title: What determines the need to morcellate the uterus during total laparoscopic hysterectomy?
abstract: OBJECTIVE
  To identify factors associated with the need to perform uterine morcellation during total laparoscopic hysterectomy (TLH). A secondary aim was to establish new cut-offs based on uterine weight for the probability of morcellation.
  
  
  METHODS
  Prospective observational study (Canadian Task Force Classification II-2).
  
  
  METHODS
  Tertiary referral laparoscopic unit.
  
  
  METHODS
  All women scheduled to undergo TLH in the study period were included.
  
  
  METHODS
  Age, parity, operating time, estimated blood loss, and final uterine weight at histology were recorded. Logistic regression analysis was performed to determine the factors associated with the need to perform uterine morcellation at the time of TLH. Multiple imputation (MI) was used to impute missing values.
  
  
  RESULTS
  A total of 112 consecutive women underwent TLH and were included in the final analysis. In all, 56 (50%) of 112 women underwent TLH without morcellation (i.e., it was possible to deliver the uterine specimen vaginally) and 56 (50%) of 112 women underwent TLH with morcellation (i.e., it was not possible to deliver the uterine specimen vaginally and, therefore, morcellation was performed). Median age in each group was 45 and 46 years, respectively. Sixteen (70%) of 23 nulliparous women underwent morcellation compared with 40 (45%) of 89 parous women. Multivariable logistic regression analysis revealed that nulliparity (OR = 6.45, 95% CI = 1.74-23.9) and uterine weight (OR/100-g increase = 4.97, 95% CI = 2.13-11.6) increased the odds of morcellation. All 20 women with a uterine weight of at least 350 g required morcellation. Based on the MI analysis results, uterine weight was at least 350 g in 1 of 5 patients, with 99.5% of the women having uterine weight of 350 g or more that required morcellation.
  
  
  CONCLUSIONS
  Nulliparity and increasing uterine weight are associated with the need to perform uterine morcellation in TLH. Studies are needed to find a reliable method for estimating uterine weight preoperatively.
authors.affiliation: Center for Advanced Reproductive Endosurgery, Royal North Shore Hospital, University of Sydney, Australia. gcondous@hotmail.com
authors.forename: George
authors.initials: G
authors.lastname: Condous
authors.forename: Tommaso
authors.initials: T
authors.lastname: Bignardi
authors.forename: Dalya
authors.initials: D
authors.lastname: Alhamdan
authors.forename: Ben
authors.initials: B
authors.lastname: Van Calster
authors.forename: Sabine
authors.initials: S
authors.lastname: Van Huffel
authors.forename: Dirk
authors.initials: D
authors.lastname: Timmerman
authors.forename: Alan
authors.initials: A
authors.lastname: Lam
mesh_terms: D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D016017:Odds Ratio; D009929:Organ Size; D010298:Parity; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011446:Prospective Studies; D012016:Reference Values; D012307:Risk Factors; D014599:Uterus / Q000033:anatomy & histology* / Q000601:surgery*