Total versus subtotal hysterectomy for benign gynaecological conditions

Anne Lethaby; Asima Mukhopadhyay; Raj Naik

doi:10.1002/14651858.CD004993.pub3

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Figure 1

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 1 Prevalence of stress urinary incontinence within 2 years post surgery.

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Analysis 1.2

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 2 Prevalence of stress urinary incontinence >2 years post surgery.

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Analysis 1.3

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 3 Prevalence of incomplete bladder emptying within 2 years post surgery.

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Analysis 1.4

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 4 Prevalence of incomplete bladder emptying >2 years post surgery.

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Analysis 1.5

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 5 Prevalence of urinary urgency within 2 years post surgery.

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Analysis 1.6

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 6 Prevalence of urinary urgency >2 years post surgery.

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Analysis 1.7

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 7 Prevalence of constipation within 2 years post surgery.

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Analysis 1.8

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 8 Prevalence of constipation >2 years post surgery.

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Analysis 1.9

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 9 Prevalence of incontinence of stools within 2 years post surgery.

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Analysis 1.10

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 10 Prevalence of incontinence of stools >2 years post surgery.

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Analysis 1.11

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 11 Satisfaction with sex within 2 years post surgery.

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Analysis 1.12

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 12 Satisfaction with sex >2 years post surgery.

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Analysis 1.13

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 13 Satisfaction with sex (cont) within 2 years post surgery.

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Analysis 1.15

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 15 Prevalence of pain during sex within 2 years post surgery.

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Analysis 1.16

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 16 Prevalence of pain during sex >2 years post surgery.

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Analysis 1.17

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 17 Quality of life within 2 years post abdominal surgery (high better).

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Analysis 1.18

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 18 Quality of life within 2 years post abdominal surgery (low better).

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Analysis 1.19

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 19 Operating time (mins).

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Analysis 1.20

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 20 Length of hospital stay (days).

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Analysis 1.21

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 21 Return to normal activities (weeks).

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Analysis 1.22

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 22 Requirement for blood transfusion.

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Analysis 1.23

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 23 Blood loss during surgery (mls).

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Analysis 1.24

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 24 Short term complications (predischarge).

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Analysis 1.25

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 25 Intermediate term complications (after discharge and within 2 years post surgery).

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Analysis 1.26

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 26 Long term complications (>2 years post surgery).

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Analysis 1.27

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 27 Alleviation of pre‐surgery symptoms.

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Analysis 1.28

Comparison 1 Subtotal hysterectomy versus total hysterectomy, Outcome 28 Readmission rate (related to surgery).

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Subtotal hysterectomy compared with total hysterectomy for benign gynaecological conditions
Patient or population: Women requiring hysterectomy for benign conditions Settings: Hospital Intervention: Subtotal hysterectomy Comparison: Total hysterectomy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	[control]	[experimental]
Prevalence of stress urinary incontinence within 2 years post surgery [follow‐up]	Low risk population		OR 1.45 (0.85 to 2.47)	955	⊕⊕⊕⊝ moderate	Stress incontinence was measured in most trials by questionnaire, but in Thakar it was more objectively determined by the use of twin‐channel subtracted cystometrography
	52 per 1000	73 per 1000
	Medium risk population
	[value] per 1000	[value] per 1000 ([value] to [value])
	High risk population
	[value] per 1000	[value] per 1000 ([value] to [value])
Prevalence of constipation within 2 years post surgery [follow‐up]	Low risk population		OR 0.80 (0.49 to 1.31)	555	⊕⊕⊝⊝ low	Evaluated by questionnaire. Inconsistency between trials.
	[value] per 1000	[value] per 1000 ([value] to [value])
	Medium risk population
	150 per 1000	126 per 1000 ([value] to [value])
	High risk population
	[value] per 1000	[value] per 1000 ([value] to [value])
Satisfaction with sex within 2 years post surgery [follow‐up]	Low risk population		OR 1.04 (0.68 to 1.59)	454	⊕⊕⊝⊝ low	Evaluated by questionnaire. Inconsistency between trials may have resulted from different questions on sexual satisfaction being asked.
	[value] per 1000	[value] per 1000 ([value] to [value])
	Medium risk population
	[value] per 1000	[value] per 1000 ([value] to [value])
	High risk population
	725 per 1000	736 per 1000 ([value] to [value])
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio; [other abbreviations, eg. OR, etc]
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

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Comparison 1. Subtotal hysterectomy versus total hysterectomy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Prevalence of stress urinary incontinence within 2 years post surgery Show forest plot	5	955	Odds Ratio (M‐H, Fixed, 95% CI)	1.45 [0.85, 2.47]

1.1 Abdominal surgery	4	826	Odds Ratio (M‐H, Fixed, 95% CI)	1.55 [0.86, 2.78]
1.2 Laparoscopic surgery	1	129	Odds Ratio (M‐H, Fixed, 95% CI)	1.05 [0.29, 3.82]
2 Prevalence of stress urinary incontinence >2 years post surgery Show forest plot	1	178	Odds Ratio (M‐H, Fixed, 95% CI)	1.15 [0.63, 2.08]

2.1 Abdominal surgery	1	178	Odds Ratio (M‐H, Fixed, 95% CI)	1.15 [0.63, 2.08]
2.2 Laparoscopic surgery	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Prevalence of incomplete bladder emptying within 2 years post surgery Show forest plot	4	768	Odds Ratio (M‐H, Fixed, 95% CI)	0.94 [0.59, 1.47]

3.1 Abdominal surgery	3	639	Odds Ratio (M‐H, Fixed, 95% CI)	0.89 [0.55, 1.45]
3.2 Laparoscopic surgery	1	129	Odds Ratio (M‐H, Fixed, 95% CI)	1.28 [0.37, 4.44]
4 Prevalence of incomplete bladder emptying >2 years post surgery Show forest plot	1	173	Odds Ratio (M‐H, Fixed, 95% CI)	0.69 [0.37, 1.29]

4.1 Abdominal surgery	1	173	Odds Ratio (M‐H, Fixed, 95% CI)	0.69 [0.37, 1.29]
4.2 Laparoscopic surgery	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Prevalence of urinary urgency within 2 years post surgery Show forest plot	2	254	Odds Ratio (M‐H, Fixed, 95% CI)	1.05 [0.47, 2.37]

5.1 Abdominal surgery	1	125	Odds Ratio (M‐H, Fixed, 95% CI)	0.86 [0.25, 2.99]
5.2 Laparoscopic surgery	1	129	Odds Ratio (M‐H, Fixed, 95% CI)	1.23 [0.42, 3.61]
6 Prevalence of urinary urgency >2 years post surgery Show forest plot	1	174	Odds Ratio (M‐H, Fixed, 95% CI)	1.26 [0.68, 2.32]

6.1 Abdominal surgery	1	174	Odds Ratio (M‐H, Fixed, 95% CI)	1.26 [0.68, 2.32]
6.2 Laparoscopic surgery	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Prevalence of constipation within 2 years post surgery Show forest plot	2	555	Odds Ratio (M‐H, Fixed, 95% CI)	0.80 [0.49, 1.31]

7.1 Abdominal surgery	2	555	Odds Ratio (M‐H, Fixed, 95% CI)	0.80 [0.49, 1.31]
7.2 Laparoscopic surgery	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Prevalence of constipation >2 years post surgery Show forest plot	1	165	Odds Ratio (M‐H, Fixed, 95% CI)	1.52 [0.67, 3.45]

8.1 Abdominal surgery	1	165	Odds Ratio (M‐H, Fixed, 95% CI)	1.52 [0.67, 3.45]
8.2 Laparoscopic surgery	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Prevalence of incontinence of stools within 2 years post surgery Show forest plot	1	166	Odds Ratio (M‐H, Fixed, 95% CI)	0.52 [0.05, 5.83]

9.1 Abdominal surgery	1	166	Odds Ratio (M‐H, Fixed, 95% CI)	0.52 [0.05, 5.83]
9.2 Laparoscopic surgery	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Prevalence of incontinence of stools >2 years post surgery Show forest plot	1	166	Odds Ratio (M‐H, Fixed, 95% CI)	0.52 [0.05, 5.83]

10.1 Abdominal surgery	1	166	Odds Ratio (M‐H, Fixed, 95% CI)	0.52 [0.05, 5.83]
10.2 Laparoscopic surgery	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Satisfaction with sex within 2 years post surgery Show forest plot	2	454	Odds Ratio (M‐H, Fixed, 95% CI)	1.04 [0.68, 1.59]

11.1 Abdominal surgery	2	454	Odds Ratio (M‐H, Fixed, 95% CI)	1.04 [0.68, 1.59]
11.2 Laparoscopic surgery	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Satisfaction with sex >2 years post surgery Show forest plot	1	131	Odds Ratio (M‐H, Fixed, 95% CI)	0.95 [0.13, 6.98]

12.1 Abdominal hysterectomy	1	131	Odds Ratio (M‐H, Fixed, 95% CI)	0.95 [0.13, 6.98]
12.2 Laparoscopic hysterectomy	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Satisfaction with sex (cont) within 2 years post surgery Show forest plot	2	192	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.15 [‐0.43, 0.13]

13.1 Abdominal surgery	1	129	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.04 [‐0.39, 0.30]
13.2 Laparoscopic surgery	1	63	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.37 [‐0.87, 0.13]
14 Satisfaction with sex (cont) >2 years post surgery	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.1 Abdominal surgery	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.2 Laparoscopic surgery	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Prevalence of pain during sex within 2 years post surgery Show forest plot	2	452	Odds Ratio (M‐H, Fixed, 95% CI)	0.87 [0.46, 1.67]

15.1 Abdominal surgery	2	452	Odds Ratio (M‐H, Fixed, 95% CI)	0.87 [0.46, 1.67]
15.2 Laparoscopic surgery	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 Prevalence of pain during sex >2 years post surgery Show forest plot	1	133	Odds Ratio (M‐H, Fixed, 95% CI)	0.56 [0.25, 1.23]

16.1 Abdominal surgery	1	133	Odds Ratio (M‐H, Fixed, 95% CI)	0.56 [0.25, 1.23]
16.2 Laparoscopic surgery	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Quality of life within 2 years post abdominal surgery (high better) Show forest plot	5		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

17.1 General (abdominal)	3	478	Mean Difference (IV, Fixed, 95% CI)	0.35 [‐0.27, 0.97]
17.2 Physical domain (abdominal)	3	652	Mean Difference (IV, Fixed, 95% CI)	‐0.52 [‐2.18, 1.14]
17.3 Mental domain (abdominal)	4	831	Mean Difference (IV, Fixed, 95% CI)	‐0.61 [‐2.05, 0.82]
18 Quality of life within 2 years post abdominal surgery (low better) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

18.1 General (abdominal)	1	179	Mean Difference (IV, Fixed, 95% CI)	‐1.0 [‐4.92, 2.92]
18.2 Anxiety (abdominal)	1	179	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐2.68, 3.08]
18.3 Depression (abdominal and laparoscopic)	2	242	Mean Difference (IV, Fixed, 95% CI)	‐0.27 [‐1.55, 1.00]
18.4 Psychological domain (laparoscopic)	1	63	Mean Difference (IV, Fixed, 95% CI)	‐2.0 [‐15.66, 11.66]
19 Operating time (mins) Show forest plot	5		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

19.1 Abdominal surgery	4	694	Mean Difference (IV, Fixed, 95% CI)	‐11.26 [‐15.07, ‐7.45]
19.2 Laparoscopic surgery	1	141	Mean Difference (IV, Fixed, 95% CI)	‐5.0 [‐14.80, 4.80]
20 Length of hospital stay (days) Show forest plot	6		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

20.1 Abdominal surgery	5	844	Mean Difference (IV, Fixed, 95% CI)	‐0.17 [‐0.39, 0.04]
20.2 Laparoscopic surgery	1	141	Mean Difference (IV, Fixed, 95% CI)	‐0.20 [‐0.62, 0.22]
21 Return to normal activities (weeks) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

21.1 Abdominal surgery	2	310	Mean Difference (IV, Fixed, 95% CI)	‐0.14 [‐0.53, 0.25]
21.2 Laparoscopic surgery	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
22 Requirement for blood transfusion Show forest plot	5		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

22.1 Abdominal surgery	4	694	Odds Ratio (M‐H, Fixed, 95% CI)	1.24 [0.61, 2.54]
22.2 Laparoscopic surgery	1	141	Odds Ratio (M‐H, Fixed, 95% CI)	1.25 [0.32, 4.86]
23 Blood loss during surgery (mls) Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

23.1 Abdominal surgery	3	589	Mean Difference (IV, Fixed, 95% CI)	‐56.63 [‐99.58, ‐13.68]
23.2 Laparoscopic surgery	1	141	Mean Difference (IV, Fixed, 95% CI)	‐36.0 [‐145.35, 73.35]
24 Short term complications (predischarge) Show forest plot	6		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

24.1 Surgical injury	3	549	Odds Ratio (M‐H, Fixed, 95% CI)	0.28 [0.06, 1.36]
24.2 Pelvic haematoma/abscess	3	660	Odds Ratio (M‐H, Fixed, 95% CI)	0.41 [0.13, 1.32]
24.3 Vaginal bleeding	3	660	Odds Ratio (M‐H, Fixed, 95% CI)	0.74 [0.29, 1.91]
24.4 Wound infection	3	733	Odds Ratio (M‐H, Fixed, 95% CI)	0.86 [0.38, 1.95]
24.5 Pyrexia (fever)	5	933	Odds Ratio (M‐H, Fixed, 95% CI)	0.48 [0.31, 0.75]
24.6 Urinary retention	5	933	Odds Ratio (M‐H, Fixed, 95% CI)	0.23 [0.06, 0.81]
24.7 Bowel obstruction/ileus	4	731	Odds Ratio (M‐H, Fixed, 95% CI)	0.59 [0.24, 1.46]
25 Intermediate term complications (after discharge and within 2 years post surgery) Show forest plot	5		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

25.1 Ongoing cyclical bleeding	5	964	Odds Ratio (M‐H, Fixed, 95% CI)	15.97 [6.14, 41.56]
25.2 Persistent pain	5	963	Odds Ratio (M‐H, Fixed, 95% CI)	0.90 [0.58, 1.38]
25.3 Removal of cervical stump	2	457	Odds Ratio (M‐H, Fixed, 95% CI)	5.14 [0.60, 44.35]
25.4 Pelvic prolapse	4	839	Odds Ratio (M‐H, Fixed, 95% CI)	2.74 [0.80, 9.34]
25.5 Gynaecological cancer	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
26 Long term complications (>2 years post surgery) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

26.1 Fistula	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
26.2 Pelvic prolapse	1	127	Odds Ratio (M‐H, Fixed, 95% CI)	0.84 [0.41, 1.70]
26.3 Gynaecological cancer	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
27 Alleviation of pre‐surgery symptoms Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

27.1 Back pain	2	266	Odds Ratio (M‐H, Fixed, 95% CI)	1.33 [0.78, 2.27]
27.2 Pelvic pressure	2	266	Odds Ratio (M‐H, Fixed, 95% CI)	0.69 [0.28, 1.68]
27.3 Menstrual abnormalities	1	141	Odds Ratio (M‐H, Fixed, 95% CI)	3.00 [0.12, 74.90]
27.4 Pelvic pain	1	141	Odds Ratio (M‐H, Fixed, 95% CI)	0.86 [0.31, 2.38]
28 Readmission rate (related to surgery) Show forest plot	5		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

28.1 Abdominal surgery	4	869	Odds Ratio (M‐H, Fixed, 95% CI)	1.10 [0.63, 1.91]
28.2 Laparoscopic surgery	1	141	Odds Ratio (M‐H, Fixed, 95% CI)	1.96 [0.68, 5.62]

Comparison 1. Subtotal hysterectomy versus total hysterectomy

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