It is ethically imperative to determine, on the best available evidence, the justification and validation of outcomes before the widespread introduction of new techniques such as LH into routine practice

 There have been 22 RCTs involving 2,950 patients from 12 different countries comparing outcomes of AH and LH since the introduction of LH 25 years ago. Some 21 of these studies reported that LH approach is to be preferred over AH. Attempts to quantify these benefits indicated smaller patient-related advantages than is often supposed, but these were still of sufficient magnitude to justify the widespread preferential use of LH. In addition there have been 11 RCT’s of 1581 patients from 10 countries comparing LH with VH. In 3 of these studies the results were considered comparable, in 1 LH was preferred to VH but in 7/11 studies VH gave better outcomes than LH. These data  suggests that, in certain largely undefined circumstances, VH should be undertaken in preference to LH. More recently 2 RCT’s comparing LH with Robotically Assisted Hysterectomy have demonstrated no patient-related benefits to the newer procedure for simple benign indications

I tried to determine the impact of these data on changes in national rates for different hysterectomy. Combining hysterectomy data from 7 different countries and comparing various hysterectomy rates between 1996-2001 and 2005-2011 the overall proportion of AH fell from 64% to 44%, VH rose slightly from 25% to 29% and LH rose from 11% to 27%. In the US at least 10% of hysterectomies are now being performed by RAH.

This paper asked the question what is the use of data in influencing clinical behavior? The answer would appear to be not as much as we would hope. The data supporting the use of LH is large and clinicians around the world have slowly but progressively included this approach into their clinical repertoire. Those data suggesting that LH should be undertaken only when VH is not indicated is also substantial but has only been taken up in a few countries such as Finland and Denmark and apparently ignored in others such as Taiwan and the UK.  The rapid uptake of Robotic assisted hysterectomy has been even less evidence-based with many cases for benign indications being undertaken without any supportive patient related benefits. The presentation will speculate as to possible reasons for these conflicts between evidence and practice.