Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroid tumors in premenopausal women: a decision analysis

Abstract

Objective: The purpose of this study was to model outcomes in laparoscopic hysterectomy with morcellation compared with abdominal hysterectomy for the presumed fibroid uterus and to examine short- and long-term complications and death.

Study design: A decision tree was constructed to compare outcomes for a hypothetical cohort of 100,000 premenopausal women who underwent hysterectomy for presumed fibroid tumors over a 5-year time horizon. Parameter and quality-of-life utility estimates were determined from published literature for postoperative complications, leiomyosarcoma incidence, death related to leiomyosarcoma, and procedure-related death.

Results: The decision-tree analysis predicted fewer overall deaths with laparoscopic hysterectomy compared with abdominal hysterectomy (98 vs 103 per 100,000). Although there were more deaths from leiomyosarcoma after laparoscopic hysterectomy (86 vs 71 per 100,000), there were more hysterectomy-related deaths with abdominal hysterectomy (32 vs 12 per 100,000). The laparoscopic group had lower rates of transfusion (2400 vs 4700 per 100,000), wound infection (1500 vs 6300 per 100,000), venous thromboembolism (690 vs 840 per 100,000) and incisional hernia (710 vs 8800 per 100,000), but a higher rate of vaginal cuff dehiscence (640 vs 290 per 100,000). Laparoscopic hysterectomy resulted in more quality-adjusted life years (499,171 vs 490,711 over 5 years).

Conclusion: The risk of leiomyosarcoma morcellation is balanced by procedure-related complications that are associated with laparotomy, including death. This analysis provides patients and surgeons with estimates of risk and benefit on which patient-centered decisions can be made.

Keywords: abdominal hysterectomy; fibroid tumor; laparoscopic hysterectomy; morcellation.

Figure 1. Decision Tree

Premenopausal women requiring hysterectomy for an enlarged uterus could undergo laparoscopic or abdominal hysterectomy. In either approach, death could occur immediately after the procedure. Women who survive the procedure could experience immediate surgical complications (blood transfusion, wound infection, or vaginal cuff dehiscence) and/or longer term surgical complications (hernia and venous thromboembolism). Women who had occult leiomyosarcoma at the time of the procedure would undergo treatment, after which point they could recover or die (sarcoma-related death).

Figure 2

Number of incremental deaths per 100,000 associated with laparoscopic hysterectomy by varying the candidates for leiomyosarcoma incidence used in the sensitivity analysis. At incidence of 0.007, 0.008, 0.009, and 0.0013, there were more deaths per 100,000 associated with abdominal hysterectomy. At incidence of 0.023, 0.027, and 0.049, there were more deaths per 100,000 associated with laparoscopic hysterectomy. (A) Base-case estimate: abdominal hysterectomy mortality 0.00032, laparoscopic hysterectomy mortality 0.00012. (B) Sensitivity analysis estimate #1: abdominal hysterectomy mortality 0.00038, laparoscopic hysterectomy mortality 0.00012. (C) Sensitivity analysis estimate #2: abdominal hysterectomy mortality 0.00038, laparoscopic hysterectomy mortality 0.000096. (D) Sensitivity analysis estimate #3 abdominal hysterectomy mortality 0.00032, laparoscopic hysterectomy mortality 0.000096.