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At this juncture the authors should be thanked for their critical observations and comments. We have shown that the rate of open hysterectomies can be reduced significantly even at a university training hospital (1). Prof. Dietl criticizes the overall rise in the rate of hysterectomies. The increase in the number of hysterectomies at our hospital is the result of an increase in the total number of cases, not a change in the cases for which it is indicated. In essence, we have demonstrated a shift from abdominal to laparoscopic surgery (1). We have not received any payment from the industry.

Different operating methods are often discussed emotionally by supporters of various schools of surgery. As supporters of the school of vaginal surgery, Dr. Steigerwald, Prof. Dietl and Prof. Nieder demand more vaginal hysterectomies. This is a completely justified demand, but as yet we consider the analysis provided to be not reproducible or evidence-based.

According to the Cochrane meta-analyses conducted in 2006 and 2009, laparoscopic methods have the shortest postoperative recovery phase (return to normal activities) ([12] in the article) (2). The results of two prospective randomized studies show less postoperative pain following laparoscopic hysterectomies than following vaginal hysterectomies (3, 4). However, the available data on major long-term parameters such as prolapse and incontinence are as yet insufficient ([12] in the article) (2). The largest cohort study conducted so far regarding incontinence and prolapse following hysterectomy shows that vaginal hysterectomy is associated in particular with the highest rate of operations for stress incontinence and surgery for prolapse following hysterectomy ([5] and [6] in the article). Is this because of the operating method or the risk factors of patients who underwent vaginal hysterectomies? Data with a reasonable level of evidence do not yet provide the answer to this question.

Dr. Steigerwald mentions the supposedly “long” operating time of vaginal hysterectomies. He seems to be referring to the operating time of the surgery–which is commonly 30 minutes–which is often “felt.” On the one hand, this does not match the facts according to statistical analysis of large cohorts. On the other, a university hospital is obliged to provide training for new doctors; if it did not, it would not deserve to be called a university hospital. Naturally, some of the operations performed at our establishment are for training purposes. Our published operating times for vaginal hysterectomies are completely in line with the published operating times of other university training hospitals in Germany ([e1] in the article) (5).

Other advantages of laparoscopy include better assessment of the abdomen as a whole (not just the adnexa) and the possibility of performing other operations at the same time in patients with multiple prior operations. In our patient satisfaction questionnaires, none of our patients has complained about the small abdominal incisions, the operating time, or the head-down position during surgery.

Discussion of hysterectomy methods remains tense. However, it must be objective and based on arguments supported by studies with appropriate levels of evidence.

DOI: 10.3238/arztebl.2010.0797b

Dr. med. Falk C. Thiel

Dr. med. Stefan P. Renner

Dr. med. Mathias Winkler

Dr. rer. nat. Lothar Häberle

Prof. Dr. med. Matthias W. Beckmann

PD Dr. med. Andreas Müller

Frauenklinik, Universitätsklinikum Erlangen

Universitätsstr. 21–23

91054 Erlangen, Germany

andreas.mueller@uk-erlangen.de

Conflict of interest statement

The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.

1.
Müller A, Thiel FC, Renner SP, Winkler M, Häberle L, Beckmann MW: Hysterectomy—A comparison of approaches. Dtsch Arztebl Int 2010; 107(20): 353–9. VOLLTEXT
2.
Nieboer TE, Johnson N, Lethaby A, et al.: Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009; 8(3): CD003677. MEDLINE
3.
Ghezzi F, Uccella S, Cromi A, et al.: Postoperative pain after laparoscopic and vaginal hysterectomy for benign gynecologic disease: a randomized trial. Am J Obstet Gynecol. 2010 Jun 2. [Epub ahead of print]. MEDLINE
5.
Altgassen C, Michels W, Schneider A, Diedrich K: Wie sicher ist die laparoskopisch assistierte vaginale Hysterektomie? How safe is laparoscopically assisted vaginal hysterectomy? Geburtsh Frauenheilk 2005; 65: 1051–7.
1.Müller A, Thiel FC, Renner SP, Winkler M, Häberle L, Beckmann MW: Hysterectomy—A comparison of approaches. Dtsch Arztebl Int 2010; 107(20): 353–9. VOLLTEXT
2.Nieboer TE, Johnson N, Lethaby A, et al.: Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009; 8(3): CD003677. MEDLINE
3.Ghezzi F, Uccella S, Cromi A, et al.: Postoperative pain after laparoscopic and vaginal hysterectomy for benign gynecologic disease: a randomized trial. Am J Obstet Gynecol. 2010 Jun 2. [Epub ahead of print]. MEDLINE
4.Candiani M, Izzo S, Bulfoni A, Riparini J, Ronzoni S, Marconi A: Laparoscopic vs vaginal hysterectomy for benign pathology. Am J Obstet Gynecol 2009; 200(4): 368 e1–7./ MEDLINE
5.Altgassen C, Michels W, Schneider A, Diedrich K: Wie sicher ist die laparoskopisch assistierte vaginale Hysterektomie? How safe is laparoscopically assisted vaginal hysterectomy? Geburtsh Frauenheilk 2005; 65: 1051–7.

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