Risk of hysterectomy at time of myomectomy – An underestimated surgical risk

OBJECTIVE To evaluate the risk of hysterectomy at the time of myomectomy, and the associated 30-day postoperative morbidity. DESIGN Cohort study. SUBJECTS Patients who underwent myomectomies identified from the American College of Surgeons’ National Surgical Quality Improvement Program from 2010-2021. MAIN OUTCOME MEASURES Current Procedural Technology codes were used to identify myomectomies performed with or without concurrent hysterectomy. Pre-operative characteristics and morbidity outcomes were obtained. Univariate analysis was performed using Chi-Square and Fisher Exact as appropriate. Multivariable logistic regression reported risk factors for individuals undergoing hysterectomy at the time of myomectomy. P values <0.05 were considered statistically significant. RESULTS A total of 13,213 individuals had a myomectomy. 399 (3.0%) had a hysterectomy performed during myomectomy. Concurrent hysterectomy was most frequently performed (7.1%) with laparoscopic approach, followed by 3.2% and 1.9% with abdominal and hysteroscopic approach, respectively. Age ≥43 years, obesity class II and higher, American Society of Anesthesiologists (ASA) class greater than II, tobacco use, longer operative time (>85 min) and laparoscopic approach significantly elevated the risk of hysterectomy. When adjusting for age, body mass index, race, ASA class, case type, surgical approach, operative time, preoperative transfusion, preoperative hematocrit, and high fibroid burden, increased odds of hysterectomy was noted for White race, longer operative time, ASA class III or higher, obesity, laparoscopic approach and low fibroid burden. Patients who underwent concurrent hysterectomy had longer median length of hospital stay (2 vs 1 day), longer median operative time (161 vs 126 minutes), increased intraoperative/postoperative blood transfusions (14.5 vs 9.0%), higher organ space surgical site infections (1.5 vs 0.5%), and return to surgery (2.0 vs 0.7%) compared to patients who did not (p< 0.05). The risk of a major complication within 30 days of myomectomy was increased for patients who underwent concurrent hysterectomy after adjusting for relevant confounders (adjusted OR 2.4, 95% CI 1.8-3.2). CONCLUSION Risk of hysterectomy during a myomectomy is higher than previously reported. Patient age ≥43 years, obesity, White race, ASA class III or higher, longer operative time, and laparoscopic approach were associated with higher odds of hysterectomy. Identification of patients with these risk factors can aid in patient counselling and surgical planning, which may help reduce the unexpectedly high rates of hysterectomy at planned myomectomy. To evaluate the risk of hysterectomy at the time of myomectomy, and the associated 30-day postoperative morbidity. Cohort study. Patients who underwent myomectomies identified from the American College of Surgeons’ National Surgical Quality Improvement Program from 2010-2021. Current Procedural Technology codes were used to identify myomectomies performed with or without concurrent hysterectomy. Pre-operative characteristics and morbidity outcomes were obtained. Univariate analysis was performed using Chi-Square and Fisher Exact as appropriate. Multivariable logistic regression reported risk factors for individuals undergoing hysterectomy at the time of myomectomy. P values <0.05 were considered statistically significant. A total of 13,213 individuals had a myomectomy. 399 (3.0%) had a hysterectomy performed during myomectomy. Concurrent hysterectomy was most frequently performed (7.1%) with laparoscopic approach, followed by 3.2% and 1.9% with abdominal and hysteroscopic approach, respectively. Age ≥43 years, obesity class II and higher, American Society of Anesthesiologists (ASA) class greater than II, tobacco use, longer operative time (>85 min) and laparoscopic approach significantly elevated the risk of hysterectomy. When adjusting for age, body mass index, race, ASA class, case type, surgical approach, operative time, preoperative transfusion, preoperative hematocrit, and high fibroid burden, increased odds of hysterectomy was noted for White race, longer operative time, ASA class III or higher, obesity, laparoscopic approach and low fibroid burden. Patients who underwent concurrent hysterectomy had longer median length of hospital stay (2 vs 1 day), longer median operative time (161 vs 126 minutes), increased intraoperative/postoperative blood transfusions (14.5 vs 9.0%), higher organ space surgical site infections (1.5 vs 0.5%), and return to surgery (2.0 vs 0.7%) compared to patients who did not (p< 0.05). The risk of a major complication within 30 days of myomectomy was increased for patients who underwent concurrent hysterectomy after adjusting for relevant confounders (adjusted OR 2.4, 95% CI 1.8-3.2). Risk of hysterectomy during a myomectomy is higher than previously reported. Patient age ≥43 years, obesity, White race, ASA class III or higher, longer operative time, and laparoscopic approach were associated with higher odds of hysterectomy. Identification of patients with these risk factors can aid in patient counselling and surgical planning, which may help reduce the unexpectedly high rates of hysterectomy at planned myomectomy.