Randomized controlled trial on nondescent vaginal hysterectomy and total laparoscopic hysterectomy versus total abdominal hysterectomy: A cost-effectiveness analysis

Aim and objective: Hysterectomy is the commonest major gynecological procedure. There is little information from randomized controlled trials (RCTs) in low-resource settings. Therefore, the aim was to study outcomes and cost-effectiveness of nondescent vaginal hysterectomy (NDVH) and total laparoscopic hysterectomy (TLH) versus total abdominal hysterectomy (TAH). Materials and methods: A pragmatic multicenter three-arm (49 per arm) RCT was done on patients needing hysterectomy for benign uterine causes. Exclusion criteria were uterus larger than 14 weeks, previous pelvic surgery, any medical illness that contraindicated laparoscopy, and any patient requiring surgery for incontinence or uterovaginal prolapse. The main clinical outcome measure was time to recover. Incremental cost-effectiveness ratios (ICERs) were calculated for NDVH and TLH. Cost-effectiveness acceptability curves of NDVH and TLH were formulated. Results: There was no significant difference in time to recover [median (inter-quartile range) days] [TAH, 35 (30–45) days; NDVH, 32 (24–60) days; and TLH, 30 (26–45) days, p = 0.89]. The direct cost (USD) of TAH [659 (632–687)] was significantly lower compared to NDVH [800 (622–1116)] and TLH [752 (719–795)] (p = 0.03). The ICERNDVH showed TAH was dominant. ICERTLH was 11 USD/day. Worst-case scenario ICERs showed that TAH was dominant. NDVH and TLH were dominant to TAH in the best-case scenario. The probability of cost-effectiveness (threshold of 3 USD/day) was 1.15 versus 0% in the study setting, 0.2 versus 0% in the worst-case scenario, and 76.1 versus 79% in the best-case scenario for NDVH and TLH, respectively. Conclusion: The main clinical outcome, time to recover, showed an insignificant difference between TAH, NDVH, and TLH. However, when considering cost-effectiveness, TAH is likely to be the cost-effective method for the generalist, while the alternate routes NDVH and TLH are likely to be cost-effective in specialized centers.