Abdominal Hysterectomy

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Summary Recommendations The recommendations of the PROSPECT Working Group are graded A–D, based on the level of evidence from the studies, which is in accordance with the Oxford Centre for Evidence-Based Medicine (CEBM website accessed Dec 2003, Sackett 2000). In the context of PROSPECT, recommendations based on procedure-specific evidence are grade A (randomised clinical trials), those based on transferable evidence are grade B (randomised clinical trials) or grade C (retrospective studies or case series) and those based on clinical practice are grade D. (Click here for further information on levels of evidence and grades of recommendation) PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted. The following pre-, intra- and postoperative interventions have been evaluated for the management of postoperative pain following abdominal hysterectomy: Pre-operative Recommended:
  • Single-dose spinal local anaesthetic plus strong opioid, for anaesthetic (grade D) and postoperative analgesic purposes (grade A), but the benefits must be weighed against the risks of the invasive nature of the procedure
  • Cognitive intervention (grade A)
Not recommended:
  • Systemic analgesics (e.g. IV COX-2 inhibitors, conventional NSAIDs, strong opioids), except to secure sufficient analgesia when the patient wakes up (e.g. oral COX-2 inhibitors) (grade A)
  • Clonidine, NMDA-receptor antagonists and benzodiazepines (grade A)
  • Epidural single dose for postoperative analgesia (grade A)
  • Local anaesthetic skin infiltration at the proposed site of incision (grade A) (but intra-operative wound infiltration is recommended, see below)
  • Homeopathic arnica and self-relaxation techniques (grade A)
Intra-operative Recommended:  
  • General anaesthesia, or single dose spinal anaesthesia with or without light general anaesthesia in low-risk patients (grade D)
  • Epidural anaesthesia combined with light general anaesthesia or combined spinal-epidural anaesthesia, in high-risk patients (grade A)
  • Strong opioids administered in enough time to secure sufficient analgesia when the patient wakes (grade A)
  • Wound infiltration before closure (grade A)
  • LAVH or VH rather than abdominal hysterectomy, only if allowed by the surgical requirements (based on technical feasibility, patient indication for hysterectomy and risk factors) (grade A)
  • Pfannenstiel incision, only if allowed by the surgical requirements (based on technical feasibility, patient indication for hysterectomy and risk factors) (grade B)
  • Diathermy incision (grade B)
  • Active patient warming in high-risk patients (grade A)
  • Intra-operative music (grade A)
Not recommended:
  • Epidural single dose for postoperative analgesia (grade A)
  • Adenosine, NMDA-receptor antagonists, benzodiazepines or tryptophan (all grade A)
  • Intraperitoneal analgesia (grade A)
  • Unsutured peritoneum, wet film dressing (both grade A) or surgical drains (grade D)
  • Therapeutic suggestions or electroacupuncture (both grade A)
Postoperative Recommended:  
  • COX-2 selective inhibitors or conventional NSAIDs, in combination with strong opioids for high-intensity pain (VAS=50) or with weak opioids for moderate- (VAS<50>30) or low-intensity pain (VAS=30) (grade A)
  • Strong opioids by IV PCA or by fixed IV dosing titrated to pain intensity (grade A)
  • Paracetamol for moderate- (VAS>30<50) or low-intensity (VAS=30) pain, in combination with COX-2 inhibitors or conventional NSAIDs (grade A)
  • Epidural analgesia in high-risk patients (grade A and D)
Not recommended:
  • Epidural analgesia for routine use in low-risk patients (grade D)
  • Repeat spinal boluses of analgesic (grade D)
  • Concomitant administration of COX-2 selective inhibitors or conventional NSAIDs with epidural analgesia (grade B)
  • Continuous infusion of strong opioid during PCA bolus dosing (grade D)
  • IM administration of strong opioids (grade D)
  • Intra-nasal, slow-release oral and transdermal patch administration of strong opioids (grade D)
  • Paracetamol for high-intensity pain (VAS=50 mm) (grade B)
  • NMDA-receptor antagonists and benzodiazepines (both grade A)
  • Clonidine, pentazocine, clomipramine, delta-9-tetrahydrocannabinol and naloxone (all grade A)
  • Continuous wound infiltration of local anaesthetics after closure (grade A) (although pre-closure wound infiltration is recommended, see above)
  • Music in PACU, homeopathic arnica or self-relaxation techniques (all grade A)
See Overall PROSPECT Recommendations  for the overall strategy for managing pain after abdominal hysterectomy  
Overall PROSPECT Recommendations

Click here for Algorithm for the management of postoperative pain

This algorithm for managing postoperative pain is based on the PROSPECT recommendations and illustrates the different treatment pathways for low-  ¢ and high-  ¢ risk patients, as well as describing the steps of the peri-operative pathway/therapies that apply to all patients ¢. Therapies that are not recommend are also indicated. a Low-risk patients are otherwise healthy patients who are not considered to be at a higher risk than is typically associated with anaesthetic or analgesic agents b High-risk patients are those considered to be at a high risk of adverse effects from inhalation anaesthetics and high-dose opioids, e.g. those at risk of organ dysfunction or undergoing extensive surgery for malignancy.  

Description of studies 

Literature search

Explanation for the focus on abdominal over vaginal hysterectomy

  • The significant majority of studies found in the literature search were in abdominal hysterectomy, with the exception of: 
  • The studies showed that LAVH is associated with significantly lower postoperative pain scores than abdominal hysterectomy: meta-analyses showed a reduction of up to 29 mm at 48 h on a 100-mm VAS (p<0.00001) (see Operative Techniques section)
  • In light of the different pain profiles for LAVH and abdominal hysterectomy, and the absence of studies in LAVH, these procedures will be assessed separately, and an analysis of analgesia for controlling postoperative pain in LAVH conducted when more studies are available  

Transferable evidence
As for all of the procedures in PROSPECT, abdominal hysterectomy-specific evidence was supplemented with transferable evidence, the majority of which was from other major gynaecological and abdominal procedures.  

PROSPECT Recommendations

  • A recommendation of anaesthetic choice based on postoperative analgesic effect cannot be made for abdominal hysterectomy, because there is no evidence for the comparative benefits of different anaesthetic techniques in reducing postoperative pain. Moreover, anaesthetic choice should be based on factors other than the management of postoperative pain, including individual patient risk factors and local practice (Grade D)
  • General anaesthesia or single shot spinal anaesthesia with or without sedation is recommended for routine use in abdominal hysterectomy, but the continuous epidural catheter technique is not recommended for routine use, based on the relative risks and benefits of these techniques in this patient population (grade D)
  • Continuous epidural with or without a light general anaesthetic or combined epidural-spinal anaesthesia is recommended over general anaesthesia alone in high-risk patients, e.g. those at risk of organ dysfunction and some patients undergoing extensive surgery for malignancy. In these high-risk patients, the benefits of neuraxial anaesthesia (e.g. reduction in inhalation anaesthetics and opioid use as well as reduced paralytic ileus and improved pulmonary function) outweigh the risks. In these pa

Clinical Practice

  • The continuous epidural technique produces a less profound block than spinal anaesthesia and takes a longer time to perform as well as conveying a higher risk of rare complications such as epidural haematoma

Transferable Evidence from Other Procedures

  • Inhaled anaesthesia was similar to combined nitrous oxide/propofol anaesthesia for postoperative pain scores, supplementary analgesic consumption and time to recovery from anaesthetic in patients undergoing laparoscopic hysterectomy Nelskyla et al 1997 Click here for more information
  • Epidural and spinal anaesthesia are not significantly different for: the need for postoperative pain relief, anaesthetic failure rate, need for additional intra-operative analgesia, need for conversion to general anaesthesia, maternal satisfaction and the need for neonatal intervention as determined in a systematic review of caesarean section Ng et al 2004
  • Combined spinal-epidural anaesthesia has a higher postoperative analgesic efficacy than epidural anaesthesia alone Lew et al 2004 Click here for more information

Abdominal Hysterectomy-Specific Evidence - Study information

  • Combined general-epidural anaesthetic was superior to general anaesthetic alone for reducing postoperative pain scores in two studies, and one study showed greater postoperative benefits with an additional epidural bolus at closure Jorgensen et al 2001 Click here for more information
  • Combined general-epidural anaesthetic plus epidural at closure was superior to general anaesthetic alone and to combined general-epidural anaesthesia alone for reducing supplementary analgesic consumption Jorgensen et al 2001 Click here for more information
  • General plus epidural anaesthesia was superior to spinal plus epidural anaesthesia for reducing postoperative pain scores at rest (p=0.026) and on movement (p<0.001; n=40) within 0–72 h Callesen et al 1999
  • General plus epidural anaesthesia was superior to spinal plus epidural anaesthesia for reducing postoperative supplementary opioid consumption from PACU-72 h (p<0.05; n=40) Callesen et al 1999
  • Spinal plus epidural was associated with a significantly lower incidence of nausea (p<0.0001) and vomiting (p<0.002) than general plus epidural anaesthesia within 0–72 h (n=40) Callesen et al 1999

PROSPECT Recommendations

  • Intra-operative strong opioids are recommended for the treatment of postoperative pain in hysterectomy based on their analgesic efficacy in the early postoperative period (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

PROSPECT Recommendations

  • Intra-operative adenosine is not recommended based on limited evidence of its analgesic efficacy (grade A) and a lack of clinical experience with this agent (grade D)
  • Intra-operative NMDA-receptor antagonists are not recommended based on inconsistent evidence of their analgesic efficacy and effect on reducing PONV (grade A), as well as a lack of clinical understanding of these agents
  • Intra-operative benzodiazepines are not recommended based on limited evidence for their analgesic efficacy (grade A)
  • Intra-operative tryptophan is not recommended based on a lack of analgesic efficacy (grade A)

Clinical Practice

  • Adenosine and tryptophan are not used routinely because of a lack of clinical experience with these agents
  • NMDA-receptor antagonists are not used routinely because of the current lack of understanding of their optimum dose, rate and route of administration as well as their cost-benefit relationship; in addition, they are associated with adverse side-effects, e.g. ketamine is known for its toxicity and for causing dysphoria

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence

PROSPECT Recommendations

  • Intra-operative administration of single dose epidural analgesia, in addition to anaesthesia, is not recommended for the treatment of postoperative pain based on evidence of a limited duration of effect in reducing postoperative pain and a lack of benefit in reducing supplementary analgesic consumption (grade A)
  • A recommendation cannot be made for epidural anaesthesia based on its postoperative analgesic effects because there is no evidence for its relative postoperative analgesic benefits compared with other methods of anaesthesia. Moreover, the choice of anaesthetic regimen should be based on anaesthetic requirement and the relative risks and benefits of the anaesthetic related to the patient and the surgical procedure (grade D) (See Anaesthetic techniques section)

Clinical Practice

  • Epidural analgesia is associated with a relatively high degree of patient monitoring and rare major complications
  • Epidural clonidine is not used routinely because it is associated with an increased risk of hypotension, sedation and bradycardia

Transferable Evidence from Other Procedures

  • Epidural and spinal anaesthesia were not significantly different for: the need for postoperative pain relief, anaesthetic failure rate, need for additional intra-operative analgesia, need for conversion to general anaesthesia, and maternal satisfaction in a systematic review of caesarean section Ng et al 2004

Abdominal Hysterectomy-Specific Evidence - Study information

  • Intra-operative epidural morphine, with or without postoperative epidural boluses, provided a significant benefit over epidural saline placebo in reducing postoperative pain scores at 6 h, but the results at 12 and 24 h were not significant Jorgensen et al 1982 Click here for more information
  • Intra-operative epidural morphine extended the time to first analgesic request in one study (p<0.05; n=14) Jorgensen et al 1982
  • Intra-operative epidural clonidine provided a significant benefit over placebo in reducing postoperative pain scores on cough and mobilisation at 4–12 h (p<0.05 for all times; n=22) Mogensen et al 1992a
  • Intra-operative epidural ketamine conferred a significant benefit over placebo for reducing the supplementary analgesic consumption within 0–4 (p<0.05), 0–8, 0–12 and 0–24 h (p<0.001), but at 0–1 and 0–2 h the results were not significant (n=40) Abdel-Ghaffar et al 1998
  • Intra-operative ketamine conferred a significant benefit over placebo for extending the time to first analgesic request (p<0.01; n=40) Abdel-Ghaffar et al 1998
  • Combined general-epidural anaesthetic plus epidural at closure was superior to general anaesthetic alone and to combined general-epidural anaesthetic alone for reducing postoperative pain Jorgensen et al 2001 Click here for more information
  • Combined general-epidural anaesthetic plus epidural at closure was superior to general anaesthetic alone and to combined general-epidural anaesthetic alone for reducing supplementary analgesic consumption Jorgensen et al 2001 Click here for more information
  • Intra-operative epidural morphine plus postoperative IV morphine was associated with a similar incidence of PONV as placebo plus IV morphine in one study (n=14) Jorgensen et al 1982
  • Intra-operative epidural morphine provided no significant benefit over placebo for reducing supplementary analgesic consumption within 0–24 h Jorgensen et al 1982 Click here for more information
  • Intra-operative epidural bupivacaine plus fentanyl conferred no significant benefit over placebo for reducing postoperative pain scores within 0–48 h in one study (n=50) Richards et al 1998
  • Intra-operative epidural bupivacaine plus fentanyl conferred no significant benefit over placebo for reducing supplementary analgesic consumption within 0–48 h in one study (n=50) Richards et al 1998
  • Intra-operative epidural clonidine provided no significant benefit over placebo in reducing postoperative pain scores at rest (n=22; n=40) Mogensen et al 1992a
  • Intra-operative epidural clonidine was associated with a significant decrease in arterial blood pressure compared with placebo in two studies (p<0.05 for both; n=40; n=22) Mogensen et al 1992a
  • Intra-operative epidural ketamine conferred no significant benefit over placebo for reducing postoperative pain scores within 0–24 h (n=40) Abdel-Ghaffar et al 1998
  • Intra-operative epidural neostigmine conferred no significant benefit for reducing postoperative pain scores or supplementary analgesic consumption within 0–24 h (n=45) Nakayama et al 2001a

PROSPECT Recommendations

  • Intra-operative wound infiltration is recommended based on specific evidence that it reduces pain following hysterectomy at 8 h (grade A). Although this outcome did not reach clinical significance, this method of analgesia is convenient and has a favourable safety profile Gallagher et al 2001 Click here for more information

Clinical Practice

  • Intra-operative wound infiltration is a well-established method of analgesia with a favourable safety profile

Transferable Evidence from Other Procedures

  • Intra-operative wound infiltration with local anaesthetic was superior to pre-incisional administration, which in turn was superior to placebo for reducing pain scores (mean VAS = 51, 59 and 76 mm, respectively) and the proportion of patients requiring postoperative analgesics (28, 50 and 76%, respectively), in patients undergoing laparoscopic cholecystectomy (n=70) Sarac et al 1996
  • Intra-operative wound infiltration plus intraperitoneal administration of bupivacaine reduced postoperative overall pain for 0–2 h and incisional pain for 0–3 h (p<0.01, for both comparisons), as well as 3-h morphine consumption (p<0.05) and nausea (p<0.05) in patients undergoing laparoscopic cholecystectomy (n=58) Bisgaard et al 1999

Abdominal Hysterectomy-Specific Evidence - Study information

  • There is mixed evidence for a benefit of intra-operative wound infiltration for reducing postoperative pain scores, and the benefits are of marginal clinical significance Cobby et al 1997 Click here for more information
  • Intra-operative wound infiltration provides no significant benefit over placebo for reducing supplementary analgesic consumption Cobby et al 1997 Click here for more information
  • Wound infiltration with ketorolac provided no significant benefit over placebo for reducing postoperative pain scores or supplementary analgesic consumption in one study (n=20) Richman et al 1994
  • Wound infiltration with local anaesthetic provided no significant benefit over placebo for extending the time to first analgesic request in one study (n=41) Hannibal et al 1996
  • Wound infiltration with local anaesthetic was not significantly different from placebo for the incidence of PONV in the three studies reporting this parameter (all groups received postoperative strong opioids) Klein et al 2000

PROSPECT Recommendations

  • Intraperitoneal analgesia is not recommended based on its lack of benefit in reducing pain scores and supplementary analgesic consumption following abdominal hysterectomy (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Intraperitoneal analgesia is an effective method for controlling postoperative pain in gynaecological laparoscopy Narchi 1995
  • Intraperitoneal wound infiltration with local anaesthetic produced a clinically significant decrease in VAS score of 13 mm on a 100-mm scale at 1–4 h in patients undergoing laparoscopic cholecystectomy, from a meta-analysis of 13 studies (p<0.05) Møiniche et al 2000
  • Intraperitoneal plus wound infiltration with bupivacaine reduced postoperative overall pain for 0–2 h and incisional pain for 0–3 h (p<0.01, for both comparisons), as well as 3-h morphine consumption (p<0.05) and nausea (p<0.05) in patients undergoing laparoscopic cholecystectomy (n=58) Bisgaard et al 1999

Abdominal Hysterectomy-Specific Evidence - Study information

PROSPECT Recommendations

  • The type of surgical technique for hysterectomy should be based on factors other than the management of postoperative pain, such as the technical feasibility of the operation, the indication for hysterectomy and operative risk-factors of the patient (grade D)
  • If the surgical requirements (based on technical feasibility, patient indication for hysterectomy and risk factors) allow, LAVH or VH is recommended over open hysterectomy because it is associated with significantly lower postoperative pain, reduced supplementary analgesic consumption and a shorter recovery time compared with abdominal hysterectomy (grade A)

Clinical Practice

  • Abdominal rather than transvaginal hysterectomy is indicated in patients who have never been pregnant, who suffer from cancer of the uterus or patients having a uterus size that precludes the transvaginal approach

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

  • LAVH provided a significant benefit over abdominal hysterectomy for reducing postoperative pain scores over the first week following surgery, providing a reduction in 100-mm VAS scores of 16 mm at 24 h, 24 mm at 48 h and 18 mm at 1 week Hwang et al 2002 Click here for more information
  • LAVH was superior to abdominal hysterectomy for reducing total supplementary analgesic consumption Falcone et al 1999 Click here for more information
  • There is some evidence that LAVH may be associated with a lower incidence of nausea at 34 h, in one study (p<0.05; n=40) Ellstrom et al 1998
  • LAVH was associated with a significantly shorter hospital stay/convalescence time than abdominal hysterectomy Howard et al 1993
  • LAVH and total vaginal hysterectomy were similar for postoperative pain scores (n=60) Hwang et al 2002
  • LAVH was associated with a lower total number of complications (e.g. febrile morbidity, infections and major organ or vessel injury) than total vaginal hysterectomy (p<0.05; n=60) Hwang et al 2002
  • Vaginal hysterectomy was superior to abdominal hysterectomy for reducing postoperative pain scores at 24 h (p<0.001; n=60) Hwang et al 2002
  • Vaginal hysterectomy was associated with a lower total number of complications than abdominal hysterectomy (p<0.05; n=60) Hwang et al 2002
  • Vaginal hysterectomy was associated with a shorter hospital stay and faster return to work than abdominal hysterectomy (p<0.05; n=60) Hwang et al 2002
  • One study reported no significant difference between vaginal and laparoscopic hysterectomy for the complication rate (n=473) Garry et al 2004
  • Vaginal hysterectomy and laparoscopic hysterectomy produced no significant difference in postoperative pain scores over 24 h in one study (n=473) Garry et al 2004
  • LAVH was associated with significantly longer operating times than abdominal hysterectomy Ellstrom et al 1998
  • LAVH was associated with longer operative times and greater blood loss than total vaginal hysterectomy (p=0.01 for both comparisons; n=60) Hwang et al 2002
  • One study reported a significantly longer operative time for laparoscopic compared with vaginal hysterectomy (p<0.05; n=45) Richardson et al 1995

PROSPECT Recommendations

  • Active patient warming is recommended in high-risk patients because there is evidence that it reduces intra-operative bleeding (grade A) and improves outcome in high-risk patients (grade D); however, it has no analgesic benefit (grade A)
  • Leaving the peritoneum open is not recommended over the conventional technique of peritoneal closure because there is evidence that it has no significant analgesic benefit (grade A)
  • Routine use of drains is not recommended, despite some evidence for an analgesic benefit in laparoscopic hysterectomy, because there is a lack of specific evidence, and a risk of infection and patient dissatisfaction (grade D)
  • Wet dressings are not recommended over conventional dressings because there is not yet sufficient evidence to support their benefit in reducing postoperative pain (grade A)
  • It is recommended that the choice of surgical incision for hysterectomy is based on surgical requirements (dependent on the technical feasibility of the operation, the indication for hysterectomy and operative risk-factors of the patient) rather than postoperative pain outcome. If allowed by the surgical requirements, a transverse incision is recommended over a vertical incision because it is associated with lower postoperative pain and less pulmonary dysfunction, while it is has a similar morbi
  • Diathermy is recommended over the scalpel for hysterectomy incisions based on lower postoperative pain and opioid use as well as greater speed of incision and less blood loss, as shown in patients undergoing elective midline laparotomy (grade B)

Clinical Practice

  • A transverse incision is the preferred method for hysterectomy for safety and cosmetic reasons. However, a vertical incision may be required where large fibroids need to be removed or where the upper abdomen must be explored. Pulmonary complications are also less likely with transverse incisions
  • Wound drains are invasive and can increase the risk of infection and, in addition, their extraction is associated with significant patient anxiety

Transferable Evidence from Other Procedures

  • Drains were superior to no drains for reducing postoperative shoulder-tip pain at 24 h (p=0.01) and 48 h (p=0.018) (non-significant at 3 h), and for reducing abdominal pain at 48 h (p=0.007) (non-significant at 3 and 24 h); but the results were not significant for back pain at any time, in LAVH Shen et al 2003 Click here for more information
  • Drains were superior to no drains for reducing postoperative paracetamol consumption, in LAVH (p<0.001; n=164) Shen et al 2003
  • The Pfannenstiel incision decreased the operating time and hospital stay without affecting morbidity and mortality compared with the vertical incision - as shown in two retrospective studies of surgery for uterine cancer, which did not assess postoperative pain (n=332; n=113) Horowitz et al 2003
  • Laparotomy incisions using diathermy were significantly faster (p<0.04) and were associated with significantly less blood loss (p=0.002), lower 48-h postoperative pain scores (p<0.05) and lower 5-day morphine consumption compared with scalpel incisions (p<0.04), in patients undergoing elective midline laparotomy (n=100) Kearns et al 2001
  • Active patient warming and prevention of intra-operative hypothermia decreases the risk of wound infection, hospitalisation time and the incidence of morbid cardiac events in high-risk patients, in a review Leslie et al 2003

Abdominal Hysterectomy-Specific Evidence - Study information

  • Operative time was significantly shorter for the unsutured compared with the conventional sutured peritoneum (n=66; n=144) Behtash et al 2001
  • Active intra-operative warming was associated with significantly less intra-operative bleeding than placebo (p<0.05; n=41) Persson et al 2001
  • Wet film dressing showed a marginally significant benefit over conventional dressing at day 3 for reducing postoperative pain scores (p=0.046; n=30), but this result was non-significant at all other times Briggs 1996
  • Unsutured and sutured peritoneum techniques were not significantly different for postoperative pain scores at rest or for supplementary analgesic consumption, for up to 5 days following the operation (n=66; n=144) Behtash et al 2001
  • There was no significant benefit of active intra-operative warming over placebo for reducing postoperative pain scores or supplementary analgesic consumption for the 48-h study period (n=41) Persson et al 2001
  • Wet film dressing was not significantly different from conventional dressing for supplementary analgesic consumption (n=30) Briggs 1996

PROSPECT Recommendations

  • Intra-operative music played to the patient during general anaesthesia is recommended based on its effects in reducing postoperative pain scores, supplementary analgesic consumption and rehabilitation time (grade A)
  • Therapeutic suggestions and electroacupuncture are not recommended based on their lack of analgesic efficacy (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

  • Intra-operative music was superior to placebo for reducing postoperative pain scores on the first postoperative day (p<0.001) (non-significant on the second and third day) (n=58) Nilsson et al 2001
  • Intra-operative music was superior to placebo for reducing supplementary analgesic consumption on the day of surgery (p=0.028), and there was a trend towards significance on the first postoperative day (p=0.057; n=89) Nilsson et al 2001
  • Intra-operative music was superior to placebo for time to sitting (p=0.008; n=89) Nilsson et al 2001
  • Of six studies, all showed no significant benefit of intra-operative therapeutic suggestions over placebo for reducing postoperative pain scores for up to 5 days Block et al 1991
  • Five out of six studies showed no significant benefit of intra-operative therapeutic suggestions over placebo for reducing supplementary analgesic consumption McLintock et al 1990 Click here for more information
  • Electroacupuncture provided no significant benefit over placebo for reducing postoperative pain scores at rest and on coughing, or for reducing supplementary analgesic consumption (n=50) Christensen et al 1993

PROSPECT Recommendations

  •  Pre-operative local anaesthetic infiltration at the proposed site of incision is not recommended for abdominal hysterectomy because of its lower benefit compared with post-incisional infiltration for reducing postoperative pain in hysterectomy (grade A). Post-incisional wound infiltration is recommended (see Intra-operative Wound Infiltration)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Pre-incisional wound infiltration of local anaesthetic had a lower analgesic efficacy than post-incisional infiltration: mean 100-mm VAS score was 59 mm and 51 mm, respectively; and the proportion of patients requiring postoperative analgesics was 50 and 28%, respectively, in patients undergoing laparoscopic cholecystectomy (n=45) Sarac et al 1996

Abdominal Hysterectomy-Specific Evidence - Study information

  • Pre-incisional wound infiltration provided a significant benefit over placebo for reducing supplementary analgesic consumption, in two of three studies Eriksson-Mjoberg et al 1997a Click here for more information
  • Pre-incisional wound infiltration and placebo were associated with a similar incidence of PONV in five of the studies reporting this parameter Hannibal et al 1996
  • Pre-incisional wound infiltration provided no significant benefit over placebo for reducing postoperative pain scores in three studies (n=19, n=41, n=40) Eriksson-Mjoberg et al 1997a
  • Pre-incisional wound infiltration provided no significant benefit over placebo for extending the time to first analgesic request in one study (n=41) Hannibal et al 1996
  • Pre-incisional wound infiltration was not significantly different from post-incisional administration for reducing postoperative pain scores within 0–96 h in two studies Click here for more information
  • Pre-incisional wound infiltration was not significantly different from post-incisional administration for reducing supplementary analgesic consumption within 0–96 h in two studies Click here for more information

PROSPECT Recommendations

  • Pre-operative cognitive intervention for patients undergoing hysterectomy is recommended based on its effect on reducing postoperative pain, analgesic consumption and anxiety as well as increasing patient satisfaction (grade A)
  • Homeopathic arnica and self-relaxation techniques are not recommended based on their lack of analgesic efficacy (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

  • Cognitive intervention reduced postoperative pain scores and the duration of pain compared with no cognitive intervention Cheung et al 2003 Click here for more information
  • Cognitive intervention was superior to placebo for reducing supplementary analgesics Ridgeway et al 1982 Click here for more information
  • One study reported that state and trait anxiety scores were significantly lower for patients receiving pre-operative cognitive therapy than those not receiving cognitive intervention (p<0.05; n=96) Cheung et al 2003
  • One study reported that patient satisfaction was significantly higher in patients receiving pre-operative cognitive therapy than those not receiving cognitive intervention (p<0.05; n=96) Cheung et al 2003
  • Homeopathic arnica had no significant benefit compared with placebo for VAS pain scores or supplementary analgesia (n=73) Hart et al 1997
  • Self-relaxation provided no significant benefit over placebo for reducing postoperative pain scores or supplementary analgesic consumption (n=28) Mogan et al 1985

Pre-operative analgesia

Data are available from studies that assessed pre-operative analgesia versus pre-operative placebo, as well as those that examine the concept of pre-emptive – or preventive – analgesia, assessed pre-operative analgesia versus the same analgesia given postoperatively. However, a previous systematic review of pre-emptive analgesia for acute or chronic postoperative pain relief in a variety of surgical procedures – such as orthopaedic, dental, gynaecological and abdominal – has concluded that there is no benefit of pre-emptive over postoperative administration (Møiniche 2002). Nevertheless, it is considered that analgesic medication needs to be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period. This may necessitate administration prior to the postoperative period. 

PROSPECT Recommendations

  • Pre- and postoperative gabapentin is recommended (Grade A) for its procedure-specific effects in reducing postoperative opioid use and postoperative nausea
  • Further studies are required before it is possible to recommend a specific dose or regimen for administration (single or repeated doses)
  • Procedure-specific and transferable evidence suggests that gabapentin may be associated with sedation, and it is recommended (Grade B) that this side effect should be considered when determining the dose that will be administered

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Two systematic reviews and a meta-analysis evaluated the use of gabapentin for postoperative analgesia and demonstrated significant reductions in postoperative pain and supplementary analgesic requirements compared with inactive controls Dahl et al 2004
  • One systematic review Ho et al 2006
  • One systematic review Ho et al 2006

Abdominal Hysterectomy-Specific Evidence – Study information

  • Three out of five studies demonstrated that pre- and postoperative oral gabapentin was superior compared with placebo for reducing pain scores Gilron et al 2005 Click here for more information
  • Two studies out of two showed a significant reduction in pain scores following pre- and postoperative oral gabapentin + rofecoxib administration compared with placebo following abdominal hysterectomy Gilron et al 2005 Click here for more information
  • Four out of five studies demonstrated a decrease in supplementary postoperative analgesic use following pre- and postoperative oral gabapentin administration compared with placebo Dierking et al 2004 Click here for more information
  • Two out of two studies demonstrated a decrease in supplementary postoperative analgesic use following pre- and postoperative oral gabapentin + rofecoxib administration compared with placebo Gilron et al 2005 Click here for more information
  • Qualitative analysis demonstrated that in three out of four studies there was no significant difference in the incidence of adverse effects following pre- and postoperative oral gabapentin administration compared with placebo Dierking et al 2004
  • Quantitative analysis showed that there was a significantly lower incidence of nausea in gabapentin group compared with the placebo group Click here for more information
  • The incidence of side effects following pre- and postoperative oral gabapentin + rofecoxib was significantly lower in two studies out of two when compared with placebo Gilron et al 2005 Click here for more information
  • Patient satisfaction with postoperative pain management was significantly higher at 24 h following pre- and postoperative oral gabapentin compared with placebo (p<0.001) Turan et al 2006
  • Patient satisfaction with postoperative pain management was significantly higher in the pre- and postoperative oral gabapentin + rofecoxib group compared with placebo at 24 (p<0.01), 48 (p<0.01) and 72 h (p value not stated) postoperatively Turan et al 2006
  • There was a significant inverse association between plasma levels of gabapentin at 2 h postoperatively, and morphine usage from 0–4 h postoperatively (R2=0.30, p=0.003, and R2=0.24, p=0.008, respectively), compared with placebo Dierking et al 2004
  • Peak expiratory flow was higher in the pre- and postoperative oral gabapentin group compared with the placebo group throughout postoperative days 1 and 2 (p=0.002-0.0032) Gilron et al 2005
  • Peak expiratory flow was higher in the pre- and postoperative oral gabapentin + rofecoxib group compared with the placebo group throughout postoperative days 1 and 2 (p<0.001) Gilron et al 2005

PROSPECT Recommendations

  • Pre-operative COX-2-selective inhibitors for hysterectomy are recommended because they have an analgesic effect postoperatively (grade A). However, there is no procedure-specific evidence that pre-operative administration of COX-2-selective inhibitors is more effective than postoperative administration
  • The use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (cardiovascular morbidity, actual or recent gastroduodenal ulcer history, renal function and hepatic function [grade B] or aspirin-sensitive asthma [grade D])

Clinical Practice

  • Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries

Transferable Evidence from Other Procedures

  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation Greenberg et al 2000
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function Bavbek et al 2004
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following noncardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) (in press, Anesthesiology)
  • Two clinical trials showed that in patients who had undergone CABG surgery COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo Nussmeier et al 2005
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents EMEA 2004a
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting Blomme et al 2003

Abdominal Hysterectomy-Specific Evidence - Study information

  • A pre-operative single bolus of IV parecoxib was superior to placebo for postoperative pain scores on sitting up over 24 h (p=0.02), providing a mean drop of 14 mm in VAS scores on a 100-mm scale (n=36) Ng et al 2003
  • A pre-operative single bolus of IV parecoxib or oral rofecoxib reduced morphine consumption over 24 h compared with placebo Ng et al 2003 Click here for more information
  • Pre-operative oral rofecoxib was associated with a lower incidence of PONV compared with placebo in one study (p<0.05; n=40) Celik et al 2003
  • Pre-operative oral COX-2-selective inhibitors were as effective as oral conventional NSAIDs for reducing postoperative pain scores in two studies (n=25; n=40) Celik et al 2003
  • COX-2-selective inhibitors are similarly effective compared with conventional NSAIDs for reducing postoperative opioid consumption Celik et al 2003 Click here for more information
  • Compared with the conventional NSAID diclofenac, pre-operative rofecoxib was associated with significantly less intra-operative blood loss (p=0.01) and a lower decrease in haemoglobin (p=0.01) in a group of patients undergoing abdominal or vaginal hysterectomy (n=25) Hegi et al 2004
  • A pre-operative single bolus of rofecoxib or parecoxib did not significantly reduce postoperative pain scores at rest compared with placebo within 0–24 h in two studies (n=40; n=36) Celik et al 2003

PROSPECT Recommendations

  • Pre-operative conventional NSAIDs are not recommended because there is evidence that pre-operative administration of conventional NSAIDs is no more effective than postoperative administration (grade A). Moreover, pre-operative administration of these agents can increase the risk of intra- and postoperative bleeding (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo Bricker et al 1987
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls Marret et al 2003
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction Niemi et al 1997
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease Stevenson 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004

Abdominal Hysterectomy-Specific Evidence - Study information

  • Pre-operative conventional NSAIDs significantly reduced postoperative pain scores compared with placebo, but a significant clinical benefit was only evident for up to 4 h Scott et al 1994 Click here for more information
  • The combination of paracetamol with a conventional NSAID was superior to a higher dose of paracetamol alone, administered as a single pre-operative rectal dose for VAS pain scores at rest at 4 h (p<0.05), but there was no significant difference at 2 h and 6–24 h (n=46) Beck et al 2000b
  • Conventional NSAIDs were equally as effective as COX-2-selective inhibitors for reducing postoperative pain scores in two studies Celik et al 2003
  • Pre-operative conventional NSAIDs showed no significant or clinically meaningful benefit over placebo in reducing supplementary analgesic consumption Beck et al 2000b Click here for more information
  • Pre-operative conventional NSAIDs provided no significant benefit over placebo for extending the time to first analgesic request in two out of the three studies that reported this parameter Scott et al 1994 Click here for more information
  • Pre-operative conventional NSAIDs and placebo were not significantly different for the incidence of PONV (all studies used postoperative PCA strong opioids) Beck et al 2000a Click here for more information
  • Conventional NSAIDs and COX-2-selective inhibitors similarly reduce the use of supplementary analgesics Celik et al 2003 Click here for more information
  • Compared with diclofenac, pre-operative rofecoxib caused significantly less intra-operative blood loss (p=0.01) and a lower decrease in haemoglobin (p=0.01) following abdominal hysterectomy (n=25) Hegi et al 2004
  • There was no significant benefit of pre-incisional conventional NSAIDs over post-incisional conventional NSAIDs in two of three studies for reducing postoperative pain scores Nakayama et al 2001b Click here for more information
  • Of three studies, all showed no significant difference between pre-incisional and post-incisional conventional NSAIDs for supplementary analgesic consumption (n=65; n=77; n=30) Gabbott et al 1997
  • Pre-incisional administration of flurbiprofen was associated with a shorter time to first analgesic request compared with post-incisional administration of a conventional NSAID, in one study (p<0.05; n=30) Nakayama et al 2001b
  • Pre-incisional administration of conventional NSAIDs conferred no significant benefit over post-incisional administration for the incidence of PONV in two studies (n=65, n=30) Gabbott et al 1997

PROSPECT Recommendations

  • Pre-incisional administration of strong opioids is not recommended because of the lack of effect in reducing postoperative pain and supplementary analgesic consumption compared with placebo, and the lack of benefit over post-incisional administration of strong opioids (grade A). Moreover, post-incisional strong opioids are significantly more effective for reducing postoperative pain compared with a similar dose of pre-incisional strong opioids (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

PROSPECT Recommendations

  • Pre-operative clonidine is not recommended based on its limited analgesic efficacy (grade A) and risk of side effects (grade D)
  • NMDA-receptor antagonists are not recommended based on inconsistent evidence of their analgesic efficacy (grade A), lack of clinical understanding of these agents, and the risk of side effects (grade D)
  • Benzodiazepines are not recommended based on their lack of analgesic efficacy (grade A)

Clinical Practice

  • Clonidine is not used routinely for postoperative analgesia, despite its analgesic efficacy, because of the risk of hypotension, sedation and bradycardia
  •  NMDA-receptor antagonists are not used routinely because of the current lack of understanding of their optimum dose, rate and route of administration as well as their cost-benefit relationship; in addition, they are associated with adverse side-effects, e.g. ketamine is known for its toxicity and for causing dysphoria

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence

  • Pre-operative clonidine provided no consistent significant benefit over placebo for reducing postoperative pain scores; and other postoperative pain outcomes were mixed Dimou et al 2003 Click here for more information
  • Pre-operative benzodiazepines provided no significant benefit in reducing postoperative pain scores, and there is evidence that they have a limited effect on reducing supplementary analgesic consumption Caumo et al 2002 Click here for more information
  • NMDA-receptor antagonists provided no significant benefit over placebo in reducing postoperative pain scores, supplementary analgesic consumption or PONV in the majority of studies, but the results were mixed and were independent of the specific type of agent and timing of administration Burstal et al 2001 Click here for more information

PROSPECT Recommendations

  • Pre-operative administration of single dose epidural analgesia, in addition to that required for anaesthetic purposes, is not recommended for the treatment of postoperative pain following hysterectomy, based on specific evidence that pre-operative epidural analgesia is not as effective as postoperative epidural analgesia (grade A)
  • A recommendation cannot be made for epidural anaesthesia based on its postoperative analgesic effect because there is no evidence for its relative postoperative analgesic benefits compared with other methods of anaesthesia. Moreover, the choice of anaesthetic regimen should be based on anaesthetic requirement and the relative risks and benefits of the anaesthetic related to the patient and the surgical procedure (grade D) (See Anaesthetic techniques section)
  • Despite the analgesic benefits of pre-operative epidural clonidine, it is not recommended for treating postoperative pain following abdominal hysterectomy because of the incidence of hypotension, sedation and bradycardia (grade D)

Clinical Practice

  • Epidural analgesia is associated with a relatively high degree of patient monitoring and rare major complications
  • Epidural clonidine is not used routinely because it is associated with an increased risk of hypotension, sedation and bradycardia

Transferable Evidence from Other Procedures

  • Epidural and spinal anaesthesia are not significantly different for: the need for postoperative pain relief, anaesthetic failure rate, need for additional intra-operative analgesia, need for conversion to general anaesthesia, and maternal satisfaction as determined in a systematic review of caesarean section Ng et al 2004

Abdominal Hysterectomy-Specific Evidence - Study information

  • Pre-operative epidural morphine bolus was superior to epidural saline placebo for reducing postoperative pain scores at rest and on movement at 1 and 6 h (p<0.05 for all comparisons; n=36) Goyagi et al 1999
  • Pre-operative epidural morphine bolus was superior to epidural saline placebo for reducing postoperative supplementary analgesic consumption at 6 and 12 h (p<0.05 for both times; n=36) Goyagi et al 1999
  • Pre-operative epidural morphine was superior to placebo for extending the time to first analgesic request (p<0.05; n=36) Goyagi et al 1999
  • Pre-operative plus postoperative treatment with epidural bupivacaine plus fentanyl was superior to postoperative treatment alone for reducing postoperative pain scores at rest and on coughing within 0–72 h (no p-values; n=41) Beilin et al 2003
  • Pre-operative epidural clonidine was superior to placebo for reducing postoperative pain scores in the PACU (p<0.003; n=40) Murga et al 1994
  • Pre-operative epidural clonidine was superior to placebo for reducing intra-operative anaesthetic requirement (p<0.0001; n=40) Murga et al 1994
  • There was no difference between epidural morphine and placebo (with rescue PCA morphine) for the incidence of postoperative nausea (n=36) Goyagi et al 1999
  • Pre-operative epidural ketamine conferred no significant benefit over placebo for reducing postoperative pain scores within 0–24 h (n=40) Murga et al 1994
  • Pre-operative epidural ketamine conferred no significant benefit over placebo for reducing supplementary analgesic consumption within 0–24 h (n=41) Abdel-Ghaffar et al 1998
  • Pre-incisional epidural analgesia provided no significant benefit over post-incisional administration for reducing postoperative pain scores in four out of four studies Garcia et al 2002 Click here for more information
  • Three of four studies showed no significant benefit of pre-incisional epidural analgesia compared with post-incisional administration for reducing supplementary analgesic consumption Espinet et al 1996 Click here for more information

PROSPECT Recommendations

  • Pre-operative single-shot spinal analgesia with local anaesthetic and strong opioid reduces postoperative pain scores and opioid consumption for up to 24 h (grade A). However, these benefits should be weighed against the risks associated with the invasive nature of this technique
  • Pre-operative single-shot spinal local anaesthetic plus strong opioid can be used, with or without sedation, as an alternative to general anaesthesia (Grade A). However, the choice of anaesthetic regimen should be based on anaesthetic requirement and the relative risks and benefits of the anaesthetic related to the patient and the surgical procedure (Grade D) (see Anaesthetic techniques section)
  • Spinal neostigmine is not recommended based on limited evidence for its analgesic efficacy, evidence of an associated increase in PONV (grade A) and a lack of clinical experience with this agent (grade D)

Clinical Practice

  • There is limited clinical experience of spinal neostigmine

Transferable Evidence from Other Procedures

  • Spinal and epidural anaesthesia are not significantly different for: the need for postoperative pain relief, anaesthetic failure rate, need for additional intra-operative analgesia, need for conversion to general anaesthesia, and maternal satisfaction as determined in a systematic review of caesarean section Ng et al 2004

Abdominal Hysterectomy-Specific Evidence - Study information

  • Pre-operative spinal analgesia (local anaesthetic, strong opioid or both) was superior to placebo for reducing postoperative pain scores within 0–24 h Vaida et al 2000 Click here for more information
  • Pre-operative spinal local anaesthetic or strong opioid provided a significant benefit over placebo for reducing supplementary analgesic consumption within 0–24 h (p<0.05; n=20) Lauretti et al 1998b
  • There was no significant difference between spinal strong opioid and placebo for the incidence of PONV in two studies (all groups received postoperative diclofenac) (n=20, n=30) Lauretti et al 1998b
  • Pre-operative spinal neostigmine (25, 50 or 75 µg) was superior to placebo for reducing postoperative pain scores at the following times: 30 and 60 min (p<0.05; n=92) Lauretti et al 1998a
  • Pre-operative spinal neostigmine (25, 50 or 75 µg) was superior to placebo for reducing supplementary analgesic consumption within 0–24 h (p<0.05; n=92, n=20) Lauretti et al 1998a
  • There is evidence from one of two studies showing a significant benefit of pre-operative spinal neostigmine over placebo for extending the time to first analgesic request (p<0.05; n=92) Lauretti et al 1998a
  • Spinal morphine was superior to IV analgesia for reducing postoperative pain scores Yokota et al 2000 Click here for more information
  • Pre-operative bolus dose of spinal morphine was superior to IV buprenorphine for extending the time to first analgesic request (p<0.01) in one study (n=29) Beltrutti et al 2002
  • Pre-operative spinal neostigmine was associated with a higher incidence of postoperative nausea than placebo Lauretti et al 1998a Click here for more information
  • Pre-operative spinal adenosine provided no significant benefit over placebo for reducing postoperative pain scores or supplementary analgesic consumption within 0–24 h (n=40) Rane et al 2000
  • Pre-induction spinal local anaesthetic was not significantly different to local anaesthetic given at extubation for postoperative pain scores within 0–12 h (n=38) Dakin et al 1996
  • Pre-induction spinal local anaesthetic was not significantly different to local anaesthetic given at extubation for postoperative pain scores within 0–12 h (n=38) Dakin et al 1996

PROSPECT Recommendations

  • The choice of anaesthetic regimen should be based on anaesthetic requirement and the relative risks and benefits of the anaesthetic related to the patient and the surgical procedure, rather than on the management of postoperative pain (grade D)
  • Combined spinal-epidural anaesthesia is a recommended alternative to epidural plus light general anaesthesia for hysterectomy in high-risk patients (grade D), and may have a greater analgesic efficacy compared with epidural alone as shown in caesarean section (grade B)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

Abdominal Hysterectomy-Specific Evidence

  • [No data found within the parameters of this review]

PROSPECT Recommendations

  • Pre- and postoperative gabapentin is recommended (Grade A) for its procedure-specific effects in reducing postoperative opioid use and postoperative nausea
  • Further studies are required before it is possible to recommend a specific dose or regimen for administration (single or repeated doses)
  • Procedure-specific and transferable evidence suggests that gabapentin may be associated with sedation, and it is recommended (Grade B) that this side effect should be considered when determining the dose that will be administered

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Two systematic reviews and a meta-analysis evaluated the use of gabapentin for postoperative analgesia and demonstrated significant reductions in postoperative pain and supplementary analgesic requirements compared with inactive controls Dahl et al 2004
  • One systematic review Ho et al 2006
  • One systematic review Ho et al 2006

Abdominal Hysterectomy-Specific Evidence - Study information

  • Three out of five studies demonstrated that pre- and postoperative oral gabapentin was superior compared with placebo for reducing pain scores Gilron et al 2005 Click here for more information
  • Two studies out of two showed a significant reduction in pain scores following pre- and postoperative oral gabapentin + rofecoxib administration compared with placebo following abdominal hysterectomy Gilron et al 2005 Click here for more information
  • Four out of five studies demonstrated a decrease in supplementary postoperative analgesic use following pre- and postoperative oral gabapentin administration compared with placebo Dierking et al 2004 Click here for more information
  • Two out of two studies demonstrated a decrease in supplementary postoperative analgesic use following pre- and postoperative oral gabapentin + rofecoxib administration compared with placebo Gilron et al 2005 Click here for more information
  • Qualitative analysis of three out of four studies demonstrated that there was no significant difference in the incidence of adverse effects following pre- and postoperative oral gabapentin administration compared with placebo Dierking et al 2004
  • Quantitative analysis showed that there was a significantly lower incidence of nausea in gabapentin group compared with the placebo group Click here for more information
  • The incidence of side effects following pre- and postoperative oral gabapentin + rofecoxib was significantly lower in two studies out of two when compared with placebo Gilron et al 2005 Click here for more information
  • Patient satisfaction with postoperative pain management was significantly higher at 24 h following pre- and postoperative oral gabapentin compared with placebo (p<0.001) Turan et al 2006
  • Patient satisfaction with postoperative pain management was significantly higher in the pre- and postoperative oral gabapentin + rofecoxib group compared with placebo at 24 (p<0.01), 48 (p<0.01) and 72 h (p value not stated) postoperatively Turan et al 2006
  • There was a significant inverse association between plasma levels of gabapentin at 2 h postoperatively, and morphine usage from 0–4 h postoperatively (R2 =0.30, p=0.003, and R2 =0.24, p=0.008, respectively), compared with placebo Dierking et al 2004
  • Peak expiratory flow was higher in the pre- and postoperative oral gabapentin group compared with the placebo group throughout postoperative days 1 and 2 (p=0.002-0.0032) Gilron et al 2005
  • Peak expiratory flow was higher in the pre- and postoperative oral gabapentin + rofecoxib group compared with the placebo group throughout postoperative days 1 and 2 (p<0.001) Gilron et al 2005

PROSPECT Recommendations

  • COX-2-selective inhibitors are recommended for their effect in reducing supplementary analgesic use (grade B). They should be given in combination with strong opioids for high-intensity pain, or with weak opioids for moderate- or low-intensity pain (grade D)
  • In patients receiving postoperative epidural analgesia, it is recommended that COX-2-selective inhibitors are used only if analgesia is inadequate (grade B) (see Postoperative, Conventional NSAIDs section)
  • COX-2-selective inhibitors may be preferred to conventional NSAIDs in the peri-operative setting, in patients who have an increased risk of bleeding, or who are at risk of gastroduodenal ulcer/erosion (grade B)
  • The use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (cardiovascular morbidity, actual or recent gastroduodenal ulcer history, renal function and hepatic function [grade B] or aspirin-sensitive asthma [grade D])

Clinical Practice

  • Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries

Transferable Evidence from Other Procedures

  • Parecoxib 20 or 40 mg IV every 12 h reduced supplementary analgesic consumption compared with placebo in patients undergoing major gynaecological surgery (n=60) (p<0.05) Tang et al 2002
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation Greenberg et al 2000
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function Bavbek et al 2004
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following noncardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) (in press, Anesthesiology)
  • Parecoxib 20 or 40 mg IV every 12 h did not significantly reduce postoperative pain scores compared with placebo in patients undergoing major gynaecological surgery (n=60) (p<0.05) Tang et al 2002
  • Two clinical trials showed that in patients who had undergone CABG surgery COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo Nussmeier et al 2005
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents EMEA 2004a
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting Blomme et al 2003

Abdominal Hysterectomy-Specific Evidence

  • [No data found within the parameters of this review]

PROSPECT Recommendations

  • Conventional NSAIDs are recommended for their analgesic and opioid-sparing effects (grade A). They should be given in combination with strong opioids for high-intensity pain, or with weak opioids for moderate- or low-intensity pain (grade D)
  • In patients receiving epidural analgesia, it is recommended that conventional NSAIDs are used only if analgesia is inadequate (grade B)
  • Conventional NSAIDs are not recommended in patients who have an increased risk of bleeding, or who are at risk of gastroduodenal ulcer/erosion (grade B)
  • The use of conventional NSAIDs should depend upon assessment of individual patient risks (bleeding complications including epidural haematoma, cardiovascular morbidity, actual or recent gastroduodenal ulcer history, aspirin-sensitive asthma, renal function and hepatic function) (grade B)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo Bricker et al 1987
  • Piroxicam plus thoracic epidural analgesia using bupivacaine and morphine provided no significant benefit over epidural analgesia alone for reducing postoperative pain scores and supplementary analgesic consumption, in major upper abdominal surgery (n=44) Mogensen et al 1992b
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls Marret et al 2003
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction Niemi et al 1997
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease Stevenson 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004

Abdominal Hysterectomy-Specific Evidence - Study information

  • Six out of eight studies showed a significant benefit of postoperative conventional NSAIDs compared with placebo for postoperative pain scores Ng et al 2002a Click here for more information
  • Conventional NSAIDs conferred a significant benefit over placebo for reducing supplementary analgesia requirements over 24 h or more Blackburn et al 1995 Click here for more information
  • One study showed a marginal but significant benefit of rectal diclofenac over rectal paracetamol for reducing mean pain scores over 24 h (p=0.008; n=44): mean reduction in VAS of 0 mm at 8 h, 8 mm at 16 h and 21 mm for 0–24 h on a 100-mm scale Cobby et al 1999
  • Ketorolac combined with morphine was not significantly different from a higher dose of morphine alone for reducing postoperative pain scores in one study (n=22) Kim et al 2001
  • Ketorolac combined with morphine was superior to a higher dose of morphine alone for significantly reducing postoperative morphine consumption at 4 h (p=0.037) and 24 h (p=0.015) in one study (n=22) Kim et al 2001
  • There was no significant difference between postoperative ketorolac and morphine each given by IM PCA for reducing postoperative pain scores at the doses studied (both study groups were allowed rescue morphine) (n=29) Black et al 1990
  • Four studies and two arms of a fifth study showed no significant difference between conventional NSAIDs and weak opioids for VAS pain scores at rest over 24 h Rodriguez et al 1993 Click here for more information
  • There was no significant difference between conventional NSAIDs and weak opioids for time to first analgesic request in one study reporting this parameter (n=58) Ilias et al 1996
  • There is evidence that diclofenac is superior to paracetamol for reducing mean 24-h postoperative pain scores Cobby et al 1999 Click here for more information
  • Results were mixed for conventional NSAIDs compared with placebo for the time to first analgesic request Ilias et al 1996 Click here for more information
  • Conventional NSAIDs and placebo were not significantly different for the incidence of PONV (all groups received background strong opioid) Blackburn et al 1995 Click here for more information
  • There is evidence that weak opioids are superior to conventional NSAIDs for reducing supplementary analgesic consumption Rodriguez et al 1993 Click here for more information
  • There was no significant difference between conventional NSAIDs and paracetamol for the requirement of postoperative supplementary analgesics Cobby et al 1999 Click here for more information
  • Conventional NSAIDs and paracetamol were not significantly different for the incidence of vomiting Cobby et al 1999 Click here for more information
  • There is limited evidence of a reduction in the incidence of PONV with a conventional NSAID compared with a weak opioid Torres et al 2001 Click here for more information

PROSPECT Recommendations

  • Strong opioids are recommended based on their analgesic efficacy in reducing high-intensity pain (VAS=50) in the early postoperative period (grade A)
  • At clinical doses, different strong opioids are equally effective (grade A)
  • IV PCA administration of strong opioids is recommended based on its greater analgesic efficacy, lower opioid load and greater patient satisfaction compared with regular (fixed-interval) or on-request dosing in hysterectomy and other procedures (grade A); however, fixed-interval IV administration titrated to pain intensity is also recognised as an effective mode of administration (grade D)
  • Continuous infusion of strong opioid during PCA bolus dosing is not recommended, despite its analgesic efficacy over PCA bolus doses alone (grade A), because of potential opioid accumulation (grade D)
  • IM administration of strong opioids is not recommended based on the pain associated with these injections (grade D)
  • To minimise the dose of strong opioids, and associated side-effects, it is recommended that strong opioids are combined with COX-2-selective inhibitors or conventional NSAIDs, plus paracetamol (grade B) (see respective sections)
  • There are not currently enough data to make a recommendation for other modes of administration of strong opioids, such as intra-nasal or slow-release tablets
  • Transdermal patches are not recommended: they are not approved for routine use due to the risk of opioid accumulation (grade D)

Clinical Practice

  • Strong opioids are considered to be an effective analgesic for postoperative pain following abdominal hysterectomy, but, because of their adverse effects, they are generally used in combination with non-opioid analgesics to minimise the opioid
  • Regular administration, titrated for pain intensity, is generally accepted as an effective method of administering strong opioids
  • IM administration of strong opioids is considered to be more painful than IV administration. However, the dose and rapidity of IV administration should be assessed to minimise the risk of respiratory depression
  • Transdermal patches are not approved for routine use because of the risk of opioid accumulation
  • Continuous infusions of strong opioids by PCA, on top of PCA bolus doses, are being used less frequently as a precaution against opioid accumulation

Transferable Evidence from Other Procedures

  • Opioids administered by PCA decreased the risk of pulmonary complications and patients preferred them compared with regular IM, IV or subcutaneous opioid treatment, although there was no significant difference for pain scores, as determined in a quantitative systematic review of randomised trials in various surgical procedures Walder et al 2001

Abdominal Hysterectomy-Specific Evidence - Study information

  • Strong opioids administered pre-, intra- and postoperatively were superior to placebo for reducing postoperative pain scores Broome et al 1995 Click here for more information
  • Three studies showed that strong opioids administered pre-, intra- and postoperatively were superior to placebo for reducing supplementary analgesic consumption Broome et al 1995 Click here for more information
  • Strong opioid administered as a single postoperative bolus provided a significant benefit over placebo for reducing postoperative pain scores at 24 h Collis et al 1995 Click here for more information
  • The incidence of PONV was not significantly different between strong opioid and placebo plus rescue strong opioid in four out of five studies reporting this parameter Broome et al 1995 Click here for more information
  • Sufentanil provided a significant benefit over morphine for reducing postoperative pain scores at rest and on movement for the first 2 h following initiation of PCA, but there was no significant difference for the remaining 24 h Ginsberg et al 2000 Click here for more information
  • Sufentanil provided a significant benefit over morphine for reducing the supplementary analgesic consumption from 0–24 h (p<0.05), in one study reporting this parameter (n=40) Ginsberg et al 2000
  • Three out of five studies showed a significant benefit of IV PCA over IM regular/on-request administration of strong opioids for reducing postoperative pain scores D'Haese et al 1998 Click here for more information
  • There is mixed evidence for the benefit of PCA compared with regular/on-request IM administration of strong opioids for reducing overall opioid consumption, although one study suggests that they produced different patterns of dosing Thomas et al 1995 Click here for more information
  • The incidence of PONV was not significantly different between PCA and IM morphine, in two studies reporting this parameter (n=126, n=22) Choiniere et al 1998
  • Bolus plus infusion IV PCA morphine conferred a significant benefit over bolus IV PCA morphine alone for reducing postoperative pain scores with no significant difference in overall analgesic consumption El-Falaki et al 2000 Click here for more information
  • IV pethidine was superior to intranasal pethidine for reducing postoperative pain scores at 5–80 min (p<0.05) and for reducing the total amount of pethidine consumed (p<0.05), in one study (n=60) Striebel et al 1993
  • Oral slow-release and IM morphine were similar for postoperative pain scores, supplementary analgesic consumption and the incidence of PONV in two studies (n=38; n=30) Fell et al 1982
  • Strong opioids gave numerically lower postoperative pain scores than weak opioids in three studies Coetzee et al 1998
  • Morphine gave a numerically longer time to first analgesic request than tramadol in one study reporting this parameter, although the result did not reach statistical significance Coetzee et al 1998
  • Different strong opioids were not significantly different from each other, for reducing postoperative pain scores, supplementary analgesia and PONV, in the majority of studies assessing different strong opioid regimens Chui et al 1992 Click here for more information
  • Bolus IV PCA plus background infusion of morphine was associated with a consistently greater consumption of morphine than IV PCA alone but the results did not reach statistical significance, in two studies (n=20, n=20) El-Falaki et al 2000
  • Three studies showed no significant benefit of a postoperative bolus of strong opioid over placebo for reducing supplementary analgesic consumption Collis et al 1995
  • Strong opioids provided no significant benefit over NMDA-receptor antagonists for postoperative pain scores or supplementary analgesic consumption in two studies Knoche et al 1983 Click here for more information

PROSPECT Recommendations

  • Weak opioids are recommended based on evidence for their analgesic efficacy in gynaecological and abdominal surgery, as well as in other procedures (grade B). Weak opioids should be combined with COX-2-selective inhibitors or conventional NSAIDs and paracetamol, for controlling moderate- (VAS<50>30) or low-intensity (VAS £30) pain later in the postoperative period (grade D)

Clinical Practice

  • It is considered that maximum doses of weak opioids have a plateau of effect on controlling high-intensity pain (VAS³ 50) following abdominal hysterectomy and that strong opioids should be used instead; weak opioids are considered to be effective for lower intensity pain later in the postoperative period

Transferable Evidence from Other Procedures

  • Tramadol 20 mg was superior to placebo for reducing postoperative pain scores measured after an initial bolus dose (p=0.002) in patients undergoing gynaecological or abdominal surgery (n=120) Stamer et al 1997
  • Tramadol plus paracetamol is superior to either drug administered alone for reducing postoperative pain in a meta-analysis of gynaecological, dental and orthopaedic patients McQuay H et al 2003

Abdominal Hysterectomy-Specific Evidence - Study information

  • Four studies and two arms of a fifth study showed that weak opioids and conventional NSAIDs had a similar effect of reducing VAS pain scores at rest over 24 h Rodriguez et al 1993 Click here for more information
  • Weak opioids and conventional NSAIDs had a similar effect of reducing supplementary analgesic consumption in one study reporting this parameter (n=130) Torres et al 2001
  • Conventional NSAIDs and weak opioids have a similar effect for prolonging the time to first analgesic request in one study reporting this parameter (n=58) Ilias et al 1996
  • Tramadol 50 mg IV administered postoperatively on request gave numerically lower postoperative pain scores than placebo, but this was not statistically significant, in one study (n=40) Ilias et al 1996
  • Tramadol 50 mg IV administered postoperatively on request gave a numerically longer time to first analgesic request than placebo but this was not statistically significant in one study (n=80) Ilias et al 1996
  • Strong opioids gave numerically lower postoperative pain scores than weak opioids in three studies Coetzee et al 1998
  • Morphine gave a numerically longer time to first analgesic request than tramadol in one study reporting this parameter, although the result did not reach statistical significance Coetzee et al 1998

PROSPECT Recommendations

  • Paracetamol is recommended for moderate- (VAS<50>30 mm) or low-intensity (VAS £30 mm) pain, in combination with COX-2-inhibitors or conventional NSAIDs, based on its mild analgesic and opioid-sparing effect following hysterectomy (grade A)
  • However, paracetamol is not recommended for high-intensity pain (VAS³ 50 mm) because it has no additional analgesic benefit over that conferred by NSAIDs following abdominal gynaecological procedures (grade B)

Clinical Practice

  • Paracetamol is a well-established analgesic for mild-to-moderate pain (VAS <50 mm) and has a favourable safety profile

Transferable Evidence from Other Procedures

  • Paracetamol 1 g plus diclofenac 100 mg was superior to diclofenac 100 mg alone given once postoperatively, for reducing postoperative pain in dental surgery (p<0.05; n=46) Breivik et al 1999
  • There was no benefit of paracetamol with NSAID compared with NSAID alone for reducing pain scores in a meta-analysis of results from a variety of surgical procedures including dental, orthopaedic and gynaecological operations Rømsing et al 2002
  • Paracetamol 1.5 g plus diclofenac 100 mg was not significantly different from diclofenac 100 mg alone given once pre-operatively, for reducing postoperative pain in abdominal gynaecological surgery (n=39) Montgomery et al 1996

Abdominal Hysterectomy-Specific Evidence - Study information

  • Paracetamol was superior to placebo for reducing postoperative pain scores, producing reductions in VAS scores of £13 mm Cobby et al 1999 Click here for more information
  • Paracetamol was superior to placebo for reducing supplementary analgesic consumption within 0–24 h Cobby et al 1999 Click here for more information
  • One study showed that IV paracetamol was as effective as IV ketorolac for reducing postoperative pain scores (n=176) Varrassi et al 1999
  • One study showed a marginal but significant benefit of rectal diclofenac compared with rectal paracetamol for reducing mean pain scores over 24 h, giving a mean difference in VAS of 0 mm at 8 h, 8 mm at 16 h and 21 mm for 0–24 h, on a 100-mm scale (p=0.008; n=44) Cobby et al 1999

PROSPECT Recommendations

  • NMDA-receptor antagonists are not recommended based on inconsistent evidence of their analgesic efficacy (grade A), lack of clinical understanding of these agents, and the risk of side-effects (grade D)
  • Benzodiazepines are not recommended based on their lack of analgesic efficacy (grade A)
  • Other agents, such as pentazocine, clomipramine, delta-9-tetrahydrocannabinol and naloxone cannot be recommended for postoperative analgesia based on limited evidence for their analgesic efficacy (grade A) and a lack of clinical experience with these agents (grade D)

Clinical Practice

  • NMDA-receptor antagonists are not used routinely because of the current lack of understanding of their optimum dose, rate and route of administration as well as their cost-benefit relationship. In addition, they are associated with adverse side-effects, e.g. ketamine is known for its toxicity and for causing dysphoria
  • There is limited clinical experience of using pentazocine, clomipramine, delta-9-tetrahydrocannabinol and naloxone for analgesic purposes

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence

  • A regimen of ketamine plus midazolam was superior to pethidine for reducing postoperative pain scores, and was associated with a lower incidence of PONV compared with pethidine Jahangir et al 1993 Click here for more information
  • Piritramide was superior to pentazocine, which was superior to ketamine for reducing postoperative pain scores Knoche et al 1983 Click here for more information
  • Buprenorphine 0.4 mg SL on request was superior to papaveretum 20 IM on request for reducing postoperative pain scores (p<0.01) and supplementary analgesic consumption (p<0.001; n=60) Fry 1979
  • NMDA-receptor antagonists provided no significant benefit over placebo in reducing postoperative pain scores, supplementary analgesic consumption or PONV in the majority of studies, but the results were mixed and were independent of the timing of administration Burstal et al 2001 Click here for more information
  • Postoperative midazolam provided no significant benefit in reducing postoperative pain scores or supplementary analgesic consumption for 0–24 h in one study Egan et al 1992 Click here for more information
  • Clomipramine 50 mg IM and pentazocine 30 mg IM, each administered 30 min postoperatively, were similar for postoperative pain scores within 0–7 h (n=40) Tiengo et al 1987
  • Delta-9-tetrahydrocannabinol 5 mg, administered as a single dose orally 24 h after surgery, did not provide a significant benefit over placebo for reducing postoperative pain scores at 0–6 h after administration (n=40) Buggy et al 2003
  • Naloxone 0.25 µg/kg/h or 1 µg/kg/h conferred no benefit over placebo for reducing postoperative pain scores within 0–24 h and high-dose naloxone increased analgesic consumption over 0–24 h (p<0.05) (although low-dose naloxone decreased analgesic consumption, p<0.05) (n=60) Gan et al 1997

PROSPECT Recommendations

  • Continuous postoperative epidural infusion is not recommended for routine use in hysterectomy patients because its analgesic benefits compared with systemic analgesia are short-lasting and are of marginal clinical significance (up to 4 h) (grade A). Therefore, the risks of the epidural technique outweigh the analgesic benefits in low-risk patients (grade D)
  • Continuous postoperative epidural analgesia with local anaesthetic plus strong opioid is recommended in high-risk patients (e.g. those at risk of organ dysfunction and some patients undergoing extensive surgery for malignancy) – and in these patients it is recommended that the epidural is also used for anaesthesia – because the benefits of the epidural technique, e.g. reduction in inhaled anaesthetics and systemic opioids as well as reduced paralytic ileus and improved pulmonary function (grade
  • Despite the analgesic benefits of epidural clonidine, it is not recommended to control postoperative pain following abdominal hysterectomy because of the incidence of hypotension (grade A), sedation and bradycardia (grade D)

Clinical Practice

  • Epidural analgesia is associated with a relatively high degree of patient monitoring and rare major complications

Transferable Evidence from Other Procedures

  • Epidural analgesia using local anaesthetic was superior to systemic strong opioid for reducing postoperative pain scores in six studies identified in a systematic review of abdominal surgery Jorgensen et al 2000b
  • Epidural analgesia using a combination of local anaesthetic and strong opioid was superior to local anaesthetic alone for reducing postoperative pain – 15 mm reduction in VAS score on a 100-mm scale – in a meta-analysis of five studies in abdominal surgery Jorgensen et al 2000b
  • Epidural analgesia using local anaesthetics was superior to epidural opioids or systemic opioids for reducing the incidence of postoperative gastrointestinal paralysis, in a systematic review in abdominal surgery Jorgensen et al 2000b

Abdominal Hysterectomy-Specific Evidence - Study information

  • Postoperative epidural ropivacaine was superior to placebo for reducing postoperative pain scores at rest and on coughing within 0–2, 0–4 and 4–12 h, but results at 2–22 h were non-significant (n=104) Chinachoti et al 2002
  • Combined epidural strong opioid and local anaesthetic was superior to epidural strong opioid alone for reducing postoperative pain scores within 12–24 h (p<0.05; n=40) Madej et al 1992
  • Combined epidural strong opioid and local anaesthetic was associated with a lower incidence of PONV than epidural strong opioid alone (p<0.05; n=40) Madej et al 1992
  • Addition of sufentanil to morphine, as an epidural bolus dose, gave lower postoperative pain scores than morphine alone for 0–6 h (n=30; n=120) Sinatra et al 1991
  • Epidural bolus morphine alone was superior to sufentanil alone and to morphine plus sufentanil, at 240 min after administration (n=45) Sinatra et al 1991
  • Bupivacaine was superior to morphine for reducing pain scores and for reducing times to recovery of bowel motility Thoren et al 1989 Click here for more information
  • Postoperative epidural high-dose naloxone (0.167 µg/kg/hr) was superior to placebo for reducing postoperative pain scores at 8, 16 and 32 h (p<0.05), but results at 2, 4 and 48 h were non-significant Choi et al 2000 Click here for more information
  • Clonidine or clonidine plus sumatriptan conferred a significant benefit over sumatriptan alone for reducing postoperative pain scores within 0–4 h (p<0.01) in one study Liu at al 1997b Click here for more information
  • Epidural bupivacaine was superior to ropivacaine for reducing supplementary ketorolac consumption and gave a larger spread of sensory block than ropivacaine, while recovery outcomes were not significantly different Jorgensen et al 2000a Click here for more information
  • Diamorphine was superior to ketamine for reducing postoperative pain scores and for extending the time to first analgesic request Peat et al 1989 Click here for more information
  • Epidural analgesia had a statistically significant, and marginally clinically significant, benefit over systemic analgesia for reducing postoperative pain scores at 4 h Hindsholm et al 1993 Click here for more information
  • Epidural analgesia provided a significant benefit over IV administration for reducing analgesic consumption over 24 h Eriksson-Mjoberg et al 1997b Click here for more information
  • Epidural analgesia was associated with a significantly lower incidence of PONV compared with systemic analgesia Camu et al 1991 Click here for more information
  • There is evidence for a limited benefit of epidural clonidine over epidural morphine for reducing postoperative pain scores, but two of two studies showed that clonidine causes hypotension Lund et al 1989 Click here for more information

PROSPECT Recommendations

  • Repeated peri-operative doses by the spinal route are not recommended because they are not considered to be safe or practical (grade D)
  • Spinal local anaesthetic plus strong opioid should be administered only as a single pre-operative bolus dose for postoperative analgesia (grade A) or anaesthetic (grade D) purposes (see Pre-operative Spinal analgesia and Intra-operative Anaesthetic techniques sections)

Clinical Practice

  • Spinal anaesthetics are generally administered as a single pre-operative bolus, and repeated peri-operative doses are not considered to be safe or practical

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

PROSPECT Recommendations

  • Postoperative wound infiltration administered by PCA may have a benefit in controlling postoperative pain, but there is not currently enough evidence to recommend it. However, intra-operative wound infiltration is recommended (grade A) (see Intra-operative Wound Infiltration)

Clinical Practice

  • Intra-operative wound infiltration is a well-established method of analgesia with a favourable safety profile. However, methods of postoperative wound infiltration are not well established

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

  • Postoperative wound infiltration administered by PCA with a 1-h lockout showed a significant benefit of reducing postoperative pain scores on coughing and when raising leg at 4 h (p=0.006 and p=0.009 respectively); however, these comparisons at 1–3 and 5–24 h were non-significant, and results at rest showed no significant benefit at all times (n=36) Zohar et al 2001
  • Postoperative wound infiltration administered by PCA with a 1-h lockout showed a significant benefit in reducing supplementary analgesic consumption within 0–24 h (p<0.001; n=36) Zohar et al 2001
  • Postoperative wound infiltration administered as regular 4-hourly doses provided no significant benefit over placebo for reducing postoperative pain scores at any time (n=41) Kristensen et al 1999
  • Postoperative wound infiltration administered as regular 4-hourly doses provided no significant benefit over placebo for reducing supplementary analgesic consumption (n=41) Kristensen et al 1999

PROSPECT Recommendations

  • Postoperative music is not recommended based on its lack of analgesic efficacy (grade A). However intra-operative music is recommended (See Intra-operative section)
  • Homeopathic arnica and self-relaxation techniques are not recommended based on their lack of analgesic efficacy (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

  • Homeopathic arnica had no significant benefit compared with placebo for VAS pain scores or supplementary analgesic consumption (n=73) Hart et al 1997
  • Postoperative music conferred no significant benefit over placebo for reducing postoperative pain scores or supplementary analgesic consumption (n=40) Taylor et al 1998
  • Self-relaxation provided no significant benefit over placebo for reducing postoperative pain scores or supplementary analgesic consumption (n=28) Mogan et al 1985
A systematic search of the literature between January 2004 and June 2006 identified additional studies of interventions in abdominal hysterectomy, as listed in this folder, together with brief summaries of the study outcomes and a comment from the PROSPECT Working Group regarding the impact of the recent evidence on the recommendations. Additional details of the studies will be included in the main review text at the next full update of the evidence and recommendations.
  • Four out of four studies found that conventional NSAID was superior to placebo or no treatment. In two studies pre-operative conventional NSAID significantly reduced postoperative VAS pain scores at 2 h (at rest and on coughing; Akarsu 2004) and 2, 4, 6 and 12 h (Karaman 2006), compared with placebo. In one study, pre- and intra-operative conventional NSAID significantly reduced postoperative VAS pain scores at 6 h compared with control (no treatment) (Yan 2004). In one study postoperative conventional NSAID significantly increased pain intensity difference (VAS) scores compared with placebo (at 30 min–24 h) and compared with morphine (at 30 min and 1–12 h) groups (Bikhazi 2004)
  • In one study, time to first request for rescue analgesia was significantly longer, and total analgesic consumed was less, following pre-operative conventional NSAID administration, compared with placebo (Akarsu 2004); in another study, PCA morphine consumption was significantly reduced in the group receiving pre-operative conventional NSAID at 2, 4, 6, 12 and 24 h compared with the saline control group (Karaman 2006)
  • In one study there was a significantly higher incidence of nausea and vomiting in the placebo group compared with the pre-operative conventional NSAID group (Akarsu 2004). In two studies there were no significant differences between the incidence of adverse events in the conventional NSAID and placebo groups (Bikhazi 2004; Karaman 2006)

No change to recommendations

  • Three studies out of three showed COX-2-selective inhibitor superior to control for reducing pain scores:
    • In one study, the pre-operative COX-2-selective inhibitor significantly reduced postoperative VAS pain scores at 1, 2, 4, 6, 8 and 12 h compared with placebo (Karamanlioglu 2004)
    • In one study peri-operative COX-2-selective inhibitor, alone and in combination with gabapentin, significantly reduced postoperative VAS pain scores at rest at 20, 24, 28, 32, 44, 48, 52 and 56 h compared with placebo; VAS pain scores at sitting were significantly reduced in the COX-2-selective inhibitor plus gabapentin group at 20h, and following the COX-2-selective inhibitor both alone and in combination with gabapentin at 24, 28, 32, 44, 48, 52, and 56 h compared with placebo; VAS pain scores at peak expiration were significantly reduced following administration of the COX-2-selective inhibitor alone and in combination with gabapentin at 20, 24, 28, 32, 44, 48, 52, and 56 h compared with placebo; VAS pain scores during coughing were significantly reduced in the COX-2-selective inhibitor plus gabapentin group at 20, 24, 28, 32 h, and following administration of the COX-2-selective inhibitor both alone and in combination with gabapentin at 44, 48, 52 and 56 h, compared with placebo (Gilron 2005)
    • In one study, peri-operative COX-2-selective inhibitor, alone and in combination with gabapentin, significantly reduced VRS postoperative pain scores at rest at 4, 8, 16 and 20 h, compared with placebo; COX-2-selective inhibitor in combination with gabapentin significantly reduced VRS pain scores at rest at 12 and 24 h compared with placebo; COX-2-selective inhibitor alone, and in combination with gabapentin, significantly reduced VRS postoperative pain scores during movement at 8 h, and the COX-2 inhibitor alone also showed a significant reduction at 20 h, compared with placebo (Turan 2006)
  • Three out of three studies showed COX-2-selective inhibitor superior to placebo for reducing supplementary analgesic consumption
    • Total and incremental supplementary analgesic consumptions were significantly less in the pre-operative COX-2-selective inhibitor group compared with placebo at 1, 2, 4, 6, 8, and 12 h postoperatively (Karamanlioglu 2004)
    • Cumulative morphine consumption was significantly less in the COX-2-selective inhibitor plus gabapentin group compared with placebo at 2, 3, 4, 8, 20, 24, 28 and 32 h postoperatively, and interval morphine consumption was significantly less in the COX-2-selective inhibitor group at 4–8, 8–20, 20–32, 32–44 and 44–56 h and in the COX-2-selective inhibitor plus gabapentin group at all time points recorded after surgery, compared with placebo (Gilron 2005)
    • PCA morphine requirement was significantly less following administration of the COX-2-selective inhibitor, alone and in combination with gabapentin at 1, 8, 12, 16, 24, and 30 h postoperatively, and at 20 h following the COX-2-selective inhibitor plus gabapentin, compared with placebo (Turan 2006)
  • Three out of three studies showed that COX-2-selective inhibitors are not superior to placebo for reducing the incidence of adverse effects
    • In two studies there was no significant difference in the incidence of adverse events between the COX-2-selective inhibitor group and control (Gilron 2005; Karamanlioglu 2004)
    • In one study there was no significant difference between COX-2 inhibitor alone or gabapentin alone compared with placebo, but there was a significantly lower incidence of nausea in the combination of COX-2-selective inhibitor and gabapentin group compared with the placebo group (Turan 2006)

No change to recommendations

  • One study showed that pre-operative oral clonidine did not significantly reduce pain scores both at rest and during movement compared with placebo at all time points assessed (Oofuvong 2005); one study showed that pre- and postoperative oral clonidine significantly reduced pain scores compared with placebo at all time points assessed (Hidalgo 2005
  • One study showed that intra-operative dexmedetomidine had no effect on pain scores at rest and during movement compared with placebo, both in the PACU and 0–48 h after surgery (Gurbet 2006)
  • Morphine consumption was not significantly different between clonidine and placebo groups at all time points assessed (Hidalgo 2005; Oofuvong 2005)
  • Patients in the intra-operative dexmedetomidine group consumed significantly less postoperative morphine compared with the placebo group, both in the PACU and 0–48 h after surgery (Gurbet 2006)

Systemic clonidine: no change to recommendation
Dexmedetomidine: limited data, so not recommended at the current time

  • One study showed that pre-operative morphine did not significantly reduce subjective pain scores (0–10) compared with saline control (Goldstein 2005)
  • One study showed that postoperative IV morphine significantly reduced VRS pain scores compared with placebo 2 min after administration, but not at any other time point assessed (5, 10 and 15 min) (Larijani 2004)
  • One study showed that intraoperative pethidine significantly reduced VAS pain scores at rest at 0–120 min after surgery compared with postoperative pethidine (Mavioglu 2005)
  • One study showed a significant reduction in supplemental analgesic demands between 15 and 30 min postoperatively, cumulative PCA demands, cumulative pethidine consumption after the first 24 h, and additional pethidine consumption during the first 2 h, in the intraoperative pethidine group compared with the postoperative pethidine group (Mavioglu 2005)

No change to recommendations

  • One study showed that postoperative tramadol significantly reduced VAS pain scores compared with saline control at all time points assessed (0–24 h) (Kocabas 2005)
  • One study demonstrated a significant reduction in PCA morphine requirements at 1, 2, 3, 4, 8, 12, 16, 20 and 24 h after surgery in the postoperative tramadol group compared with the saline control group (Kocabas 2005)

No change to recommendation

  • One study showed that pre-operative spinal morphine significantly reduced VAS pain scores at rest and during coughing at all time points assessed (up to 20 h post-surgery) compared with control (no treatment) (Karaman 2006)
  • One study showed that intra-operative spinal morphine significantly reduced VAS pain scores at 0, 1, 2, 4, and 8 h after surgery compared with IV morphine (Togal 2004)
  • One study showed that pre-operative spinal morphine significantly reduced postoperative morphine consumption in 20 h compared with control (no treatment) (Karaman 2006)
  • One study showed that postoperative total morphine consumption and PCA demands were significantly lower in the group receiving intra-operative spinal morphine compared with the IV morphine group during postoperative 24 h (Togal 2004)

No change to recommendations

  • One study showed that postoperative IV PCA droperidol (50 µg droperidol premixed with 1 mg/ml morphine compared with morphine alone) significantly reduced VRS pain scores at rest (at 72 h) and on coughing/movement (at 48 and 72 h) compared with control (no droperidol). Morphine consumption was significantly lower in the postoperative IV droperidol group at all time points assessed, when compared with control (no droperidol) (Lo 2005)

Not recommended for pain relief due to limited procedure-specific evidence (although droperidol has proven effects on nausea and vomiting)

  • One study showed that pre-operative antihistamine, combined with either a 1.2:1 or a 4.8:1 ratio of antihistamine-morphine mixture for postoperative PCA, did not significantly reduce VAS pain scores at rest or supplemental analgesic requirements at any time point assessed (0–24 h) compared with saline control (Lin 2005)
  • One study showed that neither pre-operative antihistamine alone nor postoperative antihistamine alone significantly reduced VAS pain scores at rest or during movement compared with saline control (Chia 2004)
  • One study showed that patients in the pre-operative antihistamine alone group consumed significantly less morphine at 3, 6, 12, and 24 h postoperatively compared with patients in the postoperative antihistamine alone and saline control groups (Chia 2004)

Not recommended due to limited evidence of analgesic efficacy

  • One study showed that pre- and intra-operative beta-blockers had no effect on VAS pain scores at rest and during movement at all time points assessed compared with saline control (Chia 2004)
  • Patients receiving beta-blockers consumed significantly less PCA morphine at all time points assessed, and the mean total morphine consumption was significantly less, compared with saline control (Chia 2004)

Not recommended because of limited evidence of analgesic efficacy

Single bolus wound instillation

  • One study showed that intra-operative single bolus wound instillation (topically on to peritoneum for 10 min) significantly reduced NRS pain scores at 60 min after surgery compared with placebo (pain assessed every 15 min from 0–120 min after surgery; all other time points not significantly different) (Heid 2005)
  • There were no differences in cumulative morphine consumption or adverse effects observed between the wound instillation and placebo groups (Heid 2005)

Not recommended currently due to limited procedure-specific evidence

 

Continuous wound infusion

  • One study showed that postoperative continuous wound infusion significantly reduced VAS pain scores compared with no wound infusion at rest at 4, 5, 6, and 12h, on coughing at 0–24 h, and on leg raising at 3, 4, 5, 6, and 12 h after surgery (Gupta 2005)
  • Significantly less rescue analgesia was consumed in the continuous wound infusion group compared with the no wound infusion group (pentazocine administered 0–6 h, diclofenac administered 6–24 h) (Gupta 2005)

Not recommended currently due to limited procedure-specific evidence

 

PCA wound infusion

  • One study (published January 2004–June 2006) showed that there were no significant differences in analgesic outcomes between two doses of ropivacaine delivered via PCA wound infusion (Zohar 2004)

Not recommended currently due to limited procedure-specific evidence  

  • One study showed that IP LA + IP conventional NSAID + IP weak opioid significantly reduced VAS pain scores compared with IP LA + IP conventional NSAID (at 1 and 2 h) and IP LA + IP weak opioid (at 2 h) (Pirbudak 2004)
  • Time to first analgesic request was significantly longer, and total supplementary analgesic consumption was significantly lower, in the IP LA + IP conventional NSAID + IP weak opioid group compared with the IP LA + IP conventional NSAID group and the IP LA + IP weak opioid group (Pirbudak 2004)

No change to recommendations

  • One study showed that there were no significant differences in analgesic efficacy between pre-operative and postoperative epidural analgesia (LA + ketamine) (DeCastro 2005)
  • One study showed that there were no significant differences in VAS pain scores at rest and during coughing (at 4, 8, and 21 h), or total morphine consumption, between the postoperative epidural 0.1% ropivacaine + fentanyl group and the postoperative epidural 0.2% ropivacaine group (Thienthong 2004)

No change to recommendations

Two studies showed that abdominal laparoscopic hysterectomy significantly reduced pain scores compared with abdominal hysterectomy (Garry 2004; Garry 2004). One study showed that laparoscopic hysterectomy significantly reduced pain scores compared with abdominal hysterectomy (Learman 2004). One study showed that vaginal hysterectomy significantly reduced pain compared with abdominal hysterectomy (Silva 2006)

 Vaginal hysterectomy studies:

  • Two studies showed that there were no significant differences in pain scores between vaginal hysterectomy and vaginal laparoscopic hysterectomy (Garry 2004; Garry 2004)
  • One study showed that electrosurgical bipolar vessel sealing significantly reduced pain compared with traditional suturing in vaginal hysterectomy (Cronjé 2005)

Further data are required before any changes can be made to the recommendations