Women undergoing vaginal hysterectomy are more likely to receive cold-knife morcellation if they have an enlarged uterus, leiomyoma, or no prolapse, according to new research.

Electromechanical morcellation, a technique used during laparoscopic hysterectomy to cut the uterus into small pieces for removal, has come under heavy scrutiny in recent years due to risk of disseminating undiagnosed uterine cancers. However, morcellation can also be performed manually during a vaginal hysterectomy. While current recommendations stress caution for all types of morcellation, the risks and prognostic factors for cold-knife morcellation are poorly understood.

In a retrospective cohort study, Dr. Megan Wasson, of the Mayo Clinic Arizona in Phoenix, and her colleagues examined a cohort of 743 women who underwent hysterectomy with either intact uterine removal (383 women) or with cold-knife morcellation (360 women).

Dr. Wasson and her colleagues found that women were significantly more likely to undergo morcellation, compared with intact uterine removal if they had larger uterine weight (adjusted odds ratio, 7.25; P less than .001), lack of prolapse (aOR, 3.87; P less than .001), or the presence of leiomyoma (aOR, 2.77, P = .035).

Women with prior vaginal delivery were significantly less likely to receive morcellation (aOR, 0.79, P = .005).

Younger age, lower parity, and nonwhite race were also associated with a higher likelihood of undergoing morcellation ( Obstet Gynecol. 2016;127:752–7 ).

“This study identified prognostic factors associated with an increased likelihood of morcellation required at the time of vaginal hysterectomy,” Dr. Wasson and her colleagues wrote, stressing that higher uterine weight was the strongest predictor. “The ability to preoperatively predict uterine weight and size is essential for surgical planning given that a large uterus is most predictive of needing morcellation at the time of vaginal hysterectomy.”

The findings, they wrote, may help clinicians identify those patients who need additional counseling about the potential risks of morcellation, as well as patients who may need to avoid vaginal hysterectomy to negate the risks of morcellation.

The investigators identified limitations to their study, including that the majority of the women (88%) were white, and that candidates for vaginal hysterectomy were carefully chosen by expert surgeons, leading to likely selection bias.

The investigators reported having no financial disclosures.


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