Comparison of Surgical Outcomes After Total Laparoscopic Hysterectomy or Total Vaginal Hysterectomy for Large Uteri

OBJECTIVE: To compare surgical outcomes between total laparoscopic hysterectomy and total vaginal hysterectomy with uterine weight greater than 250 g. METHODS: We conducted a retrospective cohort study using data from American College of Surgeons’ National Quality Improvement Project Hysterectomy Specific Database. Women with uterine weight greater than 250 g undergoing hysterectomy for benign indications by total laparoscopic hysterectomy or total vaginal hysterectomy were matched by propensity scores, which were calculated using preoperative characteristics and uterine weight. Total vaginal hysterectomy was matched to total laparoscopic hysterectomy at a ratio of 1:2. Pairwise analysis was performed using Wilcoxon rank-sum and Fisher exact tests as appropriate. Multivariable logistic regression was performed to identify the independent effect of total vaginal hysterectomy on surgical outcomes. RESULTS: There were 1,870 total vaginal hysterectomies that were matched to 3,740 total laparoscopic hysterectomies. No differences in preoperative demographics and comorbidities were seen for the patients. Uterine weight was similar for both groups: 376 g (interquartile range 293–501) for total vaginal hysterectomy and 384 g (interquartile range 302–515) for total laparoscopic hysterectomy (odds ratio [OR] 0.98, 95% CI 0.92–1.09). The rate of composite major complications was similar between total vaginal hysterectomy and total laparoscopic hysterectomy (4.3% vs 5.3%, OR 0.80, 95% CI 0.61–1.05). Intraoperative cystotomies were higher with total vaginal hysterectomy (0.8% vs 0.3%, OR 2.74, 95% CI 1.17–6.61), and ureteral injuries were more common with total laparoscopic hysterectomy (1.2% vs 0.2%, OR 0.12, 95% CI 0.02–0.38). Total vaginal hysterectomy operating time was significantly shorter compared with total laparoscopic hysterectomy (77 minutes, interquartile range 56–111 vs 122 minutes, interquartile range 91–164; OR 0.69, 95% CI 0.42–0.89). After adjusting for confounders, total vaginal hysterectomy was not found to be independently associated with major morbidity (adjusted odds ratio [aOR] 0.95, 95% CI 0.18–5.11) and was associated with a lower probability of operating times exceeding 2.5 hours (aOR 0.31, 95% CI 0.27–0.43). CONCLUSION: In patients matched by uterine size and preoperative characteristics, total vaginal hysterectomy is not associated with an increased composite risk of major surgical morbidity or other adverse surgical outcomes.