Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve School of Medicine, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals, Cleveland, Ohio.
Obstet Gynecol. 2021 Mar 1;137(3):445-453. doi: 10.1097/AOG.0000000000004274.
To compare surgical outcomes between total laparoscopic hysterectomy and total vaginal hysterectomy with uterine weight greater than 250 g.
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.
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).
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.
比较子宫重量大于 250g 的患者行全腹腔镜子宫切除术与经阴道全子宫切除术的手术结局。
我们使用美国外科医师学会国家质量改进计划子宫切除术特定数据库中的数据进行了回顾性队列研究。对因良性疾病接受全腹腔镜子宫切除术或经阴道全子宫切除术治疗且子宫重量大于 250g 的患者，根据术前特征和子宫重量，采用倾向评分进行匹配。将经阴道全子宫切除术与全腹腔镜子宫切除术以 1:2 的比例进行匹配。使用 Wilcoxon 秩和检验和 Fisher 确切检验对适当的配对分析进行了比较。采用多变量逻辑回归确定经阴道全子宫切除术对手术结局的独立影响。
共有 1870 例经阴道全子宫切除术与 3740 例全腹腔镜子宫切除术相匹配。两组患者的术前人口统计学和合并症无差异。两组子宫重量相似：经阴道全子宫切除术组为 376g（四分位距 293-501），全腹腔镜子宫切除术组为 384g（四分位距 302-515）（比值比[OR]0.98，95%置信区间[CI]0.92-1.09）。经阴道全子宫切除术组与全腹腔镜子宫切除术组复合主要并发症发生率相似（4.3% vs 5.3%，OR 0.80，95%CI 0.61-1.05）。经阴道全子宫切除术组术中膀胱切开术发生率较高（0.8% vs 0.3%，OR 2.74，95%CI 1.17-6.61），而全腹腔镜子宫切除术组输尿管损伤更为常见（1.2% vs 0.2%，OR 0.12，95%CI 0.02-0.38）。与全腹腔镜子宫切除术相比，经阴道全子宫切除术的手术时间明显缩短（77 分钟，四分位距 56-111 与 122 分钟，四分位距 91-164；OR 0.69，95%CI 0.42-0.89）。在调整混杂因素后，未发现经阴道全子宫切除术与主要发病率增加（校正比值比[aOR]0.95，95%CI 0.18-5.11）相关，与手术时间超过 2.5 小时的概率降低相关（aOR 0.31，95%CI 0.27-0.43）。
在子宫大小和术前特征相匹配的患者中，经阴道全子宫切除术与主要手术发病率或其他不良手术结局的复合风险增加无关。
