Preoperative Factors That Predict the Need to Morcellate in Total Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To determine which preoperative factors best predict the need for uterine morcellation at the time of total laparoscopic hysterectomy (TLH) and to identify cut-offs that can help guide clinical decision-making.

DESIGN: Retrospective cohort (Canadian Task Force classification II).

SETTING: Tertiary care center.

PATIENTS: Women (n = 420) who underwent TLH between July 2012 and June 2015: 223 cases without and 197 cases with morcellation.

INTERVENTIONS: Laparoscopic hysterectomies with either laparoscopic power, vaginal, or open morcellation via mini-laparotomy were analyzed.

MEASUREMENTS AND MAIN RESULTS: Preoperative factors assessed included uterine volume, cross-sectional area, length, size of largest leiomyoma, and bimanual exam. Receiver operator curves (ROC) were used to establish cut-offs that maximized sensitivity and specificity for each factor. Bivariate and multivariate Poisson regression analyses were used to calculate relative risks associated with these objective cut-offs. ROC curves demonstrated maximized sensitivities and specificities with a cross-sectional area of 48.6 cm2 , largest leiomyoma dimension of 4.4 cm, bimanual exam of 11.5 weeks, and uterine volume of 262 mL. Multivariate Poisson regression analysis revealed that the strongest predictors of morcellation were cross-sectional area (adjusted relative risk, 2.94; 95% confidence interval, 1.20-7.19), largest leiomyoma diameter (adjusted relative risk, 2.06; 95% confidence interval, 1.24-3.41), and bimanual exam (adjusted relative risk, 1.88; 95% confidence interval, 1.05-3.37).

CONCLUSION: Uterine cross-sectional area, largest leiomyoma dimension, and uterine size on bimanual exam can all be used to predict the need to morcellate at the time of TLH.