Determining Optimal Route of Hysterectomy for Benign Indications

Abstract

Objective To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy. Methods A retrospective post-robot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded laparoscopic hysterectomy route. A pre-robot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated. Results Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the pre-robot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy, with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the post-robot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%), robot-assisted; and 136 (11.4%), abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when vaginal approach was expected. Robotic hysterectomies had longer operations (141 vs 59 minutes, P<.001) and higher rates of surgical site infection (4.7% vs 0.2%, P<.001) and urinary tract infection (8.1% vs 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years. Conclusion When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.

Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women

“…While there is gynecologic disease (e.g., large fibroids or adhesive disease due to previous surgery or endometriosis) that might complicate or even contraindicate a vaginal approach, systematic protocols can increase the proportion of vaginal hysterectomies. 14,15 Programs promoting rational and safe utilization of vaginal hysterectomy could be a responsible strategy for further decreasing expenditures related to hysterectomy.…”

Robotic transvaginal natural orifice transluminal endoscopic surgery for bilateral salpingo oophorectomy

“…Clearly, NOTES in general, and RvNOTES in particular, represents a new paradigm for both surgeons and patients. Nonetheless, the underutilization of NOTES even among gynecologists [ 13 , 16 ] highlights the urgent need for appropriate and designated instrumentation, in addition to the assimilation of a new paradigm. This is precisely the gap to be filled by robotic-assisted technology designed specifically for NOTES.…”

“…For example, vaginal access is considered the preferred option for benign hysterectomy, when feasible [ 11 , 12 ]. Vaginal access is considered feasible in more than 60 % of hysterectomies for benign indications [ 13 ], including women without previous vaginal delivery [ 14 ]. However, this approach is underutilized in gynecological surgery due to the restricted surgical space, the lack of exposure and the limited training [ 15 ].…”

“…However, this approach is underutilized in gynecological surgery due to the restricted surgical space, the lack of exposure and the limited training [ 15 ]. Indeed, the proportion of vaginally-feasible hysterectomies performed by other approaches increased since laparoscopic and robot-assisted laparoscopic surgeries became popular [ 13 , 16 ]; the consequence is longer operative time and higher infection rates. This trend suggests that more appropriate instrumentation could increase utilization of the vaginal approach.…”

Retrospective Analysis of Route Selection for Hysterectomy for Benign Indications at Ochsner Baptist Hospital

“…The algorithm detailed by Schmitt et al 15 was used to retrospectively reclassify the optimal route of hysterectomy based on objective characteristics—preoperative pathology, vaginal accessibility, uterine size, and uterine weight—instead of surgeon preference. We defined vaginal accessibility by a history of ≥1 vaginal delivery and history of ≤1 laparotomy combined with physical examination findings of a uterus ≤12 weeks’ gestation size and adequate mobility.…”