Objective
The purpose of this study was to compare complications from vaginal hysterectomy with abdominal hysterectomy in renal transplant recipients.
Study Design
Women who underwent renal transplantation then hysterectomy from 1966-2008 at Mayo Clinic, Rochester, MN, were identified. Data were collected about preoperative, intraoperative, and postoperative events. Main outcome measure was loss of allograft function; secondary outcomes included types of complications and treatment methods.
Results
Of 58 women with renal transplants, 42 women (72.4%) underwent abdominal hysterectomy. The most common indication for hysterectomy was menorrhagia (n = 20; 34.5%). Overall, 24 women (41.4%) had complications, the most common of which were infection (n = 15) and transfusion (n = 8). Women who underwent abdominal hysterectomy were no more likely to have perioperative complications than were women who underwent vaginal hysterectomy (odds ratio, 1.25; 95% confidence interval, 0.38–4.08).
Conclusion
Although patients with renal transplants had perioperative complications, none of these complications led to renal graft loss. Hysterectomy can be considered in these patients when accompanied by diligent postoperative care.
The number of renal transplantations performed in the United States has been increasing steadily from approximately 3800 in 1980 to >18,000 renal transplantations in 2006 ( Figure ). The most common indications for renal transplantation are diabetes mellitus and hypertension, which are often seen in conjunction with obesity. Additionally, patients with a renal transplant face lifelong immunosuppression because of graft rejection medications. These comorbid conditions may contribute to the fact that women who underwent renal transplantation were found to have an increased rate of endometrial hyperplasia and cervical dysplasia. Furthermore, arterial and venous anastomoses require anticoagulation, which may be associated with abnormal uterine bleeding in a menstruating woman. Given these predisposing factors combined with the increasing prevalence of renal transplantation surgery, it is possible that more women with renal transplants will see a gynecologic surgeon for a hysterectomy. Hysterectomy for patients after renal transplantation has been explored only briefly. To date, no study has analyzed a large sample of patients with renal transplants who undergo hysterectomy. Therefore, the risk of complications from hysterectomy in these patients is unknown.
In a study from Mayo Clinic, investigators evaluated the risks of elective surgery among patients with renal transplants. They initially agreed with the theory that these patients are at increased risk for elective surgery. However, they ultimately concluded that, although special precautions were needed because of long-term immunosuppressive therapy, the risk of adverse events from surgery was within reasonable limits.
Our objective was to evaluate a cohort of women who underwent renal transplantation and thereby identify the types and incidence of complications that are associated with subsequent hysterectomy. We aimed to report incidence rates of all complications and compare these in accordance with the hysterectomy procedure.
We hypothesized that women with renal transplants have higher rates of complications because of hysterectomy than reported in previous morbidity data. We also hypothesized that, for patients with no transplantation, the risks of abdominal hysterectomy are increased compared with the risks of vaginal hysterectomy.
Materials and Methods
After receiving study approval from the Mayo Clinic Institutional Review Board, we used the clinic’s Surgical Information Recording System to identify women who underwent both renal transplantation and hysterectomy between 1966 and 2008 at Mayo Clinic, Rochester, MN. From this cohort of patients, all medical records were reviewed to verify that hysterectomy was subsequent to transplantation. All women gave previous authorization for their records to be used for research.
A combination of paper and electronic medical records was used to abstract data regarding demographic characteristics, patient characteristics, preoperative medical conditions, preoperative medications, intraoperative factors, and recovery through postoperative week 9. We identified loss of allograft function as our primary endpoint. Secondary endpoints included other perioperative complications that were defined as unexpected events that required hospital readmission, reoperation, additional medical therapy, or admission to the intensive care unit. Specifically, the type of complication was identified (ie, cardiac failure, pulmonary complications, infection, injury to the urinary tract, and hematologic complications).
Descriptive statistics and odds ratios were reported. The t test and χ 2 test were used to determine probability values with the use of statistical software (JMP, version 7.0.1; SAS Institute Inc, Cary, NC) for the continuous and categoric data. Results were considered statistically significant at a probability value < .05.
Results
Between 1966 and 2008, 58 women underwent renal transplantation and had subsequent hysterectomy by 1 of 16 gynecologic surgeons. Of these, 16 women (27.6%) underwent vaginal hysterectomy, and 42 women (72.4%) underwent abdominal hysterectomy. Thirty-four women (58.6%) had a living related donor; 5 women (8.6%) had a living nonrelated donor, and 19 women (32.8%) received a cadaveric transplant.
Table 1 describes patient characteristics. Mean age and body mass index at hysterectomy were similar between the groups. Parity was greater among the vaginal hysterectomy group, with 26 of 34 parous women (76.5%) having a history of vaginal delivery. No differences were found in the number of medical comorbidities between the groups (2.6 vs 2.8; P = .79). Reflective of their preexisting medical conditions, 37 women (63.8%) overall were assigned an American Society of Anesthesiologists classification of ≥3. Furthermore, women reported taking numerous medications (mean ± SD, 3.9 ± 0.9); the most common medications being corticosteroids and antihypertensives. Table 2 lists indications for hysterectomy; the most common indication was menorrhagia followed by cervical dysplasia, pelvic organ prolapse, and adnexal masses.
| Characteristic | Overall (n = 58) | Hysterectomy | P value | |
|---|---|---|---|---|
| Abdominal (n = 42) | Vaginal (n = 16) | |||
| Age, y | 45.3 ± 11.7 | 43.6 ± 9.5 | 49.8 ± 15.5 | .07 |
| Parity, n | 1.3 ± 1.4 | 0.9 ± 1.1 | 2.3 ± 1.7 | .001 |
| Body mass index, kg/m 2 | 27.9 ± 8.5 | 27.8 ± 9.1 | 28.3 ± 7.2 | .82 |
| Comorbidities, n | 2.7 ± 1.4 | 2.6 ± 1.4 | 2.8 ± 1.2 | .79 |
| Preoperative medication, n | 3.9 ± 0.9 | 3.7 ± 1.0 | 4.3 ± 0.6 | .02 |
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