Preoperative Factors That Predict the Need to Morcellate in Total Laparoscopic Hysterectomy

To determine which preoperative factors best predict the need for uterine morcellation at the time of total laparoscopic hysterectomy (TLH) and to identify cut-offs that can help guide clinical decision-making.

Retrospective cohort (Canadian Task Force classification II).

Tertiary care center.

Women (n = 420) who underwent TLH between July 2012 and June 2015: 223 cases without and 197 cases with morcellation.

Laparoscopic hysterectomies with either laparoscopic power, vaginal, or open morcellation via mini-laparotomy were analyzed.

Preoperative factors assessed included uterine volume, cross-sectional area, length, size of largest leiomyoma, and bimanual exam. Receiver operator curves (ROC) were used to establish cut-offs that maximized sensitivity and specificity for each factor. Bivariate and multivariate Poisson regression analyses were used to calculate relative risks associated with these objective cut-offs. ROC curves demonstrated maximized sensitivities and specificities with a cross-sectional area of 48.6 cm², largest leiomyoma dimension of 4.4 cm, bimanual exam of 11.5 weeks, and uterine volume of 262 mL. Multivariate Poisson regression analysis revealed that the strongest predictors of morcellation were cross-sectional area (adjusted relative risk, 2.94; 95% confidence interval, 1.20-7.19), largest leiomyoma diameter (adjusted relative risk, 2.06; 95% confidence interval, 1.24-3.41), and bimanual exam (adjusted relative risk, 1.88; 95% confidence interval, 1.05-3.37).

Uterine cross-sectional area, largest leiomyoma dimension, and uterine size on bimanual exam can all be used to predict the need to morcellate at the time of TLH.