1. Risk factors for trachelectomy following supracervical hysterectomy
ZIV TSAFRIR1 , JOELLE AOUN1 , ELENI PAPALEKAS2 , ANDREW TAYLOR3 , LAUREN SCHIFF4 , EVAN THEOHARIS1 & DAVID EISENSTEIN1
1Division 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
ACTA Obstetricia et Gynecologica Scandinavica Journal Club
-Gynecology-
April 2017
Edited by Francesco D’Antonio

2. Background
The reported incidence of trachelectomy following supracervical hysterectomy (SCH) for benign gynecologic disease ranges between 2% and 23%.
SCH can lead to impaired sexual response, urinary function and pelvic support, while increasing operative time and complications.
However, there is no evidence that mantaining the cervix might lead to any benefit to the women.
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

3. To predict the risk of re-operation.
Aims of the study
To identify the incidence of and risk factors for trachelectomy following SCH for benign gynecologic disease.
To predict the risk of re-operation.

4. Methodology Study design: Retrospective case–control study.
Inclusion criteria:
Study group: All women who underwent a trachelectomy for nonmalignant etiologies following a SCH between June 2002 and October 2014.
Control group: Randomly selected women who underwent SCH within the same time period. For each study case there were four randomly selected controls.
Statistical analysis: 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. Univariate logistic regression models were used to identify which clinical variables were significant predictors for trachelectomy following SCH.

5. Results (1)
Women who had a subsequent trachelectomy were younger compared with women who did not need a trachelectomy.
Past medical history of endometriosis was significantly more common among women who had a trachelectomy.
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.

6. Results (2)
Abnormal uterine bleeding and anemia were less common in the study group.
Duration of symptoms before surgery was shorter in the study group.
Pathology diagnosed endometriosis only in the study group, whereas uterine fibroids were more evident in the control group.

7. Results (3)
A univariate logistic regression analysis, 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)

8. Results (4)
Leading indications for surgery were pain (70%) and bleeding (59%).
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
94% of women reported complete resolution or improvement of symptoms after a median follow up of 44 months.

9. Strengths Limitations
First study on risk factors for trachelectomy after SCH for benign disease.
Relatively large series.
Long time at follow-up.
The patient population was diverse with a substantial representation of minority patients.
Limitations
Retrospective design.
Low incidence for trachelectomy.
The study is from a single academic institution, which may not be representative of the surgical and clinical practices in other institutions.

10. Conclusion
Young age and endometriosis are significant risk factors for trachelectomy following SCH.