Is total laparoscopic hysterectomy with longer operative time associated with a decreased benefit compared with total abdominal hysterectomy?

The impact of body mass index on surgical complications in minimally invasive hysterectomy for uterine fibroids

RESEARCH QUESTION

We aimed to assess the impact of Body Mass Index (BMI) on 30-day postoperative complications in patients undergoing minimally invasive hysterectomy (MIH) for fibroids.

DESIGN

Using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2012-2020), we analyzed major and minor 30-day postoperative complications, stratified by BMI, in patients with uterine fibroids who underwent MIH. Complications were stratified according to the Clavien-Dindo classification.

RESULTS

Among 61,192 patients, overall complication rates ranged from 6.3 % to 8.1 %, with the highest rates in obesity class 3. Significant differences were observed in minor complication rates across BMI groups, though major complication rates did not significantly vary. Higher BMI classes correlated with longer operative times, with mean durations ranging from 127.1 min in the lowest BMI group to 158.1 min in the highest BMI group (p < 0.001). In multivariable regression, higher BMI was associated with increased odds of minor complications [

CONCLUSION

After adjusting for confounding factors, overweight, obesity class 2 and 3 are associated with a decreased risk of major complications compared to normal BMI. In contrast, BMI categories were not associated with any- or minor complications. Higher BMI classes were associated with longer operative times.

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Key Words

• Minimally invasive hysterectomy (MIH)
• Myoma
• Obesity paradox
• Postoperative complications
• Uterine fibroids
• body mass index (BMI)

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MESH Headings

• Humans
• Female
• Body Mass Index
• Leiomyoma/surgery
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Hysterectomy/adverse effects
• Hysterectomy/methods
• Middle Aged
• Adult
• Uterine Neoplasms/surgery
• Minimally Invasive Surgical Procedures/adverse effects
• Obesity/complications
• Operative Time
• Retrospective Studies

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Affiliation(s)

Michal Axelrod Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel; The School of Medicine, Tel Aviv University, Israel.
Kacey M Hamilton Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States
Rebecca J Schneyer Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States
Gabriel Levin Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Quebec, Canada
Yotam Weiss The School of Medicine, Tel Aviv University, Israel; Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Israel
Matthew T Siedhoff Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States
Kelly N Wright Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States
Raanan Meyer Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel; The School of Medicine, Tel Aviv University, Israel; Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States; The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel

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Comparison of Recurrence and Survival Between Patients With Pathological Stage I Epithelial Ovarian Cancer After Laparoscopic or Laparotomic Surgery: Retrospective Analysis of a Propensity-Matched Cohort

OBJECTIVE

To compare oncologic outcomes after laparoscopic or laparotomic surgery to treat epithelial ovarian carcinoma in FIGO Stage I.

DESIGN

Retrospective cohort study.

SETTING

Gynecological cancer ward in a tertiary hospital.

PARTICIPANTS

A total of 85 patients with FIGO Stage I epithelial ovarian carcinoma who underwent laparoscopic staging surgery and 206 who underwent laparotomic staging surgery at West China Second Hospital, Sichuan University (Chengdu, China) between January 1, 2013 and December 31, 2019.

INTERVENTIONS

Laparoscopic surgery or laparotomic staging surgery.

RESULTS

Before propensity score-based matching, the laparotomy group showed higher prevalence of preoperative elevated CA125 level (48.5% vs 35.3%, p = .045) and tumors >15 cm (27.2% vs 5.9%, p <.001). Multivariate analysis associated higher body mass index with better overall survival (adjusted HR 0.83, 95% CI 0.70-0.99, p = .043). Among propensity score-matched patients (82 per group) who were matched to each other according to propensity scoring based on age, body mass index, CA125 level, largest tumor diameter, FIGO stage, history of abdominal surgery, and American Society of Anesthesiologists grade, the rate of progression-free survival at 5 years was similar between the laparoscopy group (87.1%, 95% CI 79.3-95.7%) and the laparotomy group (90.9%, 95% CI 84.7-97.6%, p = .524), as was the rate of overall survival at 5 years (93.9%, 95% CI 88.0-100.0% vs 94.7%, 95% CI 89.8-99.9%, p = .900). Regardless of whether patients were matched, the two groups showed similar rates of recurrence of 9-11% during follow-up lasting a median of 54.9 months.

CONCLUSIONS

Rates of recurrence and survival may be similar between laparoscopy or laparotomy to treat Stage I epithelial ovarian cancer. Since laparoscopy is associated with less bleeding and faster recovery, it may be a safe, effective alternative to laparotomy for appropriate patients.

Operative Time and Accrual of Postoperative Complications in Minimally Invasive Versus Open Myomectomy

STUDY OBJECTIVE

To compare the prevalence and accrual of 30-day postoperative complications by operative time for open myomectomy (OM) and minimally invasive myomectomy (MIM).

DESIGN

Retrospective cohort study SETTING: Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2021.

PATIENTS

Female patients aged ≥18 years undergoing OM or MIM.

INTERVENTIONS

Patients were categorized into OM and MIM cohorts. Covariates associated with operative time and composite complications were identified using general linear model and chi-square or Fisher's exact test as appropriate. Adjusted spline regression was performed as a test of linearity between operative time and composite complications. Adjusted risk ratios of 30-day postoperative individual, minor, major, and composite complications by 60-minute operative time increments were estimated using Poisson regression with robust error variance.

MEASUREMENTS AND MAIN RESULTS

Of 27 728 patients, 11 071 underwent MIM and 16 657 underwent OM. Mean operative times (SD) were 164.6 (82.0) for MIM and 129.2 (67.0) for OM. Raw composite complication rates were 5.5% for MIM and 15.8% for OM. Adjusted spline regression demonstrated linearity between operative time and relative risk of composite postoperative complications for both MIM and OM. MIM had higher adjusted relative risk (aRR, 95% CI) compared to OM of blood transfusion (1.55, 1.45-1.64 versus 1.29, 1.25-1.34), overall minor complications (1.13, 1.03-1.23 versus 1.01, 0.92-1.10), and overall major complications (1.43, 1.35-1.51 versus 1.27, 1.12-1.32). Operative time had greater impact on risk of composite complications for MIM than OM, reaching aRR 2.0 at 296 minutes versus 461 minutes for OM.

CONCLUSION

OM has a higher overall rate of composite, minor, and major complications compared to MIM. While operative time is independently and linearly associated with postoperative complications with myomectomy regardless of approach, optimizing surgical efficiency for MIM may be more critical than for OM.

Comparison of surgical and oncological outcomes between different surgical approaches for overweight or obese cervical cancer patients

The purpose was to investigate the safety and advantages of different surgical approaches applied to overweight or obese cervical cancer patients by comparing their surgical and oncological outcomes. This is a retrospective cohort study. 382 patients with a body mass index of at least 24.0 kg/m2 and stage IB-IIA (The International Federation of Gynecology and Obstetrics, FIGO 2009) cervical cancer were enrolled, and then were divided into three groups: open radical hysterectomy (ORH) group, laparoscopic radical hysterectomy (LRH) group, and robot-assisted radical hysterectomy (RRH) group according to the surgical approach. IBM SPSS version 25.0 was used to analyze data. There were 51 patients in ORH group, 225 patients in LRH group and 106 patients in RRH group. In the comparison of surgical outcomes, compared to LRH and ORH, RRH had the shortest operating time, the least estimated blood loss, the shortest postoperative hospital stay, and the shortest recovery time for bowel function (P < 0.05). In the comparison of postoperative complications, ORH has the highest rate of postoperative infection and wound complication compared to LRH and RRH (P < 0.05), and RRH has the highest proportion of urinary retention. After a median follow-up time of 61 months, there was no statistically significant difference between the three groups in terms of 5-year overall survival (OS) rate and 5-year recurrence-free survival (RFS) rate, (P = 0.262, P = 0.453). In patients with overweight or obese cervical cancer, the long-term outcomes of the three surgical approaches were comparable, with RRH showing significant advantages over ORH and LRH in terms of surgical outcomes.

Reducing patient's perception of postoperative vaginal bleeding after laparoscopic hysterectomy via independent closure of the vaginal cuff angles (RCT)

STUDY OBJECTIVE

Determine if independently suturing the vaginal cuff angles in addition to running barbed suture has an effect on patients' perception of postoperative bleeding after laparoscopic hysterectomy.

DESIGN

Randomized controlled trial.

SETTING

University-based medical center.

PATIENTS

Females ages 18-60 undergoing laparoscopic hysterectomy.

INTERVENTIONS

Patients were randomly assigned to either cuff closure via single layer of barbed suture (control) vs adding figure-of-eight stitches at each angle (intervention). A survey was given between 10 and 25 days after surgery inquiring about bleeding and dyspareunia. A second survey was given between postoperative days 90-114. Chart review was performed to record emergency room visits, complications, infections, and reoperations during the first 90 postoperative days.

RESULTS

n = 117 patients were analyzed. 62 (control) and 55 (intervention). Groups were similar in terms of age (42.92 v 44.29p =.35), BMI (33.79 v 34.06p =.85), diabetes (5.26 % (3/55) v 15.09 % (8/53) p =.08) p =.97). Bleeding was decreased in intervention arm (24.19 % (15/62) v 9.09 % (5/55) p =.03). Median (IQR) pelvic pain score was similar (2.0 (0-5.0) v 2.0 (0-4.0) p =.26). Median total operative time (IQR) (129 min (102, 166) v 139 min (120, 163) p =.39) and median EBL (IQR) (50 mL (30-75) vs 50 mL (20-75) p =.43) were similar. Cuff closure in seconds (IQR) was higher in intervention group (373 sec (323, 518) v 571 sec (520, 715) p <.01). 8/60 control patients visited the ED (13.33 %) v 7/54 (12.96 %) p =.95. Readmissions (1.67 % (1/60) v 1.85 % (1/55) p = 1), re-operations (0 % (0/60) v 1.85 % (1/55) p =.47) and postoperative infections (5.0 % (3/60) v 1.85 % (1/54) p =.62) were similar. Secondary survey showed no significant difference in bleeding (15.38 % (4/26) v 4.35 % (1/23) p =.35) and SF-36 results were similar.

CONCLUSION

Independently suturing the vaginal cuff angles reduces patients' perception of vaginal bleeding in the early postoperative period. Incidence of complications, reoperations, and long-term quality of life are similar.

Venous Thromboembolism After Abdominal and Minimally Invasive Large Specimen Hysterectomy

STUDY OBJECTIVE

To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route of surgery and operative time in the development of VTE in this population.

DESIGN

Retrospective cohort study (Canadian Task Force Classification II2) of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program involving over 500 hospitals across the United States.

SETTING

National Surgical Quality Improvement Program Database.

PATIENTS

Women aged 18 years or older undergoing hysterectomy for benign indications between 2014 and 2019. Patients were further classified into 4 groups according to uterine weight: <100 g, 100-249 g, 250 g-499 g, and specimens ≥500 g.

INTERVENTIONS

Current Procedural Terminology codes were used to identify cases. Variables including age, ethnicity, body mass index, smoking status, diabetes, hypertension, blood transfusion, and American Society of Anesthesiologists classification system scores were collected. Cases were stratified by route of surgery, operative time, and uterine weight.

MEASUREMENTS AND MAIN RESULTS

A total of 122,418 hysterectomies occurring between 2014 and 2019 were included in our study, of which 28,407 (23.2%) patients underwent abdominal, 75,490 (61.7%) laparoscopic, and 18,521 (15.1%) vaginal hysterectomy. The overall rate of VTE in patients with large specimen hysterectomies (≥500 g) was 0.64%. After multivariable adjustment, there was no significant difference in the odds of VTE between uterine weight groups. Only 30% of the surgeries with uterine weight above 500 g were performed with minimally invasive surgical routes. Patients who underwent minimally invasive hysterectomy had lower odds of VTE via laparoscopic (adjusted odds ratio [aOR] 0.62; confidence interval [CI]: 0.48-0.81) and vaginal (aOR 0.46; CI: 0.31-0.69) routes compared to laparotomy. Prolonged operative time (>120 min) was associated with increased odds of VTE (aOR 1.86; CI:1.51-2.29).

CONCLUSION

The occurrence of VTE after a benign large specimen hysterectomy is rare. The odds of VTE is higher with longer operative times and lower with minimally invasive approaches, even for markedly enlarged uteri.