IS THE PROBLEM A PRIORITY? Yes
Research evidence and remarks from the panel
Vaginal hysterectomy is a common surgical procedure estimated to be
needed by at least 11% of women by age 80 years.
It has specific complications. Vaginal packing is often used after
surgery to reduce the number of haemorrhagic (e.g., vaginal
bleeding/hematoma) and infectious (e.g., vaginal cuff abscess)
complications, but this practice is not free from additional
complications.
Although the use and duration of packing have reduced in recent years,
there is still no consensus on its indication or the most appropriate
situations in which it should be used.
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HOW SUBSTANTIAL ARE THE DESIRABLE ANTICIPATED EFFECTS?
Moderate
HOW SUBSTANTIAL ARE THE UNDESIRABLE ANTICIPATED EFFECTS?
Small
Research evidence and remarks from the panel
See TABLE 1. SUMMARY OF FINDINGS FOR THE OUTCOMES OF INTEREST.
The lack of data on important outcomes (e.g., acute urine retention or
hospital stay) requires emphasis. Available data does not show
differences between the intervention and its alternative.
Despite the importance of knowing the impact of the procedure on
hematoma risk, the studies did not report data on its impact or its
associated morbidity (pain, anaemia, vaginal cuff abscess).
Despite some discrepancies between author judgements, we finally
agreed that the magnitude of desired effects was moderate and small
for the undesired effects.
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WHAT IS THE OVERALL CERTAINTY OF THE EVIDENCE OF THE EFFECTS?
Moderate
Research evidence and remarks from the panel
The trials had small sample sizes that directly affected the precision
of their effect estimates.
For vaginal bleeding, the outcome measurement varied between studies,
making interpretation difficult.
The authors decided that the judgements regarding the certainty of the
available evidence should focus on mid-term complications
(specifically, on hematomas).
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IS THERE MAJOR UNCERTAINTY ABOUT OR VARIABILITY IN HOW MUCH
PEOPLE VALUE THE MAIN OUTCOMES? There may be uncertainty or
variability
Research evidence and remarks from the panel
We did not identify relevant studies to inform this domain, but we
anticipated some variability in the value placed by women on the
different outcomes of interest.
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DOES THE BALANCE BETWEEN DESIRED AND UNDESIRED EFFECTS FAVOUR
THE INTERVENTION OR THE COMPARISON? The balance between desired
and undesired effects from the intervention varies
Research evidence and remarks from the panel
We did not reach agreement about this domain: two authors considered
that the balance probably favoured the alternative (not vaginal
packing), two considered that the desired and undesired effects did
not favour either the intervention or the alternative, and the
remainder wanted more data to inform their judgement.
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IS THE INTERVENTION ACCEPTABLE TO KEY STAKEHOLDERS (POPULATION,
PROFESSIONALS)? Probably
Research evidence and remarks from the panel
One trial [Westermann 2016] measured satisfaction and
inconveniencies associated with packing by visual analogue scale
(range, 0–100). Women allocated to the packing group reported high
satisfaction before packing removal (mean ± SD, 81.0 ± 29.0) and
before discharge (90.0 ± 20.0), similar to scores in the control
group.
The discomfort produced by packing during the night was not important
(mean VAS score 18, IQR 81, with one-third of women reporting scores
of 0).
Women reported more discomfort during pack removal (mean VAS score 53,
IQR 57).
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DOES THE COST-EFFECTIVENESS OF THE INTERVENTION FAVOUR THE
INTERVENTION OR THE COMPARISON? Cost-effectiveness probably
favour the intervention
Research evidence and remarks from the panel
We identified no directly relevant studies to inform this domain.
We did obtain indirect data from a case-control study on the
effectiveness of an enhanced recovery after surgery (ERAS) pathway for
vaginal hysterectomy (20) that avoided using vaginal packs and
indwelling catheters after surgery. Comparing 45 women to 45 matched
controls revealed shorter hospitalizations (23.5 versus 42.9 hours)
and lower readmission rates (6.7% versus 0.0%) with the ERAS
pathway. By contrast, women in the ERAS pathway were more likely to
consult for minor symptoms after discharge (15.6% vs. 0%).
Despite the additional costs to implement the ERAS pathway, there was
a 15% saving per patient.
The certainty of the evidence is very low due to the indirectness of
the data for the scope of our clinical question.
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