AOGS O R I G I N A L R E S E A R C H A R T I C L E

Risk factors for trachelectomy following supracervical hysterectomy ZIV TSAFRIR1, JOELLE AOUN1, ELENI PAPALEKAS2, ANDREW TAYLOR3, LAUREN SCHIFF4, EVAN THEOHARIS1 & DAVID EISENSTEIN1 1

Division of Minimally Invasive Gynecology, Department of Obstetrics and Gynecology, Henry Ford Health System, Detroit, MI, 2Department of Obstetrics and Gynecology, Beaumont Health System, Royal Oak, MI, 3Division of Biostatistics, Public Health Sciences, Henry Ford Health System, Detroit, MI, and 4Division of Advanced Laparoscopy and Pelvic Pain, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA

Key words Benign gynecologic disease, risk factors, supracervical hysterectomy, trachelectomy Correspondence Ziv Tsafrir, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI 48202, USA. E-mail: [email protected] Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Tsafrir Z, Aoun J, Papalekas E, Taylor A, Schiff L, Theoharis E, et al. Risk factors for trachelectomy following supracervical hysterectomy. Acta Obstet Gynecol Scand 2017; 96:421–425. Received: 21 April 2016 Accepted: 12 January 2017 DOI: 10.1111/aogs.13099

Abstract Introduction. We identified risk factors for trachelectomy after supracervical hysterectomy (SCH) due to persistence of symptoms. Material and methods. A retrospective case–control study in a university-affiliated hospital. Seventeen women who underwent a trachelectomy following SCH for nonmalignant indications between June 2002 and October 2014 were compared with 68 randomly selected women (controls) who underwent a SCH within the same time period. Demographics and clinical characteristics were compared between the study and control groups. Univariate analysis identified potential risk factors for trachelectomy following SCH. Univariate logistic regression models predicted which patients would have a trachelectomy following SCH. Results. The occurrence of trachelectomy following SCH during the study period was 0.9% (17/1892). The study group was younger than the control group (mean age 38  6 years vs. 44  5 years; p < 0.001). Patients who had a history of endometriosis [odds ratio (OR) 6.23, 95% CI 1.11–40.5, p = 0.038] had increased risk for trachelectomy. Pathology diagnosed endometriosis only among women in the study group. Preoperative diagnosis of abnormal uterine bleeding (OR 0.22, 95% CI 0.06–0.075, p = 0.016), anemia (OR 0.12, 95% CI 0.01–0.53; p = 0.003), and fibroid uterus (OR 0.24, 95% CI 0.07–0.82, p = 0.024) reduced the risk for future trachelectomy. Conclusion. Young age and endometriosis are significant risk factors for trachelectomy following SCH. Abbreviation:

SCH, supracervical hysterectomy.

Introduction Advancements in minimally invasive surgery in the 1990s led to a renewed interest in supracervical hysterectomy (SCH). Advocates of this procedure hypothesized that removing the entire cervix may diminish sexual response, urinary function and pelvic support, while increasing operative time and complications (1–5). Subsequent studies failed to find benefit from retention of the cervix at hysterectomy (6–9). Moreover, persistent symptoms in

some women, mainly pelvic pain and vaginal bleeding, force removal of the cervical stump (6,10,11). The reported incidence of trachelectomy following SCH for

Key Message An age of under 40 years and endometriosis are significant risk factors for trachelectomy following supracervical hysterectomy.

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benign gynecologic disease ranges between 2% and almost 23% (11–13). Although some experts opine that SCH may not be the treatment of choice in women with preexisting pelvic pain or endometriosis, there are few data regarding risk factors for trachelectomy following SCH (10,11,14). The objective of our study was to identify the incidence of and risk factors for trachelectomy following SCH for benign gynecologic disease, and thereby predict which patients have the greatest risk for re-operation.

SCH within the same time period. For each study case there were four randomly selected controls. The electronic patient medical record identified demographics and past medical, obstetric, gynecologic and surgical history, including patient’s chief complaints and indications for SCH, intraoperative findings, and pathology results. In women who subsequently had a trachelectomy, the time interval from SCH to the recurrence of symptoms, description of symptoms, indication for trachelectomy, surgical approach, and pathology diagnosis were retrieved. The study was approved by the Henry Ford Health System Institutional Review Board on 22 April 2014; reference number 8904. Welch’s t-test, chosen for reliability to compare groups of unequal sizes, was applied for continuous variables, and either chi-squared test or Fisher’s exact test was used for categorical variables, as appropriate. A two-sided probability value of p < 0.05 was considered to be significant. Univariate logistic regression models were used to identify which clinical variables were significant predictors for trachelectomy following SCH.

Material and methods This retrospective case–control study was conducted at Henry Ford Hospitals, university-affiliated tertiary medical centers in southeastern Michigan. The study group consisted of all women who underwent a trachelectomy for nonmalignant etiologies following a SCH between June 2002 and October 2014. The control group was comprised of randomly selected women who underwent a

Table 1. Demographic and clinical history (at supracervical hysterectomy). Characteristic

Type

Race

African American White Asian Hispanic Other

Age, years, (mean  SD) Body mass index (kg/m2) Smoking Past medical history

Past obstetric history

Past surgical history

Family history

Depression/Anxiety/Chronic pain Endometriosis Gravida 0 ≥1 Para 0 ≥1 Cesarean section ≥ 1 Laparoscopy Diagnostic Tubal ligation Salpingectomy Adnexectomy Resection of endometriosis Endometrial ablation Uterine artery embolization Myomectomy Hysteroscopy Endometriosis

Trachelectomy (n = 17)

No trachelectomy (n = 68)

p value

6 (40%) 8 (53.3%) 1 (6.7%) 0 (0.00%) 0 (0.00%) 38.00  6 31.00  6.9 1 (6.3%) 6 (35.3%)

37 (59.7%) 21 (33.9%) 1 (1.6%) 1 (1.6%) 2 (3.2%) 44.0  5 31.8  7.1 14 (22.6%) 14 (21.2%)

0.33

0.001 0.73 0.23 0.37

2 (3%)

0.05

3 (17.7%) 3 (17.6%) 14 (82.4%)

5 (7.5%) 62 (92.5%)

0.35

5 (29.4%) 12 (70.6%) 3 (17.7%)

7 (10.3%) 60 (89.6%) 43 (62.9%)

0.06

1 2 1 3 2 1 0 1 16 2

5 22 0 3 3 10 2 1 49 0

0.24

(6%) (11.8%) (6%) (17.7%) (11.8%) (6%) (0%) (6%) (94%) (11.8%)

(7.3%) (32.3%) (0%) (4.5%) (4.5%) (15%) (3%) (1.5%) (74.2%) (0%)

0.003

0.65 0.65 0.37 0.47 0.05

SD, standard deviation.

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Results During the study period, 1892 SCH procedures were performed at our medical center. Our analysis included a total of 85 women: 17 who underwent a trachelectomy following SCH, and the control group of 68 women who only had a SCH. The occurrence of trachelectomy following SCH was 0.9%. Demographics and clinical characteristics are presented in Table 1. Women who had a subsequent trachelectomy were younger at the time of SCH compared with women who did not need a trachelectomy (38  6 years vs. 44  5 years, respectively; p = 0.001). Past medical history of endometriosis was significantly more common among women who had a trachelectomy (3/17 (17.7%) vs. 2/68 (3%), p = 0.05). Finally, the percentage of women who had a history of at least one cesarean section was lower in the study group compared with the control group (17.7% vs. 62.9%, p = 0.003). Symptoms, signs and surgical findings at the time of SCH are depicted in Table 2. Abnormal uterine bleeding and anemia were less common in the study group, compared with the controls (65% vs. 90%, p = 0.029, and 6% vs. 43%, p = 0.004, respectively). The duration of symptoms before surgery was shorter in the study group compared with the control group (17  13 months vs. 30  36 months, p = 0.04). Pathology diagnosed endometriosis only in the study group (17.7% vs. 0%, p = 0.005), whereas uterine fibroids were more evident in the control group (85% vs. 57%, p = 0.04). A univariate logistic regression analysis of risk factors for trachelectomy following SCH is shown in Table 3. A history of endometriosis predicted an increased risk for trachelectomy [odds ratio (OR) 6.23, 95% CI 1.11–40.5, p = 0.038]. Older age at the time of the SCH and presenting symptoms of abnormal uterine bleeding and anemia were associated with a lower risk for trachelectomy. A pathology finding of fibroid uterus also correlated with a reduced risk for future trachelectomy (OR 0.24, 95% CI 0.07–0.82, p = 0.024). Clinical and surgical characteristics of women who had a trachelectomy are detailed in Table 4. Seventy percent of women had more than a single complaint: the leading indications for surgery were pain (70%) and bleeding (59%). The median time interval from SCH to trachelectomy was 28 months, and a minimally invasive approach was implemented in 94% of the cases. Endometriosis (29%) was the most common pathologic diagnosis. Postoperative complications occurred in three women: a vesico-vaginal fistula, which was repaired with a robotassisted laparoscopic approach; a case of small bowel

Risk factors for trachelectomy post supracervical hysterectomy

obstruction; and a vaginal-cuff hematoma. The latter two cases resolved with conservative management. Ninety-four percent of women reported complete resolution or improvement of symptoms after a median follow up of 44 months. One woman had multiple small bowel surgeries following trachelectomy due to recurrent obstruction.

Discussion In our review of the literature we found no controlled studies on risk factors for trachelectomy after SCH for benign disease. Previous reports described the clinical characteristics of women who required trachelectomy following SCH (11,15–17). However, none of these studies matched patients to a cohort of women who had SCH only. Our data demonstrate that patients with a history of endometriosis and those who had SCH at an age < 40 years were at an increased risk for trachelectomy. In spite of clinical trends, such as the debate over morcellation (18,19), that may decrease the utilization of SCH, this approach to hysterectomy still has its proponents and remains an attractive option in many patients. Therefore, the establishment of a risk stratification model that identifies the probability of recurrent symptoms post-SCH is essential to both patients and surgeons in making informed decisions about the optimal surgical approach (10–12). The overall occurrence of trachelectomy varies in the literature. While Okaro et al. reported a 23% incidence (11), other series presented a lower incidence of 2–3% (12,13), which is in keeping with our 0.9% during a study period of 12 years. In their retrospective observation of the long-term outcomes following laparoscopic SCH, Lieng and colleagues acknowledged that women who underwent SCH for pelvic pain or endometriosis were at an increased risk for persistent pain. Moreover, in almost half of their cases where trachelectomy was performed following SCH, the indication for removal of the cervix was endometriosis (20). Okaro and colleagues reported that 82% of the patients who suffered from cervical stump symptoms post-SCH had been treated for endometriosis before the hysterectomy procedure (11). Other authors have also advised against SCH in the presence of endometriosis (6,10). Our data, which show that endometriosis was a pathology diagnosis only in the specimens of patients who had trachelectomy, crystallizes this literature and gives strong evidence that endometriosis predicts a second surgery. We observed that women who presented with abnormal uterine bleeding, anemia, and finding of a fibroid

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Table 2. Symptoms, signs and surgical findings at the time of supracervical hysterectomy.

Parameter

Type

Duration of symptoms (months) leading to SCH Pain

Mean  SD

Trachelectomy (n = 17)

No trachelectomy (n = 68)

p value

17  13

30  36

0.04

No pain Pelvic pain only Dyspareunia/Dysmenorrhea

AUB Anemia Type of SCH

Additional adnexal procedure Additional urogynecologic procedure Findings at SCH Uterine pathology Uterine weight (g)

7 6 4 11 1 11 6 0 0

Laparoscopic Laparotomy Robot-assisted laparoscopy Laparoscopy converted to Laparotomy Yes Yes

(41.2%) (35.3%) (23.5%) (65%) (6%) (64.7%) (35.3%) (0%) (0%)

5 (29.4%) 1 (6%)

Endometriosis Enlarged fibroid uterus Fibroids Endometriosis Mean  SD

3 (20.00%) 9 (60.00%) 8 (57.1%) 3 (17.7%) 357.7  454

43 10 15 61 29 52 12 1 3

(63.3%) (14.7%) (22%) (90%) (43%) (76.5%) (17.6%) (1.5%) (4.4%)

0.12

0.029 0.004 0.41

17 (25%) 8 (11.7%)

0.95 0.79

3 (4.5%) 53 (84.1%) 57 (85%) 0 (0%) 372.6  352

0.07 0.085 0.04 0.005 0.91

AUB, Abnormal uterine bleeding; SCH, supracervical hysterectomy; SD, standard deviation.

Table 3. Risk factors for trachelectomy following supracervical hysterectomy.

Parameter

Odds ratio (95% CI)

p value

Past medical history of endometriosis Age at surgery Abnormal uterine bleeding Anemia Surgical finding: enlarged fibroid uterus Pathology findings: fibroid uterus

6.23 (1.11–40.5) 0.81 (0.70–0.91) 0.22 (0.06–0.75) 0.12 (0.01–0.53) 0.29 (0.9–0.97) 0.24 (0.07–0.82)

0.038 < 0.001 0.016 0.003 0.045 0.024

uterus were correlated with a reduced risk for subsequent removal of the cervix. Older patients were also less likely to require a trachelectomy, consistent with Lieng and associates observation that persistent bleeding following SCH was less common among older women (20). SCH may be most appropriate for this distinct group of patients. Our data demonstrate that 94% of women who underwent trachelectomy reported either resolution or substantial improvement of their symptoms during follow up of 3.5 years. Nezhat et al. shared similar results in their laparoscopic trachelectomy series (10). A major strength of our study is that it used a single medical system with electronic medical records that permitted complete data extraction from 1892 records over the study period. Patients were followed for a median of

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Table 4. Trachelectomy: clinical and surgical characteristics. Variable

Value/n (%)

Age, years (mean  SD) Indication for trachelectomya Pain Bleeding Pelvic mass Other Time interval from SCH to trachelectomy, months (median) Surgical approach Robotic Laparoscopic Vaginal Abdominal Concomitant procedure Pathology results Endometriosis Uterine remnant Chronic cervicitis Normal cervix Other Follow up Resolution of symptoms Improvement of symptoms Persistence/no change of symptoms

43.5  9.5 12/17 10/17 4/17 3/17 28

(70%) (59%) (23%) (18%)

11/17 3/17 2/17 1/17 16/17

(64.7%) (17.7%) (11.8%) (5.9%) (94%)

5/17 3/17 4/17 3/17 2/17

(29%) (18%) (23%) (18%) (12%)

11/17 (65%) 5/17 (29%) 1/17 (6%)

SCH, supracervical hysterectomy; SD, standard deviation. Some patients had more than one indication.

a

ª 2017 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 96 (2017) 421–425

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3.5 years with a maximum of 12 years. The patient population was diverse with a substantial representation of minority patients. The results support most of the literature and clarify who should not have the procedure. A limitation of this retrospective study may be the relatively low incidence for trachelectomy. The overall low incidence of post-SCH trachelectomy makes statistical analysis of risk factors challenging. Additionally, cases of post-hysterectomy trachelectomy that were performed in outside institutions could not be accounted for in our data. This study is from a single academic institution, which may not be representative of the surgical and clinical practices in other institutions. We conclude that young age (< 40 years) and endometriosis are significant risk factors for trachelectomy following SCH. It is our obligation, as physicians, to address patients’ symptoms and tailor the appropriate treatment. Given the importance of this clinical challenge, a prospective multicenter study will best confirm the ability to predict the women who most benefit from SCH.

Acknowledgments We thank Dr. Ronald Strickler, Department of Obstetrics and Gynecology, Henry Ford Hospital for scientific counseling and editorial assistance. We thank Ms. Stephanie Stebens, Sladen Library, Henry Ford Hospital, for editorial assistance. References 1. Lyons TL. Laparoscopic supracervical hysterectomy. Baillieres Clin Obstet Gynaecol. 1997;11:167–79. 2. Lyons TL. Laparoscopic supracervical hysterectomy. Obstet Gynecol Clin North Am. 2000;27:441–50, ix. 3. Kilkku P. Supravaginal uterine amputation vs. hysterectomy. Effects on coital frequency and dyspareunia. Acta Obstet Gynecol Scand. 1983;62:141–5. 4. Kilkku P. Supravaginal uterine amputation versus hysterectomy with reference to subjective bladder symptoms and incontinence. Acta Obstetricia Gynecol Scand. 1985;64:375–9. 5. Kilkku P, Gronroos M, Hirvonen T, Rauramo L. Supravaginal uterine amputation vs. hysterectomy. Effects on libido and orgasm. Acta Obstetricia Gynecol Scand. 1983;62:147–52. 6. Jenkins TR. Laparoscopic supracervical hysterectomy. Am J Obstet Gynecol. 2004;191:1875–84.

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