J Clin Gynecol Obstet

Journal of Clinical Gynecology and Obstetrics, ISSN 1927-1271 print, 1927-128X online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Gynecol Obstet and Elmer Press Inc

Journal website http://www.jcgo.org

Original Article

Volume 4, Number 1, March 2015, pages 153-159

Postoperative Morbidity of Minimally Invasive Hysterectomy Approach and Uterine Size

**Table 1.** Current Procedural Terminology Coding System, 4th Edition for Minimally Invasive Hysterectomy
CPT-4 code	Description
58541	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less
58542	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less, with removal of tube(s) and/or ovary(s)
58543	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
55844	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary(s)
58550	Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less
58552	Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less, with removal of tube(s) and/or ovary(ies)
58553	Laparoscopy surgical, with vaginal hysterectomy, for uterus greater than 250 g
58554	Laparoscopy surgical, with vaginal hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary(ies)
58570	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
58571	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less, with removal of tube(s) and/or ovary(ies)
58572	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g
58573	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary(ies)
58260	Vaginal hysterectomy, for uterus 250 g or less
58262	Vaginal hysterectomy, for uterus 250 g or less, with removal of tube(s) and/or ovary(s)
58263	Vaginal hysterectomy, for uterus 250 g or less, with removal of tube(s) and/or ovary(s), with repair of enterocele
58267	Vaginal hysterectomy, for uterus 250 g or less, with colpo-urethrocystopexy (Marshall-Marchetti-Kranz type, Pereyra type, with or without endoscopic control)
58270	Vaginal hysterectomy, for uterus 250 g or less, with repair of enterocele
58290	Vaginal hysterectomy, for uterus greater than 250 g
58291	Vaginal hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary(ies)
58292	Vaginal hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary(ies), with repair of enterocele
58293	Vaginal hysterectomy, for uterus greater than 250 g, with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
58294	Vaginal hysterectomy, for uterus greater than 250 g, with repair of enterocele

Table 1. Current Procedural Terminology Coding System, 4th Edition for Minimally Invasive Hysterectomy

CPT-4 code

Description

58541

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less

58542

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less, with removal of tube(s) and/or ovary(s)

58543

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g

55844

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary(s)

58550

Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less

58552

Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less, with removal of tube(s) and/or ovary(ies)

58553

Laparoscopy surgical, with vaginal hysterectomy, for uterus greater than 250 g

58554

Laparoscopy surgical, with vaginal hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary(ies)

58570

Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less

58571

Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less, with removal of tube(s) and/or ovary(ies)

58572

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g

58573

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary(ies)

58260

Vaginal hysterectomy, for uterus 250 g or less

58262

Vaginal hysterectomy, for uterus 250 g or less, with removal of tube(s) and/or ovary(s)

58263

Vaginal hysterectomy, for uterus 250 g or less, with removal of tube(s) and/or ovary(s), with repair of enterocele

58267

Vaginal hysterectomy, for uterus 250 g or less, with colpo-urethrocystopexy (Marshall-Marchetti-Kranz type, Pereyra type, with or without endoscopic control)

58270

Vaginal hysterectomy, for uterus 250 g or less, with repair of enterocele

58290

Vaginal hysterectomy, for uterus greater than 250 g

58291

Vaginal hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary(ies)

58292

Vaginal hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary(ies), with repair of enterocele

58293

Vaginal hysterectomy, for uterus greater than 250 g, with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control

58294

Vaginal hysterectomy, for uterus greater than 250 g, with repair of enterocele

**Table 2.** Characteristics of the Study Population
	Uterine size < 250 g by CPT-4 (n = 31,754)	Uterine size > 250 g by CPT-4 (n = 5,067)	P*
CPT-4: current procedural terminology, 4th edition; TIA: transient ischemic attack; RVU: relative work value unit. Data are mean ± standard deviation or % unless otherwise specified. *χ² or Student’s t-test.
Age (years)	47.9 ± 11.7	47.4 ± 7.2	0.002
BMI (kg/m²)	29.6 ± 7.3	30.7 ± 8.0	< 0.001
Race
White	78.6%	64.5%	< 0.001
Hispanic	10.3%	11.4%	0.854
Black of African American	8.0%	22.7%	< 0.001
Asian	2.2%	3.6%	< 0.001
Other	11.2%	9.2%	< 0.001
Clinical characteristics
Active smoker	19.5%	14.2%	< 0.001
Steroid use	1.1%	0.7%	0.012
Comorbidities
Hypertension	25.1%	25.2%	0.818
Diabetes	6.5%	5.7%	0.023
Dyspnea	3.4%	3.0%	0.185
History of cardiac procedures	0.6%	0.4%	0.059
History of TIA or stroke	0.8%	0.5%	0.005
Bleeding disorder	0.9%	1.1%	0.200
Primary indication
Fibroids	53.1%	73.3%	< 0.001
Abnormal bleeding	24.2%	16.1%	< 0.001
Pelvic pain	9.2%	2.3%	< 0.001
Endometriosis	7.3%	4.0%	< 0.001
Prolapse	20.4%	4.2%	< 0.001
Postmenopausal	2.9%	2.1%	< 0.001
Ovarian mass	2.8%	1.8%	< 0.001
Endometrial hyperplasia	4.7%	3.0%	< 0.001
Cervical dysplasia	3.6%	1.0%	< 0.001
Surgical characteristics
Concurrent adnexal surgery	47.7%	41.7%	< 0.001
Concurrent pelvic support procedure	19.0%	7.1%	< 0.001
Total concurrent RVU	7.2 ± 12.0	4.7 ± 9.6	< 0.001
Pre-operative hematocrit < 30%	38%	25%	< 0.001

Table 2. Characteristics of the Study Population

Uterine size < 250 g by CPT-4 (n = 31,754)

Uterine size > 250 g by CPT-4 (n = 5,067)

CPT-4: current procedural terminology, 4th edition; TIA: transient ischemic attack; RVU: relative work value unit. Data are mean ± standard deviation or % unless otherwise specified. *χ² or Student’s t-test.

Age (years)

47.9 ± 11.7

47.4 ± 7.2

0.002

BMI (kg/m²)

29.6 ± 7.3

30.7 ± 8.0

< 0.001

Race

White

78.6%

64.5%

< 0.001

Hispanic

10.3%

11.4%

0.854

Black of African American

8.0%

22.7%

< 0.001

Asian

2.2%

3.6%

< 0.001

Other

11.2%

9.2%

< 0.001

Clinical characteristics

Active smoker

19.5%

14.2%

< 0.001

Steroid use

1.1%

0.7%

0.012

Comorbidities

Hypertension

25.1%

25.2%

0.818

Diabetes

6.5%

5.7%

0.023

Dyspnea

3.4%

3.0%

0.185

History of cardiac procedures

0.6%

0.4%

0.059

History of TIA or stroke

0.8%

0.5%

0.005

Bleeding disorder

0.9%

1.1%

0.200

Primary indication

Fibroids

53.1%

73.3%

< 0.001

Abnormal bleeding

24.2%

16.1%

< 0.001

Pelvic pain

9.2%

2.3%

< 0.001

Endometriosis

7.3%

4.0%

< 0.001

Prolapse

20.4%

4.2%

< 0.001

Postmenopausal

2.9%

2.1%

< 0.001

Ovarian mass

2.8%

1.8%

< 0.001

Endometrial hyperplasia

4.7%

3.0%

< 0.001

Cervical dysplasia

3.6%

1.0%

< 0.001

Surgical characteristics

Concurrent adnexal surgery

47.7%

41.7%

< 0.001

Concurrent pelvic support procedure

19.0%

7.1%

< 0.001

Total concurrent RVU

7.2 ± 12.0

4.7 ± 9.6

< 0.001

Pre-operative hematocrit < 30%

38%

25%

< 0.001

**Table 3.** Comparison of Unadjusted Minimally Invasive Hysterectomy Outcomes by Uterine Size
	Uterine size < 250 g by CPT-4 code (n = 31,754)	Uterine size > 250 g by CPT-4 code (n = 5,067)	P*
CPT-4: current procedural terminology, 4th edition; DVT: deep vein thrombosis; PE: pulmonary embolus; OR: operating room. Data are n (%) or mean ± standard deviation unless otherwise specified. *χ² or Wilcoxon rank-sum tests.
Overall morbidity	1,093 (3.4)	293 (5.8)	< 0.001
Vascular morbidity	18 (0.1)	2 (0.7)	0.625
Wound morbidity	592 (1.9)	122 (2.4)	0.009
Respiratory morbidity	25 (0.1)	3 (0.1)	0.640
Renal morbidity	15 (0.1)	2 (0.1)	0.811
Blood transfusions	353 (1.1)	154 (3.0)	< 0.001
DVT/PE morbidity	68 (0.2)	11 (0.2)	0.966
Infectious morbidity	166 (.5)	35 (0.7)	0.132
Return to OR	412 (1.3)	85 (1.7)	0.030
Operative time (min)	124.1 ± 65.4	162 ± 78.1	< 0.001
Length of stay (days)	1.31 ± 5.3	1.36 ± 7.5	0.535

Table 3. Comparison of Unadjusted Minimally Invasive Hysterectomy Outcomes by Uterine Size

Uterine size < 250 g by CPT-4 code (n = 31,754)

Uterine size > 250 g by CPT-4 code (n = 5,067)

CPT-4: current procedural terminology, 4th edition; DVT: deep vein thrombosis; PE: pulmonary embolus; OR: operating room. Data are n (%) or mean ± standard deviation unless otherwise specified. *χ² or Wilcoxon rank-sum tests.

Overall morbidity

1,093 (3.4)

293 (5.8)

< 0.001

Vascular morbidity

18 (0.1)

2 (0.7)

0.625

Wound morbidity

592 (1.9)

122 (2.4)

0.009

Respiratory morbidity

25 (0.1)

3 (0.1)

0.640

Renal morbidity

15 (0.1)

2 (0.1)

0.811

Blood transfusions

353 (1.1)

154 (3.0)

< 0.001

DVT/PE morbidity

68 (0.2)

11 (0.2)

0.966

Infectious morbidity

166 (.5)

35 (0.7)

0.132

Return to OR

412 (1.3)

85 (1.7)

0.030

Operative time (min)

124.1 ± 65.4

162 ± 78.1

< 0.001

Length of stay (days)

1.31 ± 5.3

1.36 ± 7.5

0.535

**Table 4.** Independent Risk Factor Association With Overall Morbidity
Preoperative variable	aOR	95% CI	P
aOR: adjusted odds ratio; CI: confidence interval; BMI: body mass index; RVU: relative work value units.
Uterine size > 250 g by CPT-4 code	1.73	1.31 - 2.29	< 0.001
Black race	1.77	1.13 - 2.79	0.013
Hispanic ethnicity	1.82	1.30 - 2.54	0.004
Bleeding disorders	4.35	2.43 - 8.46	< 0.001
BMI > 30	1.37	1.07 - 1.74	0.011
Concurrent pelvic support procedure	0.48	0.33 - 0.70	< 0.001
Total concurrent RVU	1.47	1.04 - 2.07	0.027
Hosmer-Lemeshow	0.941
C-statistic	0.672

Table 4. Independent Risk Factor Association With Overall Morbidity

Preoperative variable

aOR

95% CI

aOR: adjusted odds ratio; CI: confidence interval; BMI: body mass index; RVU: relative work value units.

Uterine size > 250 g by CPT-4 code

1.73

1.31 - 2.29

< 0.001

Black race

1.77

1.13 - 2.79

0.013

Hispanic ethnicity

1.82

1.30 - 2.54

0.004

Bleeding disorders

4.35

2.43 - 8.46

< 0.001

BMI > 30

1.37

1.07 - 1.74

0.011

Concurrent pelvic support procedure

0.48

0.33 - 0.70

< 0.001

Total concurrent RVU

1.47

1.04 - 2.07

0.027

Hosmer-Lemeshow

0.941

C-statistic

0.672

**Table 5.** Independent Association of Operative Approach With Overall Morbidity by Uterine Size
Hysterectomy approach	aOR	95% CI	P	Hosmer-Lemeshow	C-statistic
aOR: adjusted odds ratio; CI: confidence interval; CPT-4: current procedural terminology, 4th edition; LAVH: laparoscopic-assisted vaginal hysterectomy; LSCH: laparoscopic supracervical hysterectomy; TLH: total laparoscopic hysterectomy; TVH: total vaginal hysterectomy, with or without concurrent adnexal surgery; MIS: minimally invasive.
Among uterine size < 250 g by CPT-4 code
LAVH (n = 8,687)	1.36	0.99 - 1.85	0.052	0.939	0.650
LSCH (n = 4,877)	0.76	0.53 - 1.10	0.152	0.188	0.651
TLH (n = 8,192)	0.61	0.42 - 0.90	0.012	0.379	0.651
TVH (n = 9,998)	1.32	0.97 - 1.806	0.079	0.005	0.652
Among uterine size > 250 g by CPT-4 code
LAVH (n = 1,430)	1.23	0.73 - 2.07	0.448	0.020	0.645
LSCH (n = 863)	1.081	0.55 - 2.120	0.821	0.039	0.648
TLH (n = 2,112)	0.66	0.40 - 1.10	0.108	0.025	0.654
TVH (n = 626)	1.41	0.74 - 2.69	0.290	0.226	0.651
All MIS hysterectomy > 250 g by CPT-4 code (n = 5,067)	1.73	1.30 - 2.29	< 0.001	0.941	0.672

Table 5. Independent Association of Operative Approach With Overall Morbidity by Uterine Size

Hysterectomy approach

aOR

95% CI

Hosmer-Lemeshow

C-statistic

aOR: adjusted odds ratio; CI: confidence interval; CPT-4: current procedural terminology, 4th edition; LAVH: laparoscopic-assisted vaginal hysterectomy; LSCH: laparoscopic supracervical hysterectomy; TLH: total laparoscopic hysterectomy; TVH: total vaginal hysterectomy, with or without concurrent adnexal surgery; MIS: minimally invasive.

Among uterine size < 250 g by CPT-4 code

LAVH (n = 8,687)

1.36

0.99 - 1.85

0.052

0.939

0.650

LSCH (n = 4,877)

0.76

0.53 - 1.10

0.152

0.188

0.651

TLH (n = 8,192)

0.61

0.42 - 0.90

0.012

0.379

0.651

TVH (n = 9,998)

1.32

0.97 - 1.806

0.079

0.005

0.652

Among uterine size > 250 g by CPT-4 code

LAVH (n = 1,430)

1.23

0.73 - 2.07

0.448

0.020

0.645

LSCH (n = 863)

1.081

0.55 - 2.120

0.821

0.039

0.648

TLH (n = 2,112)

0.66

0.40 - 1.10

0.108

0.025

0.654

TVH (n = 626)

1.41

0.74 - 2.69

0.290

0.226

0.651

All MIS hysterectomy > 250 g by CPT-4 code (n = 5,067)

1.73

1.30 - 2.29

< 0.001

0.941

0.672