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ORIGINAL RESEARCH |
From the Division of Pelvic Surgery, Department of Obstetrics and Gynecology, and Department of Biometry, Louisiana State University Health Sciences Center, Shreveport, Louisiana.
Address reprint requests to: James B. Unger, MD, Louisiana State University Health Sciences Center, Department of Obstetrics and Gynecology, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130; E-mail: junger{at}lsuhsc.edu.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: Three groups of women undergoing abdominal hysterectomy were analyzed according to uterine size: group 1, 208 women with uteri less than 500 g; group 2, 63 women with uterine weights of 500–999 g; and group 3, 47 women with leiomyomata whose uteri weighed at least 1000 g. Logistic regression was used to compare the groups on the risks of having at least one major complication. Adjusted comparisons on other surgical outcomes were performed using a logistic model (for qualitative variables) or a general linear model (for quantitative variables).
RESULTS: The risk of experiencing at least one perioperative complication, including blood loss over 500 mL, perioperative blood transfusion, major organ injury, therapeutic antibiotic use, and hospital readmission, increased significantly with uterine weight (P = .006). Group 3 women were at greater risk of having at least one of these complications than either group 1 or group 2 women, with adjusted odds ratios of 3.42 (95% confidence interval [CI] 1.62, 7.25) and 2.64 (95% CI 1.14, 6.13), respectively. Estimated blood loss with surgery also increased with increasing uterine weight (P < .001). Mean estimated blood losses for the study groups were 555.8 ± 386.5 mL (group 3), 464.33 ± 285.2 mL (group 2), and 387.6 ± 281.4 mL (group 1) (P = .032).
CONCLUSION: The complication rate from hysterectomy increases with increasing uterine weight, due mainly to an increased blood loss associated with surgery for larger uteri.
Between 1988 and 1993, 3,350,961 hysterectomies were performed in the United States.1 Over 1.1 million of these were done for uterine leiomyomas. Indeed, the highest rate of hysterectomy in the United States occurs in black women between 35 and 44 years of age with myomas—12.1 per 1000 women.1 Although small myomas are extremely common and are usually asymptomatic, larger ones may cause problems such as heavy menstrual bleeding, anemia, pelvic pain and pressure, and symptoms from extrinsic compression on adjacent organs, especially the urinary tract. Although hysterectomy is indicated for symptomatic uterine leiomyomas, controversy exists regarding the appropriateness of hysterectomy purely on the basis of uterine size.2,3
Uterine leiomyomas can reach massive proportions, weighing 1 or more kilograms. These large myomas can significantly distort the pelvic anatomy, have an extensive and impressive vascular supply, and compromise the operative field because of their size. These factors can increase the difficulty of hysterectomy and may increase the risks of operative complications. Hillis et al4 demonstrated an increased risk of blood transfusion, vaginal cuff cellulitis, and at least one operative complication in women with uteri greater than 500 g. On the other hand, Reiter et al3 found no increase in operative complications with hysterectomy for uteri larger than 12-week size. We performed a retrospective study of abdominal hysterectomy done for uterine myomas to determine if the complication rate of surgery is increased in this group of women.
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MATERIALS AND METHODS |
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2 or Fisher exact test, as appropriate, was used to compare proportions among the three study groups for categoric data. Logistic regression was used to compare the groups on risks for having at least one major operative complication and an estimated blood loss greater than 500 mL and to calculate odds ratios (ORs) with corresponding 95% confidence intervals (CIs) adjusted for group differences on race; age; parity; body weight; and findings at surgery consistent with pelvic inflammatory disease, prior surgery, and surgical adhesions. A general linear model for estimated blood loss was performed to determine significant effects of the aforementioned factors and uterine weight on estimated blood loss. A maximum significance level of 5% was assumed for all statistical tests. SAS 8.2 (SAS Institute Inc., Cary, NC) was used to perform statistical calculations. |
RESULTS |
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. All women in group 1 had surgery because of gynecologic problems, particularly bleeding and pain, severe enough to warrant hysterectomy. However, 3.7% of women in group 2 and 17.5% of women in group 3 were essentially asymptomatic and underwent hysterectomy because of concerns based solely on uterine size. These concerns included the undiagnosed pelvic mass, suspected malignancy of the uterus or ovary, and inability to evaluate the ovaries. The mean uterine weight in group 3 was 1658.8 ± 793.5 g, compared with mean weights of 729.3 ± 120.3 and 227.7 ± 129.6 for groups 2 and 1, respectively (P < .001). There were significantly more black women in groups 3 and 2 than in group 1 (93.6% and 93.6%, respectively, versus 63.1%) (P < .001). Women with larger uteri (group 3) were also significantly older than other women, with a mean of 45.1 ± 5 years, versus means of 42.8 ± 6.0 years (group 2) and 41.0 ± 8.7 years (group 1) (P < .034). There were no significant differences in parity or body weight among the three groups.
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). In addition to those who had blood loss greater than 500 mL or a perioperative blood transfusion (Table 2), some women also experienced operative injury, postoperative antibiotics, or hospital readmission. There were five major organ injuries, and all occurred in group 1. These consisted of four simple cystotomies and one enterotomy. All were repaired at the time the injury occurred, without sequelae. Nine women in group 1, three women in group 2, and three women in group 3 received postoperative antibiotics. Finally, two women required readmission for postoperative pelvic abscess and one for a small bowel obstruction, all in group 1. Although there were no significant differences in operative time or length of hospital stay, the mean estimated blood loss with surgery was significantly greater for women with the largest uteri (group 3) than for women with the smallest uteri (group 1). This was true even when other factors such as race, findings consistent with prior pelvic inflammatory disease, surgical adhesions, prior operation(s), age, race, and body weight are controlled for using a general linear model analysis. An analysis using uterine weight rather than uterine weight group as one of the independent variables in the linear model shows that estimated blood loss increases significantly with increasing uterine weight (P < .001). Table 3 shows that women with the largest uteri (group 3) had a statistically significant increased risk of experiencing blood loss greater than 500 mL relative to women with the smallest uteri (group 1), with an adjusted OR of 3.42 (CI 1.63, 7.19). Finally, Table 3 also shows a significantly increasing risk of having at least one major complication with increasing uterine weight. Adjusted ORs for group 3 women compared with those in group 2 and group 1 are 2.64 (95% CI 1.14, 6.13) and 3.42 (95% CI 1.62, 7.25), respectively.
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DISCUSSION |
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We studied this question of uterine size and the risk of operative complications, especially blood loss, by reviewing our experience with abdominal hysterectomy for the myomatous uterus, including a large number over 1000 g (roughly 20-week gestational size5). In our population, the largest myomas occurred in black women. This is consistent with recent observations by two other groups of investigators that black women are affected disproportionately by both larger myomas and multiple myomas.6,7 It is also interesting that women in the largest uterine group were on average 4 years older than women in the smaller uterus group.
We report a significantly greater surgical blood loss in women having hysterectomy in the larger uterine groups, even after controlling for factors such as race and age. Perioperative blood transfusion occurred in over twice as many women in the over 1000 g group in our study relative to those in the less than 500 g group, just as was reported by Hillis et al.4 Also, like Reiter et al,3 we report a significant correlation between uterine enlargement and surgical blood loss. However, we found that this relationship is most apparent when hysterectomy for uteri less than 500 g is compared with that for uteri over 1000 g. This may be why these investigators were unable to demonstrate a significant difference in blood loss in their study, because the mean uterine weight for their enlarged uterus group was only 519 g.3 As in the Hillis study,4 we also found a significant increase in perioperative complications for women with uterine enlargement. Indeed, the overall complication rates in our over 1000 g uterus group of 61.7% and in the over 500 g group of 41.3% are very similar to the 60% rate they reported in their over 500 g group.
There are many reasons that one would expect increased perioperative complications including greater blood loss with hysterectomy for the massive myomatous uterus, such as those we and Hillis et al4 reported. At times, our surgeons encountered problems with exposure even with a generous vertical abdominal incision. This was especially true when lateral and posterior myomas compromised access to the posterior cul-de-sac and pelvic sidewalls. Identification and safe ligation of the uterine vessels was often problematic with broad ligament and lower uterine segment myomas. Also, distorted uterine cornua not infrequently caused problems with clamp placement during ovarian conservation. These as well as other practical problems during hysterectomy plus the overall increased vascularity of these massive uteri often led to greater than average blood loss in these women.
We recognize that there are always limitations with retrospective studies. The possibility of surgeon bias in one form or another must always be considered. For example, we did not have a mechanism for completely objective measurement of blood loss at the time of surgery. However, in our cases blood loss was estimated by anesthesia personnel only and not by the surgeon, using semiobjective measurements such as amount of blood collected in the suction canister and number of bloody laparotomy pads. Our study also does not address issues such as preoperative gonadotropin-releasing hormone use to decrease uterine size and vascularity, prophylactic uterine artery embolization before surgery,8 or intraoperative injection of vasopressin into the uterus during the hysterectomy,9,10 each of which has been reported to decrease blood loss with hysterectomy. Further investigation is needed in women with massive leiomyomas such as those in our current report to determine effectiveness of such treatment in uteri of this size.
We are not recommending hysterectomy for all women with large uterine leiomyomas. Indeed, we did not analyze the relationship between uterine size and symptoms. However, it is clear to us from our experience reported here that hysterectomy for the uterus weighing 1 kg or more is associated with an increase in surgical morbidity, especially increased surgical blood loss relative to surgery for uteri that are smaller. Therefore, we recommend hysterectomy be considered even for the asymptomatic woman with an enlarging myomatous uterus before it reaches 20 weeks or more in size in order to minimize surgical morbidity.
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Footnotes |
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Received March 27, 2002. Received in revised form June 6, 2002. Accepted June 27, 2002.
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REFERENCES |
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2. Friedman AJ, Haas ST. Should uterine size be an indication for surgical intervention in women with myomas? Am J Obstet Gynecol 1993;168:751–5.[Medline]
3. Reiter RC, Wagner PL, Gambone JC. Routine hysterectomy for large asymptomatic uterine leiomyomata: A reappraisal. Obstet Gynecol 1992;79:481–4.
4. Hillis SD, Marchbanks PA, Peterson HB. Uterine size and risk of complications among women undergoing abdominal hysterectomy for leiomyomas. Obstet Gynecol 1996; 87:539–43.[Abstract]
5. Flickinger L, D’Ablaing G, Mishell DR. Size and weight determinations of nongravid enlarged uteri. Obstet Gynecol 1986;68:855–8.
6. Kjerulff KH, Langenberg P, Seidman JD, Stolley PD, Guzinski GM. Uterine leiomyomas: Racial differences in severity, symptoms, and age at diagnosis. J Reprod Med 1996;41: 483–90.[Medline]
7. Marshall LM, Spiegelman D, Barbieri RL, Goldman MB, Manson JE, Colditz GA, et al. Variation in the incidence of uterine leiomyoma among premenopausal women by age and race. Obstet Gynecol 1997;90:967–73.[Abstract]
8. Ravina JH, Bouret JM, Fried D, Benifla JL, Darai E, Pennehouat G, et al. Advantage of preoperative embolization of fibroids: A multicenter study of 31 cases. Contracept Fertil Sex 1995;23:45–9.[Medline]
9. Okin CR, Guido RS, Meyn LA, Ramanathan S. Vasopressin during abdominal hysterectomy: A randomized controlled trial. Obstet Gynecol 2001;97:867–72.
10. Speer P, Unger JB. Does saline really decrease blood loss at vaginal hysterectomy as much as vasopressin. J Pelvic Surg 2001;7:340–3.
This article has been cited by other articles:
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  T. Muffly, I. Vadlamani, and J. C. Weed Massive Leiomyoma of the Broad Ligament Obstet. Gynecol., February 1, 2007; 109(2): 563 - 565. [Abstract] [Full Text] [PDF]
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R. Worthington-Kirsch, J. B. Spies, E. R. Myers, J. Mulgund, M. Mauro, G. Pron, E. D. Peterson, S. Goodwin, and for the FIBROID Investigators The Fibroid Registry for Outcomes Data (FIBROID) for Uterine Embolization: Short-Term Outcomes Obstet. Gynecol., July 1, 2005; 106(1): 52 - 59. [Abstract] [Full Text] [PDF]
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