Predictive factors of the need to morcellate in total laparoscopic hysterectomy

Abstract

Background Specimen extraction is a major challenge in total laparoscopic hysterectomy (TLH) and tissue morcellation may be needed to extract a large uterus. Aims The study aims to determine preoperative factors that could predict the need for uterine morcellation in TLH, and also find the best cut‐off values of each measured parameter leading to optimum sensitivity and specificity. Materials and Methods This was a cross‐sectional study of women from August 2019 to May 2020 who underwent TLH, with or without salpingo‐oophorectomy in our department. We performed bimanual exams preoperatively to estimate the uterine size and recorded the uterine ultrasonographic dimensions and myoma size in myomatous uteri. Receiver operating characteristic (ROC) were used to establish cut‐offs that maximised the sensitivity and specificity of each factor in predicting the need for morcellation. Poisson regression was used to calculate the relative risks (RR) of each cut‐off. Results One hundred and sixty‐two women were recruited in the study. ROC curves demonstrated maximum sensitivities and specificities with a cross‐sectional area of 36.5 cm2, the largest leiomyoma dimension of 40 mm, uterine length of 10 cm, and bimanual uterine size of 13 weeks. Multiple modified Poisson regression revealed that the strongest predictors of morcellation were the largest leiomyoma diameter of >40 mm (RR: 3.58), the uterine cross‐sectional area of >36.5 cm2 (RR: 6.38), and uterine size in the bimanual exam of >13 weeks pregnancy (RR: 3.57). Conclusion The largest leiomyoma diameter, uterine cross‐sectional area, and size on a bimanual exam can all be used to predict needing morcellation preoperatively in TLH.

An intrauterine cavity morcellator: A novel approach to high volume uterus morcellation. Ex-vivo study

“…Two recent studies [21,22] found that the strongest pre-operative predictors Relative Risk (RR) for the need of morcellation were the leiomyoma diameter of >40-44 mm (RR: 3.58), uterine cross-sectional area of >36.5-48.6 cm 2 (RR: 6.38), uterine size in the bimanual exam of >11.5-13 weeks pregnancy (RR: 3.57) and uterine volume of 262 ml. Highlighting, that during the selection of the surgical approach, uterine size plays a major and foremost decisive factor, over patient or surgeon's preference.…”