Hysterectomy Trends and Risk of Vaginal Cuff Dehiscence: An Update by Mode of Surgery

STUDY OBJECTIVE

To analyze hysterectomy trends and vaginal cuff dehiscence (VCD) rates by mode of surgery at a tertiary care medical center and to describe characteristics of VCD cases.

DESIGN

Observational retrospective cohort study.

SETTING

Large academic hospital and affiliated community hospital.

PATIENTS

4722 patients who underwent hysterectomy at Columbia University Irving Medical Center between January 2010 and August 2021.

INTERVENTIONS

Current Procedural Terminology and International Classification of Diseases codes identified hysterectomies and VCD cases. Hysterectomy trends and VCD rates were calculated by mode of surgery. Relative risks of VCD for each mode were compared with total abdominal hysterectomy (TAH). Clinical characteristics of VCDs were reviewed.

MEASUREMENTS AND MAIN RESULTS

There were 4059 total hysterectomies. Laparoscopic hysterectomies, including total laparoscopic hysterectomies (TLHs), laparoscopic-assisted vaginal hysterectomies, and robot-assisted TLHs (RA-TLHs), increased from 41.9% in 2010 to 65.9% in 2021 (p <.001). RA-TLH increased from 5.7% in 2010 to 40.2% in 2021. Supracervical hysterectomies followed similar trends and were excluded from VCD analysis. There were 15 VCDs (overall rate 0.37%). VCD was highest after RA-TLH (0.66%), followed by TLH (0.32%) and TAH (0.27%), with no VCDs after laparoscopic-assisted vaginal hysterectomy or total vaginal hysterectomy. Compared with TAH, the relative risk for VCD after RA-TLH was 2.44 (95% confidence interval 0.66-9.00) and after TLH was 1.18 (95% confidence interval 0.24-5.83), which were not statistically significant. The mean time to dehiscence was 39 days (range 8-145 days). The most common trigger event was coitus (41%).

CONCLUSION

VCD rates were low (<1%) for all modes of hysterectomy, and rates after robotic and laparoscopic hysterectomy were much lower than previously reported. Although VCD rates trended higher after robotic and laparoscopic hysterectomy compared with abdominal hysterectomy, the difference was not significant. It is difficult to determine whether this finding represents true lack of difference vs a lack of power to detect a significant difference given the rarity of VCD.

Radiofrequency Ablation of Uterine Fibroids and Pregnancy Outcomes: An Updated Review of the Literature

OBJECTIVE

To provide a systematic review of pregnancy outcomes after radiofrequency ablation of uterine fibroids.

DATA SOURCES

A literature search was conducted using PubMed, Cochrane Library, Scopus, Web of Science, and EMBASE, from database inception until October 2021.

METHODS OF STUDY SELECTION

Two reviewers conducted independent literature searches. Studies that met criteria based on title and abstract underwent full text review. Publications were included if they reported pregnancies and obstetric outcomes after laparoscopic or transcervical radiofrequency ablation (RFA) of fibroids.

TABULATION, INTEGRATION, AND RESULTS

405 publications were initially identified and screened, 39 underwent full text review, and 10 publications were ultimately included. There were 50 pregnancies reported among 923 RFA patients: 40 pregnancies after 559 laparoscopic RFAs and 10 pregnancies after 364 transcervical RFAs. The number of patients from these studies actively trying to conceive after RFA is unknown. Among the RFA patients who conceived, the average age at ablation was 37 years old (range 27 to 46 years). The majority of patients had between 1 and 3 fibroids ablated, and fibroid size ranged from less than 2 centimeters to 12.5 centimeters. There were 6 spontaneous abortions (12%) and 44 full-term pregnancies (88%), of which 24 were vaginal deliveries and 20 were cesarean deliveries. There were only 2 complications among 44 deliveries: 1 placenta previa that underwent an uncomplicated cesarean delivery and 1 delayed postpartum hemorrhage with expulsion of a degenerated myoma, with no long-term sequelae. There were no cases of uterine rupture, uterine window, or invasive placentation, and no fetal complications. The spontaneous abortion rate was comparable to the general obstetric population.

CONCLUSION

Almost all pregnancies after radiofrequency ablation of fibroids were full-term deliveries with no maternal or neonatal complications. These findings add to the literature that radiofrequency fibroid ablation may offer a safe and effective alternative to existing treatments for women who desire future fertility.

Where Have All the Emergencies Gone? The Impact of the COVID-19 Pandemic on Obstetric and Gynecologic Procedures and Consults at a New York City Hospital

Study Objective

The purpose of this study was to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical volume and emergency department (ED) consults across obstetrics-gynecology (OB-GYN) services at a New York City hospital.

Design

Retrospective cohort study.

Setting

Tertiary care academic medical center in New York City.

Patients

Women undergoing OB-GYN ED consults or surgeries between February 1, 2020 and April 15, 2020.

Interventions

March 16 institutional moratorium on elective surgeries.

Measurements and Main Results

The volume and types of surgeries and ED consults were compared before and after the COVID-19 moratorium. During the pandemic, the average weekly volume of ED consults and gynecology (GYN) surgeries decreased, whereas obstetric (OB) surgeries remained stable. The proportions of OB-GYN ED consults, GYN surgeries, and OB surgeries relative to all ED consults, all surgeries, and all labor and delivery patients were 1.87%, 13.8%, 54.6% in the pre–COVID-19 time frame (February 1–March 15) vs 1.53%, 21.3%, 79.7% in the COVID-19 time frame (March 16–April 15), representing no significant difference in proportions of OB-GYN ED consults (p = .464) and GYN surgeries (p = .310) before and during COVID-19, with a proportionate increase in OB surgeries (p <.002). The distribution of GYN surgical case types changed significantly during the pandemic with higher proportions of emergent surgeries for ectopic pregnancies, miscarriages, and concern for cancer (p <.001). Alternatively, the OB surgery distribution of case types remained relatively constant.

Conclusion

This study highlights how the pandemic has affected the ways that patients in OB-GYN access and receive care. Institutional policies suspending elective surgeries during the pandemic decreased GYN surgical volume and affected the types of cases performed. This decrease was not appreciated for OB surgical volume, reflecting the nonelective and time-sensitive nature of obstetric care. A decrease in ED consults was noted during the pandemic begging the question “Where have all the emergencies gone?” Although the moratorium on elective procedures was necessary, “elective” GYN surgeries remain medically indicated to address symptoms such as pain and bleeding and to prevent serious medical sequelae such as severe anemia requiring transfusion. As we continue to battle COVID-19, we must not lose sight of those patients whose care has been deferred.

Use of Fundamentals of Laparoscopic Surgery Testing to Assess Gynecologic Surgeons: A Retrospective Cohort Study of 10-Years Experience

STUDY OBJECTIVE

To compare the Fundamentals of Laparoscopic Surgery (FLS) exam scores between obstetrics and gynecology (OBGYN) and general surgery (GS) providers.

DESIGN

This is a retrospective cohort study at a single institution from July 2007 to May 2018. Categorical and continuous variables were analyzed with χ2 test, t test, and Wilcoxon rank sum test.

SETTING

Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, a tertiary care academic medical center.

PATIENTS

All providers who took the FLS exam at the Carl J. Shapiro Simulation and Skills Center at BIDMC.

INTERVENTIONS

FLS certification.

MEASUREMENTS AND MAIN RESULTS

A total of 205 BIDMC trainees and faculty took the FLS exam between July 2007 and May 2018, of which 176 were identified to be OBGYN or GS providers. The FLS certification pass rate was high for both specialties (97.0% OBGYN vs 96.1% sGS, p = .76). When comparing all providers, no significant difference was found in the mean manual skill test scores between surgical specialties (594.9 OBGYN vs 601.0 GS, p = .59); whereas, a significant difference was noted in the mean cognitive scores, with GS providers scoring higher than OBGYN providers (533.8 OBGYN vs 583.4 GS, p <.001). However, when adjusting for several variables in a multivariate linear regression model, surgical specialty was not a predictor for cognitive scores. In the multivariate analysis, age, sex, and test year were predictors for cognitive scores, with higher scores associated with younger age, male sex, and advancing calendar year. None of the variables were significant predictors of manual scores.

CONCLUSION

Both OBGYN and GS providers had extremely high FLS pass rates. In the multivariate analysis, surgical specialty was not a predictor for higher FLS test scores for either manual or cognitive test scores. Although OBGYN residency programs offer fewer years of training, OBGYN trainees demonstrate the capacity to perform well on the FLS exam.

ACOG Simulation Working Group: A Needs Assessment of Simulation Training in OB/GYN Residencies and Recommendations for Future Research

OBJECTIVE

To evaluate current availability and needs of simulation training among obstetrics/gynecology (OB/GYN) residency programs.

DESIGN

Cross-sectional survey.

SETTING

Accreditation Council for Graduate Medical Education accredited OB/GYN residency programs in the United States.

PARTICIPANTS

Residency program directors, gynecology simulation faculty, obstetrics simulation faculty, and fourth-year residents.

RESULTS

Of 673 invited participants, 251 (37.3%) completed the survey. Among the survey responses, OB procedures were more broadly represented compared to the GYN procedures for simulation teaching: 8 (50%) of 16 OB procedures versus 4 (18.2%) of 22 GYN procedures had simulation teaching. Among the simulated procedures, a majority of residents and faculty reported that simulation teaching was available for operative vaginal delivery, postpartum hemorrhage, shoulder dystocia, perineal laceration repair, conventional laparoscopic procedures, and robotic surgery. There were significant differences between residents and faculty perceptions regarding the availability and needs of simulated procedures with a minority of residents having knowledge of Council on Resident Education in Obstetrics and Gynecology (47.2%) and American College of Obstetrics and Gynecology (27.8%) simulation tools compared to the majority of faculty (84.7% and 72.1%, respectively). More than 80% of trainees and faculty reported they felt the average graduating resident could perform vaginal, laparoscopic, and abdominal hysterectomies independently.

CONCLUSIONS

Simulation is now widely available for both gynecologic and obstetric procedures, but there remains tremendous heterogeneity between programs and the perceptions of residents, program directors, and faculty. The variations in simulation training and readiness for performing different procedures following residency support the need for objective, validated assessments of actual performance to better guide resident learning and faculty teaching efforts.

Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention

Objective

To examine narrative feedback to understand surgical team perceptions about surgical safety checklists (SSCs) and their impact on the safety of surgical practice.

Design

We reviewed free-text comments from surveys administered before and after SSC implementation between 2011 and 2013. We categorized feedback thematically and as positive, negative or neutral.

Setting

South Carolina hospitals participating in a statewide collaborative on checklist implementation.

Participants

Surgical teams from 11 hospitals offering free-text comments in both pre-and post-implementation surveys.

Intervention

Implementation of the World Health Organization SSC.

Main Outcome Measure

Differences in comments made before and after implementation and by provider role; types of complications averted through checklist use.

Results

Before SSC implementation, the proportion of positive comments among provider roles differed significantly (P = 0.04), with more clinicians offering negative comments (87.9%, (29/33)) compared to other surgical team members (58.3% (7/12) to 60.9% (14/23)), after SSC implementation, these proportions did not significantly differ (clinicians 77.8% (14/18)), other surgical team members (50% (2/4) to 76.9% (20/26)) (P = 0.52). Distribution of negative comments differed significantly before and after implementation (P = 0.01); for example, there were more negative comments made about checklist buy-in after implementation (51.3 % (20/39)) compared to before implementation (24.5% (13/53)). Surgical team members most frequently reported that checklist use averted complications involving antibiotic administration, equipment and side/site of surgery.

Conclusions

Narrative feedback suggested that SSC implementation can facilitate patient safety by averting complications; however, buy-in is a persistent challenge. Presenting information on the impact of the SSC on lives saved, teamwork and complications averted, adapting the SSC to fit the local context, demonstrating leadership support and engaging champions to promote checklist use and address concerns could improve checklist adoption and efficacy.

Structured vs narrative reporting of pelvic MRI for fibroids: clarity and impact on treatment planning

OBJECTIVES

To evaluate clarity and usefulness of MRI reporting of uterine fibroids using a structured disease-specific template vs. narrative reporting for planning of fibroid treatment by gynaecologists and interventional radiologists.

METHODS

This is a HIPAA-compliant, IRB-approved study with waiver of informed consent. A structured reporting template for fibroid MRIs was developed in collaboration between gynaecologists, interventional and diagnostic radiologists. The study population included 29 consecutive women who underwent myomectomy for fibroids and pelvic MRI prior to implementation of structured reporting, and 42 consecutive women with MRI after implementation of structured reporting. Subjective evaluation (on a scale of 1-10, 0 not helpful; 10 extremely helpful) and objective evaluation for the presence of 19 key features were performed.

RESULTS

More key features were absent in the narrative reports 7.3 ± 2.5 (range 3-12) than in structured reports 1.2 ± 1.5 (range 1-7), (p < 0.0001). Compared to narrative reports, gynaecologists and radiologists deemed structured reports both more helpful for surgical planning (p < 0.0001) (gynaecologists: 8.5 ± 1.2 vs. 5.7 ± 2.2; radiologists: 9.6 ± 0.6 vs. 6.0 ± 2.9) and easier to understand (p < 0.0001) (gynaecologists: 8.9 ± 1.1 vs. 5.8 ± 1.9; radiologists: 9.4 ± 1.3 vs. 6.3 ± 1.8).

CONCLUSION

Structured fibroid MRI reports miss fewer key features than narrative reports. Moreover, structured reports were described as more helpful for treatment planning and easier to understand.

KEY POINTS

• Structured reports missed only 1.2 ± 1.5 out of 19 key features, as compared to narrative reports that missed 7.3 ± 2.5 key features for planning of fibroid treatment. • Structured reports were more helpful and easier to understand by clinicians. • Structured template can provide essential information for fibroids treatment planning.

Needs assessment for electrosurgery training of residents and faculty in obstetrics and gynecology

Background and Objectives:

Effective application of electrosurgical techniques requires knowledge of energy sources and electric circuits to produce desired tissue effects. A lack of electrosurgery knowledge may negatively affect patient outcomes and safety. Our objective was to survey obstetrics-gynecology trainees and faculty to assess their basic knowledge of electrosurgery concepts as a needs assessment for formal electrosurgery training.

Methods:

We performed an observational study with a sample of convenience at 2 academic hospitals (Beth Israel Deaconess Medical Center and Mount Auburn Hospital). Grand rounds dedicated to electrosurgery teaching were conducted at each department of obstetrics and gynecology, where a short electrosurgery multiple-choice examination was administered to attendees.

Results:

The face validity of the test content was obtained from a gynecologic electrosurgery specialist. Forty-four individuals completed the examination. Test scores were analyzed by level of training to investigate whether scores positively correlated with more advanced career stages. The median test score was 45.5% among all participants (interquartile range, 36.4%–54.5%). Senior residents scored the highest (median score, 54.5%), followed by attendings (median score, 45.5%), junior residents and fellows (median score in both groups, 36.4%), and medical students (median score, 27.3%).

Conclusion:

Although surgeons have used electrosurgery for nearly a century, it remains poorly understood by most obstetrician-gynecologists. Senior residents, attendings, junior residents, and medical students all show a general deficiency in electrosurgery comprehension. This study suggests that there is a need for formal electrosurgery training. A standardized electrosurgery curriculum with a workshop component demonstrating clinically useful concepts essential for safe surgical practice is advised.

Developing an Objective Structured Assessment of Technical Skills for Laparoscopic Suturing and Intracorporeal Knot Tying

OBJECTIVE

To develop a teaching and assessment tool for laparoscopic suturing and intracorporeal knot tying.

DESIGN AND SETTING

We designed an Objective Structured Assessment of Technical Skills (OSATS) tool that includes a procedure-specific checklist (PSC) and global rating scale (GRS) to assess laparoscopic suturing and intracorporeal knot-tying performance. Obstetrics and Gynecology residents at our institution were videotaped while performing a laparoscopic suturing and intracorporeal knot-tying task at a surgical simulation workshop. A total of 2 expert reviewers assessed resident performance using the OSATS tool during live performance and 1 month later using the videotaped recordings. OSATS scores were analyzed using the Wilcoxon rank-sum test. Data are presented as median scores (interquartile range [IQR]). Intrarater and interrater reliabilities were assessed using a Spearman correlation and are presented as an r correlation coefficient and p value. An r ≥ 0.8 was considered as a high correlation. After testing, we received feedback from residents and faculty to improve the OSATS tool as part of an iterative design process.

PARTICIPANTS

In all, 14 of 21 residents (66.7%) completed the study, with 9 junior residents and 5 senior residents.

RESULTS

Junior residents had a lower score on the PSC than senior residents did; however, this was not statistically significant (median = 6.0 [IQR: 4.0-10.0] and median = 13.0 [IQR: 10.0-13.0]; p = 0.09). There was excellent intrarater reliability with our OSATS tool (for PSC component, r = 0.88 for Rater 1 and 0.93 for Rater 2, both p < 0.0001; for GRS component, r = 0.85 for Rater 1 and 0.88 for Rater 2, both p ≤ 0.0002). The PSC also has high interrater reliability during live evaluation (r = 0.92; p < 0.0001), and during the videotape scoring with r = 0.77 (p = 0.001).

CONCLUSIONS

Our OSATS tool may be a useful assessment and teaching tool for laparoscopic suturing and intracorporeal knot-tying skills. Overall, good intrarater reliability was demonstrated, suggesting that this tool may be useful for longitudinal assessment of surgical skills.

Validity and reliability of the robotic Objective Structured Assessment of Technical Skills

OBJECTIVE

Objective Structured Assessments of Technical Skills have been developed to measure the skill of surgical trainees. Our aim was to develop an Objective Structured Assessments of Technical Skills specifically for trainees learning robotic surgery.

METHODS

This is a multiinstitutional study conducted in eight academic training programs. We created an assessment form to evaluate robotic surgical skill through five inanimate exercises. Gynecology, general surgery, and urology residents, Fellows, and faculty completed five robotic exercises on a standard training model. Study sessions were recorded and randomly assigned to three blinded judges who scored performance using the assessment form. Construct validity was evaluated by comparing scores between participants with different levels of surgical experience; interrater and intrarater reliability were also assessed.

RESULTS

We evaluated 83 residents, nine Fellows, and 13 faculty totaling 105 participants; 88 (84%) were from gynecology. Our assessment form demonstrated construct validity with faculty and Fellows performing significantly better than residents (mean scores 89±8 faculty, 74±17 Fellows, 59±22 residents; P<.01). In addition, participants with more robotic console experience scored significantly higher than those with fewer prior console surgeries (P<.01). Robotic Objective Structured Assessments of Technical Skills demonstrated good interrater reliability across all five drills (mean Cronbach's α 0.79±0.02). Intrarater reliability was also high (mean Spearman's correlation 0.91±0.11).

CONCLUSION

We developed a valid and reliable assessment form for robotic surgical skill. When paired with standardized robotic skill drills, this form may be useful to distinguish between levels of trainee performance.

LEVEL OF EVIDENCE

II.

Fundamentals of laparoscopic surgery: a surgical skills assessment tool in gynecology

This analysis suggests that the fundamentals of laparoscopic surgery skills test may be a valuable assessment tool for gynecology residents; however, the cognitive test may need further adaptation for application to gynecologists.

Objective:

To describe our experience with the Fundamentals of Laparoscopic Surgery (FLS) program as a teaching and assessment tool for basic laparoscopic competency among gynecology residents.

Methods:

A prospective observational study was conducted at a single academic institution. Before the FLS program was introduced, baseline FLS testing was offered to residents and gynecology division directors. Test scores were analyzed by training level and self-reported surgical experience. After implementing a minimally invasive gynecologic surgical curriculum, third-year residents were retested.

Results:

The pass rates for baseline FLS skills testing were 0% for first-year residents, 50% for second-year residents, and 75% for third- and fourth-year residents. The pass rates for baseline cognitive testing were 60% for first- and second-year residents, 67% for third-year residents, and 40% for fourth-year residents. When comparing junior and senior residents, there was a significant difference in pass rates for the skills test (P=.007) but not the cognitive test (P=.068). Self-reported surgical experience strongly correlated with skills scores (r-value=0.97, P=.0048), but not cognitive scores (r-value=0.20, P=.6265). After implementing a curriculum, 100% of the third-year residents passed the skills test, and 92% passed the cognitive examination.

Conclusions:

The FLS skills test may be a valuable assessment tool for gynecology residents. The cognitive test may need further adaptation for applicability to gynecologists.

Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement

The Society of Radiologists in Ultrasound convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, Ill, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

Improvement of the resolution in direct membrane integrity test by controlling solution surface tension

Membrane-based treatment technologies have been introduced as a promising tool for the removal of water-borne pathogens. To ensure successful application of membrane processes, the integrity of the membrane system should be maintained. Related with evaluation of the membrane integrity, USEPA guidance recommends pressure-based membrane integrity (MIT). Based on the bubble point theory, the ability of detecting smallest integrity breakage during the MIT is defined as "Resolution". However, the response to remarkably small breach demands significantly high initial test pressure of the pressure decay test. In this study, the surface tension of the test liquid was controlled to improve the resolution without increasing the corresponding test pressure. Three common chemicals were chosen to control the solution surface tension. It is concluded that 0.1 M of the citric acid can decrease the initial test pressure significantly for the same pore size. Subsequently, the improvement of the resolution with controlled surface tension was confirmed by the results of pressure decay test and marker test.

Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies

STUDY OBJECTIVE

The purposes of this study were to estimate and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopic-assisted vaginal and laparoscopic) and to review the characteristics of hysterectomies complicated by vaginal dehiscences.

DESIGN

Observational case series (Canadian Task Force classification II-3).

SETTING

Large, urban, university teaching hospital.

PATIENTS

All patients undergoing a total hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were analyzed.

INTERVENTIONS

Vaginal repair of vaginal cuff separation with reduction of eviscerating organ when appropriate.

MEASUREMENTS AND MAIN RESULTS

From January 2000 through March 2006, 7286 hysterectomies (7039 total and 247 supracervical) were performed at MWH by abdominal, vaginal, laparoscopic-assisted vaginal, or laparoscopic approach. Ten of these hysterectomies were complicated by vaginal cuff dehiscences and were repaired during this time period. The resulting overall cumulative incidence of vaginal cuff dehiscence after total hysterectomy at MWH was 0.14%. The annual cumulative incidence of vaginal dehiscences after total hysterectomy was 0%, 0%, 0%, 0%, 0.09%, 0.70%, and 0.31% from January 2000 to March 2006, respectively. There was a notable increase in the cumulative incidence of dehiscence in 2005 and thereafter. From January 2005 through March 2006, the cumulative incidence of vaginal dehiscence by mode of hysterectomy was 4.93% among total laparoscopic hysterectomies (TLH), 0.29% among total vaginal hysterectomies (TVH), and 0.12% among total abdominal hysterectomies (TAH). The relative risks of a vaginal cuff dehiscence complication after TLH compared with TVH and TAH were 21.0 and 53.2, respectively. Both were statistically significant, with 95% CIs of 2.6 to 166.9 and 6.7 to 423.4, respectively. Among the 10 dehiscences repaired, 8 (80%) were complications of TLHs, 1 (10%) was associated with TAH, and 1 (10%) followed a TVH. The median age at time of dehiscence was 39 years, and the median time between initial hysterectomy to vaginal dehiscence was 11 weeks. Six of the 10 patients presented with both cuff dehiscence and bowel evisceration. Six patients reported first postoperative intercourse as the trigger event. Half the patients with dehiscence report smoking cigarettes. All patients with dehiscence received preoperative prophylactic antibiotics at the time of hysterectomy. Until October 2006, there have been no reported recurrent dehiscences at MWH.

CONCLUSIONS

Total laparoscopic hysterectomies may be associated with an increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy. We postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible; however, prospective randomized trials are needed to support this hypothesis. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a TLH is present.