Outcomes of vaginal and laparoscopic hysterectomy with concomitant pelvic reconstructive surgery

Introduction and hypothesis: Although vaginal hysterectomy(VH) is traditionally considered the safest route of hysterectomy, newer data suggest that laparoscopic hysterectomy (LH) might have lower risks of perioperative complications in contemporary practice. Using a large surgical database, we aimed to assess the hypothesis that there are no significant differences in rates of major and minor complications between LH and VH when performed with pelvic reconstructive surgery, controlling for the number and type of pelvic reconstructive procedures. Methods: A total of 27,941 eligible LH and VH from the 2010–2018 National Surgical Quality Improvement Program database were identified. Concomitant pelvic reconstructive surgery was defined as either an apical suspension, enterocele repair, or colporrhaphy. Laparoscopy-assisted VH, gynecological malignancy, and concomitant nongynecological procedures were excluded. Complications within 30 days of surgery were grouped into major (Clavien–Dindo grade ≥3) or minor (grade 1–2) classifications. Bivariate analysis and inverse propensity-weighted logistic regression compared the outcomes of the VH and LH groups. Cochran–Armitage tests and multivariate regression assessed changes over time. Results: The majority of hysterectomies (72%) were vaginal, although its utilization declined from 89% in 2010 to 64% in 2018 (p < 0.001). In multivariate analysis controlling for patient factors and the type and number of concomitant pelvic reconstructive procedures, LH was associated with a lower odds of major (adjusted odds ratio [aOR] 0.711, 95% confidence interval [CI]:0.639–0.791) and minor (aOR 0.659, 95% CI: 0.612–0.710) complications. Conclusions: Relative safety profiles should be considered among other patient factors when counseling women undergoing surgical prolapse repair. Our findings suggest that laparoscopic approaches can be safely utilized among older and sicker patients traditionally counseled toward a vaginal approach.