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

Abstract

Objective To model outcomes in laparoscopic hysterectomy with morcellation compared to abdominal hysterectomy for the presumed fibroid uterus, examining short-and long-term complications, as well as mortality. Study Design A decision tree was constructed to compare outcomes for a hypothetical cohort of 100,000 premenopausal women undergoing hysterectomy for presumed fibroids 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 leiomyomsarcoma, and procedure-related death. Results The decision analysis predicted fewer overall deaths with laparoscopic hysterectomy compared to abdominal hysterectomy (98 vs. 103 per 100,000). While there were more deaths from leiomyosarcoma following 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 (2,400 vs. 4,700 per 100,000), wound infection (1,500 vs 6,300 per 100,000), venous thromboembolism (690 vs. 840 per 100,000) and incisional hernia (710 vs. 8,800 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 five years). Conclusion The risk of leiomyosarcoma morcellation is balanced by procedure-related complications associated with laparotomy, including death. This analysis provides patients and surgeons with estimates of risk and benefit, upon which patient-centered decisions can be made.

Association of the U.S. Food and Drug Administration Morcellation Warning With Rates of Minimally Invasive Hysterectomy and Myomectomy

“…We do suspect there is a general trend at our institution, and nationally, toward less vaginal and abdominal hysterectomies and more laparoscopic and robotic hysterectomies. 11,15 Seidhoff et al 16 recently published a decision analysis that predicted fewer overall deaths with continued rates of minimally invasive hysterectomy compared with abdominal hysterectomy even when accounting for morcellation and upstaging of leiomyosarcomas. Quality-adjusted life-year analysis also favored minimally invasive hysterectomy even when accounting for a 20% variation in the utility measures of various outcomes.…”

Impact of the 2014 Food and Drug Administration Warnings Against Power Morcellation

“…These concerns must be balanced with the overall risk of an occult uterine sarcoma, which is reported to range from 0.01% to 0.49% in studies [8][9][10][11][12][13][14]22]. A decision analysis from Siedhoff et al [23] predicted fewer overall deaths from laparoscopic hysterectomy with morcellation than with abdominal hysterectomy, which is associated with increased postoperative complications and lower quality of life.…”

Risk of Occult Uterine Sarcoma in Presumed Uterine Fibroids

“…Recent cost effectiveness analyses support the use of morcellation in low-risk populations, citing lowerratesofintraoperativeandperioperative complications, 65,66 fewer overall deaths, 65,66 andlowersocietalcostsduetoshorterhospitalizations and fewer days lost from work compared with laparotomy. 66,67 Quality of life analyses have yielded conflicting results [65][66][67] ; however, ageseems to be the driving factor in determining the effectiveness of morcellation. 65,66 Younger women seem to benefit from the procedure; however, as the risk of occult malignancy increases with age, the risks outweigh the benefits.…”