienced and two are considered particularly experienced in laparoscopic surgery. For all the surgeons, the operating time decreased as one would expect. One of the criticisms we received from reviewers was that the study had come five years too late. If the study is delayed too long, then it becomes impossible to recruit women because of personal bias. We timed the study to coincide with a level of expertise in the surgeons in which they felt confident at being able to perform laparoscopic-assisted vaginal hysterectomy. However, with greater experience, it is likely that the operating time will decrease further.
No attempt was made to base the size of the study on economic outcomes. In hindsight, this may have been more appropriate but was not considered at the time of formulating the study. Recent advice has been to compare costs in pragmatic studies on the basis of mean costs. Thomson and Barber (BMJ 2000;320:1197–1120) state that statistical analysis based on transforming data on costs or comparing medians using standard non-parametric methods may provide misleading conclusions.