SCOTTSDALE, ARIZ. – Rates of perioperative complications among women undergoing hysterectomy for benign indications vary according to the route, an ancillary analysis of a retrospective cohort study found.
Analyses were based on 1,440 women who underwent hysterectomy at four teaching hospitals, with procedures about evenly split between the eras before and after introduction of robotic surgery, lead author Dr. Salma Rahimi of Mount Sinai Hospital, New York, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.
In the prerobot era, the rate of intraoperative complications – injury of the ureter, bladder, or bowel, or transfusion – was lowest at 3.7% for laparoscopic hysterectomy, about half that for abdominal procedures, and roughly the same as that for vaginal ones. The rate of postoperative complications – infection requiring antibiotics, transfusion, small bowel obstruction, or ileus – was 1.8% with laparoscopic hysterectomy, roughly a third of that seen with the other approaches.
In the postrobot era, the rate of intraoperative complications was 2.8% with vaginal hysterectomy, the lowest value for any approach, including the robotic one. The rate of postoperative complications was 3.0% for robotic hysterectomy, about a quarter of that for abdominal procedures and roughly on a par with that for vaginal and laparoscopic ones.
"Our data demonstrate that a vaginal hysterectomy is associated with fewer intraoperative complications in both the pre- and postrobot period," Dr. Rahimi commented. However, "vaginal hysterectomy was associated with more postoperative infections in the prerobot period."
"The highest complications were noted in the abdominal group, mostly due to transfusions, infections, small bowel obstructions, and ileus," she added.
Introducing the study, she noted that the American College of Obstetricians and Gynecologists recommends vaginal hysterectomy as a first choice over other routes given its relatively better outcomes and lower rates of complications (Obstet. Gynecol. 2009;114:1156-8). "Despite this, most are performed by laparotomy, and there is an increasing trend toward the use of minimally invasive abdominal approaches. Only about 20% are performed by the vaginal approach," she said.
The investigators studied women undergoing hysterectomy identified through the Fellows’ Pelvic Research Network. All of the operations were performed at hospitals with an obstetrics and gynecology residency and had a fellow belonging to the network. Women were excluded if their hysterectomy was performed by a gynecologic oncologist, was for a suspected malignancy, or was done emergently (including cesarean hysterectomies).
Analyses were based on 732 women in the prerobot era (the year before introduction of robotics at each hospital) and 708 in the postrobot era (2011). Characteristics of the women from the two eras were essentially the same, Dr. Rahimi reported at the meeting, jointly sponsored by the American College of Surgeons.
In the prerobot era, the rate of intraoperative complications was 3.9% for vaginal hysterectomy, compared with 7.4% for abdominal hysterectomy (P less than .05) and 3.7% for laparoscopic hysterectomy (P not significant).
The rate of postoperative complications was 8.3% for vaginal hysterectomy, compared with 7.4% for abdominal hysterectomy (P not significant) and 1.8% for laparoscopic hysterectomy (P = .001). These differences were mainly driven by higher rates of infection with the vaginal and abdominal approaches, and a higher rate of small bowel obstruction and ileus with the abdominal approach.
In the postrobot era, the rate of intraoperative complications was 2.8% for vaginal hysterectomy, compared with 10.8% for abdominal hysterectomy (P = .003), 4.6% for laparoscopic hysterectomy (P not significant), and 3.0% for robotic hysterectomy (P not significant). The differences were mainly due to a higher rate of transfusion with the abdominal approach.
The rate of postoperative complications was 5.1% for vaginal hysterectomy, compared with 13.9% for abdominal hysterectomy (P = .008), 3.6% for laparoscopic hysterectomy (P not significant), and 3.0% for robotic hysterectomy (P not significant). The differences again were mainly due to a higher rate of transfusion when surgery was done abdominally.
Dr. Rahimi disclosed no relevant conflicts of interest.