Value-based Assessment of Hysterectomy Approaches

J Obstet Gynaecol Res. 2019 Feb;45(2):389-398. doi: 10.1111/jog.13853. Epub 2018 Nov 6.


Aim: By evaluating operative outcomes relative to cost, we compared the value of minimally invasive hysterectomy approaches, including a technique discussed less often in the literature, laparoscopic retroperitoneal hysterectomy (LRH), which incorporates retroperitoneal dissection and ligation of the uterine arteries at their vascular origin.

Methods: Retrospective chart review of all women (N = 2689) aged greater than or equal to 18 years who underwent hysterectomy for benign conditions from 2011 to 2013 at a high-volume hospital in Maryland, USA. Procedures included: laparoscopic supracervical hysterectomy, robotic-assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total vaginal hysterectomy (TVH), and LRH.

Results: Total vaginal hysterectomy had the highest intraoperative complication rate (9.6%; P < 0.0001) but the lowest postoperative complication rate (1.8%; P < 0.0001). Robotics had the highest postoperative complication rate (11.4%; P < 0.0001). LRH had the shortest operative time (71.2 min; P < 0.0001) and the lowest intraoperative complication rates (2.1%; P < 0.0001). LRH and TVH were the least costly (averaging $4061 and $6416, respectively), while RALH was the most costly ($9354). Taking both operative outcomes and cost into account, LRH, TVH and laparoscopic-assisted vaginal hysterectomy yielded the highest value scores; total laparoscopic hysterectomy, RALH, and laparoscopic supracervical hysterectomy yielded the lowest.

Conclusion: Understanding the value of surgical interventions requires an evaluation of both operative outcomes and direct hospital costs. Using a quality-cost framework, the LRH approach as performed by high-volume laparoscopic specialists emerged as having the highest calculated value.

Keywords: cost; hysterectomy; laparoscopic; retroperitoneal; value.

MeSH terms

  • Adult
  • Female
  • Humans
  • Hysterectomy* / adverse effects
  • Hysterectomy* / economics
  • Hysterectomy* / methods
  • Hysterectomy* / statistics & numerical data
  • Hysterectomy, Vaginal / adverse effects
  • Hysterectomy, Vaginal / economics
  • Hysterectomy, Vaginal / methods
  • Hysterectomy, Vaginal / statistics & numerical data
  • Intraoperative Complications* / epidemiology
  • Laparoscopy* / adverse effects
  • Laparoscopy* / economics
  • Laparoscopy* / methods
  • Laparoscopy* / statistics & numerical data
  • Middle Aged
  • Postoperative Complications* / epidemiology
  • Retroperitoneal Space / surgery
  • Retrospective Studies
  • Robotic Surgical Procedures* / adverse effects
  • Robotic Surgical Procedures* / economics
  • Robotic Surgical Procedures* / methods
  • Robotic Surgical Procedures* / statistics & numerical data