Hysterectomy or a minimal invasive alternative? A systematic review on quality of life and satisfaction

Nowadays, an increasing number of minimal invasive treatment alternatives to hysterectomy may be offered to the patient. In determining the appropriate treatment option, the patient has a distinct dilemma if a minimal invasive treatment with lesser effect than hysterectomy should be chosen or if a hysterectomy should be chosen which is a major surgery and requires longer recovery than the minimal invasive alternative. Quality-of-life (QoL) questionnaires that take subjective health perception into account are currently used to assess the treatment effects. The objective of this literature study is to determine and discuss the role of QoL as an outcome in randomized controlled trials (RCT) or systematic reviews of RCTs that study the treatment effect of hysterectomy compared to that of minimal invasive alternatives. A systematic literature search was performed in the PubMed database and in the Cochrane database to find randomized trials and systematic reviews of randomized trials, comparing hysterectomy with minimal invasive or conservative treatment options with sufficient follow-up using satisfaction, health status, and quality of life as outcomes. The results were based on nine randomized trials and two systematic reviews. The differences are mostly in favor of hysterectomy. In two out of four studied treatment alternatives, the satisfaction or health status is different in favor of hysterectomy while the QoL is equivalent. After 2 years of follow-up, differences between both groups have disappeared, possibly because of the crossover effect. Possible reasons for the lesser response of QoL compared to satisfaction or health status are discussed. The fundamental question if patients have a better quality of life at all times if they choose for a minimal invasive alternative of hysterectomy remains unresolved. Information, individualization, and freedom of choice before surgery probably best serve the sense of well being and quality of life thereafter.