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Which Hysterectomy is best for you?

Written by Larry Butler, MD

Hysterectomy (removal of a woman’s uterus) is the second most common surgical procedure performed in the United States. Approximately 433,000 in-patient hysterectomies are performed annually. Although more than 50% of the hysterectomies performed are abdominal hysterectomies, there is an increasing trend toward minimally invasive approaches. In 2010, 30.5% of benign hysterectomies were performed laparoscopically which is an increase from 14% in 2005.  This increase has been ever steeper for the robot-assisted hysterectomy with 9.5% performed robotically in 2010, compared to 0.5% in 2007. There are four different ways of performing a Hysterectomy:

  1. Vaginal (to remove the uterus through the vaginal opening)
  2. Laparoscopic (removal of the uterus through the laparoscope by making small incisions in the abdomen for the scope or laparoscopic assisted vaginal hysterectomy where part is done laparoscopically and part is done vaginally)
  3. Abdominal (an incision is made in the abdominal wall and the uterus is removed through the abdomen), and
  4. Robotic-assisted (performed with the aid of a robot with the surgeon sitting at a console).

The common reason for a patient and their physician to consider a hysterectomy is fibroids in about 40.7% of women, followed by endometriosis by 17.7%, and uterine prolapse makes up approximately 14.5%. It is important for patients to know what studies are showing and what experts in the field of Obstetrics and Gynecology are finding with completed studies. The American College of OB/GYN (ACOG), who set standards and certifies the Obstetricians and Gynecologist Providers stated emphatically that the best hysterectomy for a patient is the vaginal approach. In addition, four large randomized controlled trails have shown that the vaginal hysterectomy is better for women in terms of fewer complications and scars to the abdomen. As stated previously, the vaginal hysterectomy is performed through the vaginal opening creating a quicker recovery process than with the abdominal, laparoscopic, or robotic-assisted approach. However, the vaginal hysterectomy is not feasible in every situation; the overriding concern is that we provide the safest procedure for our patient. Based on national data it is clear that more hysterectomies in the US could be performed using a less invasive vaginal approach than are currently performed. The current statistics are showing a drop in the number of vaginal procedures in which 85% of gynecologists are performing five or fewer vaginal hysterectomies per year. A review of 34 randomized trials of abdominal hysterectomies (including both laparoscopic and vaginal hysterectomies), which involved almost 5,000 patients, concluded that the vaginal hysterectomy had the best outcomes out of the four methods. In all of the studies that compared the four modalities to the vaginal approach, the findings consistently showed a shorter hospital stay, less blood loss, fewer complications, and faster rates of recovery and return to work dates for patients following a vaginal hysterectomy. Patients undergoing an abdominal hysterectomy showed longer hospitalization, a higher risk of complications, and slower recovery periods. Notably at times, performing and abdominal hysterectomy is the method of choice depending on patient presentation with certain conditions, such as cancer, etc. The head-to-head studies showing the newer robotic technology with the traditional laparoscopic technology has not shown an improvement in patient outcomes post-operatively. What cannot be supported is the rapid adoption of the robot technology with the traditional laparoscopic technology has not shown an improvement in patient outcomes post-operatively. What cannot be supported is the rapid adoption of the robot technology for gynecological surgery and high quality patient outcomes of safety and cost data. At a price of more than $1.7 million per robot machine and as much as $125,000 in annual maintenance, this easily pushes up the costs to perform surgery robotically to $2,000 per procedure for the single use of robotic instrument. This is clearly the most expensive approach. A comment for the American College President, Dr. James T. Breeding, in 2013 states, “If most women undergoing a hysterectomy for benign conditions each year chose a vaginal or laparoscopic approach – rather than total abdominal or robotic-assisted hysterectomy –performed by a skilled or experienced surgeon, their pain and recovery time would be reduced, while providing dramatic savings to our healthcare system.” Conversely, an estimated $960 million to $1.9 billion will be added to the healthcare system if robotic surgery is used for all hysterectomies each year. There is no question that aggressive, direct consumer promoting of the latest medical equipment may mislead the public into believing use of the robot to perform surgery such as a hysterectomy is the best choice. In our practice patient are taking a vital interest and role how they can minimize their medical expenses. Patients deserve and need information regarding treatment options to make informed decisions. Patients should know that the robotic hysterectomy is best served for unusual or complex clinical conditions in which improved outcomes over standard minimally invasive approaches have been demonstrated. They best clinical scenario the patient can have is for a physician to tailor which type hysterectomy is best based on each patient’s individual surgical need and not try to fit all patients in to one particular operation. It is very important for us to keep in mind what the controlled evidence-based randomized trials are showing us and be able to differentiate the marketing publicity from the proven medical outcomes/data when considering the best surgical approach for our patients.