Trends in surgical approach to hysterectomy and perioperative outcomes in Michigan hospitals from 2010 through 2020

The objective of this study was to determine the trends in surgical approach to hysterectomy over the last decade and compare perioperative outcomes and complications. This retrospective cohort study used clinical registry data from the Michigan Hospitals that participated in Michigan Surgical Quality Collaborative (MSQC) from January 1st, 2010 through December 30th, 2020. A multigroup time series analysis was performed to determine how surgical approach to hysterectomy [open/TAH, laparoscopic (TLH/LAVH), and robotic-assisted (RA)] has changed over the last decade. Abnormal uterine bleeding, uterine fibroids, chronic pelvic pain, pelvic organ prolapse, endometriosis, pelvic mass, and endometrial cancer were the most common indications for hysterectomy. The open approach to hysterectomy declined from 32.6 to 16.9%, a 1.9-fold decrease, with an average decline of 1.6% per year (95% CI − 2.3 to − 0.9%). Laparoscopic-assisted hysterectomies decreased from 27.2 to 23.8%, a 1.5-fold decrease, with an average decrease of 0.1% per year (95% CI − 0.7 to 0.6%). Finally, the robotic-assisted approach increased from 38.3 to 49.3%, a 1.25-fold increase, with an average of 1.1% per year (95% CI 0.5 to 1.7%). For malignant cases, open procedures decreased from 71.4 to 26.6%, a 2.7-fold decrease, while RA-hysterectomy increased from 19.0 to 58.7%, a 3.1-fold increase. After controlling for the confounding variables age, race, and gynecologic malignancy, RA hysterectomy was found to have the lowest rate of complications when compared to the vaginal, laparoscopic and open approaches. Finally, after controlling for uterine weight, black patients were twice as likely to undergo an open hysterectomy compared to white patients. Similar content being viewed by others Availability of data and material Upon Request.

Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BJ, Kluivers KB (2015) Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD003677.pub5 Matteson, KA, Butts, SF (2017) Committee Opinion No 701: choosing the route of hysterectomy for benign disease. Obstet Gynecol 129(6):e155–e159. Carbonnel M, Moawad GN, Tarazi MM, Revaux A, Kennel T, Favre-Inhofer A, Ayoubi JM (2021) Robotic hysterectomy for benign indications: what have we learned from a decade? JSLS. 25(1):e2020.00091. https://doi.org/10.4293/JSLS.2020.00091 Swenson CW, Kamdar NS, Harris JA, Uppal S, Campbell DA Jr, Morgan DM (2016) Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications. Am J Obstet Gynecol. 215(5):650.e1-650.e8. https://doi.org/10.1016/j.ajog.2016.06.027 Settnes A, Topsoee MF, Moeller C, Dueholm M, Kopp TI, Norrbom C, Rasmussen SC, Froeslev PA, Joergensen A, Dreisler E, Gimbel H (2020) Reduced complications following implementation of laparoscopic hysterectomy: a Danish population-based cohort study of minimally invasive benign gynecologic surgery between 2004 and 2018. J Minim Invasive Gynecol 27(6):1344-1353.e3. https://doi.org/10.1016/j.jmig.2019.11.005 Baracy MG Jr, Martinez M, Hagglund K, Afzal F, Kulkarni S, Corey L, Aslam MF (2022) Minimally invasive hysterectomy for benign indications-surgical volume matters: a retrospective cohort study comparing complications of robotic-assisted and conventional laparoscopic hysterectomies. J Robot Surg. https://doi.org/10.1007/s11701-021-01340-2 Giep BN, Giep HN, Hubert HB (2010) Comparison of minimally invasive surgical approaches for hysterectomy at a community hospital: robotic-assisted laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy and laparoscopic supracervical hysterectomy. J Robot Surg 4(3):167–175 Roh HF, Nam SH, Kim JM (2018) Robot-assisted laparoscopic surgery versus conventional laparoscopic surgery in randomized controlled trials: a systematic review and meta-analysis. PLoS ONE 13(1):e0191628 van Weelden WJ, Gordon BBM, Roovers EA, Kraayenbrink AA, Aalders CIM, Hartog F et al (2017) Perioperative surgical outcome of conventional and robot-assisted total laparoscopic hysterectomy. Gynecol Surg. 14(1):5 Soto E, Lo Y, Friedman K, Soto C, Nezhat F, Chuang L et al (2011) Total laparoscopic hysterectomy versus da Vinci robotic hysterectomy: is using the robot beneficial? J Gynecol Oncol 22(4):253–259 Albright BB, Witte T, Tofte AN, Chou J, Black JD, Desai VB, Erekson EA (2016) Robotic versus laparoscopic hysterectomy for benign disease: a systematic review and meta-analysis of randomized trials. J Minim Invasive Gynecol 23(1):18–27. https://doi.org/10.1016/j.jmig.2015.08.003 Sarlos D, Kots L, Stevanovic N, von Felten S, Schär G (2012) Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol 120(3):604–611. https://doi.org/10.1097/AOG.0b013e318265b61a Paraiso MF, Ridgeway B, Park AJ, Jelovsek JE, Barber MD, Falcone T, Einarsson JI (2013) A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. Am J Obstet Gynecol 208(5):368.e1–7. https://doi.org/10.1016/j.ajog.2013.02.008 Sheetz KH, Norton EC, Dimick JB, Regenbogen SE (2020) Perioperative outcomes and trends in the use of robotic colectomy for medicare beneficiaries from 2010 through 2016. JAMA Surg 155(1):41–49. https://doi.org/10.1001/jamasurg.2019.4083 Melamed A, Margul DJ, Chen L, Keating NL, Del Carmen MG, Yang J, Seagle BL, Alexander A, Barber EL, Rice LW, Wright JD, Kocherginsky M, Shahabi S, Rauh-Hain JA (2018) Survival after minimally invasive radical hysterectomy for early-stage cervical cancer. N Engl J Med. 379(20):1905–1914. https://doi.org/10.1056/NEJMoa1804923 Nitecki R, Ramirez PT, Frumovitz M, Krause KJ, Tergas AI, Wright JD, Rauh-Hain JA, Melamed A (2020) Survival after minimally invasive vs open radical hysterectomy for early-stage cervical cancer: a systematic review and meta-analysis. JAMA Oncol 6(7):1019–1027. https://doi.org/10.1001/jamaoncol.2020.1694 Ramirez PT, Frumovitz M, Pareja R, Lopez A, Vieira M, Ribeiro R, Buda A, Yan X, Shuzhong Y, Chetty N, Isla D, Tamura M, Zhu T, Robledo KP, Gebski V, Asher R, Behan V, Nicklin JL, Coleman RL, Obermair A (2018) Minimally invasive versus abdominal radical hysterectomy for cervical cancer. N Engl J Med 379(20):1895–1904. https://doi.org/10.1056/NEJMoa1806395 Nie JC, Yan AQ, Liu XS (2017) Robotic-assisted radical hysterectomy results in better surgical outcomes compared with the traditional laparoscopic radical hysterectomy for the treatment of cervical cancer. Int J Gynecol Cancer 27(9):1990–1999. https://doi.org/10.1097/IGC.0000000000001101 Chen L, Liu LP, Wen N, Qiao X, Meng YG (2019) Comparative analysis of robotic vs laparoscopic radical hysterectomy for cervical cancer. World J Clin Cases 7(20):3185–3193. https://doi.org/10.12998/wjcc.v7.i20.3185 Han L, Yan P, Yao L, Liu R, Shao R, Liu J, Chen X, Wang L, Yang K, Guo T, Wang H (2019) Safety and effectiveness of robotic hysterectomy versus conventional laparoscopic hysterectomy in patients with cervical cancer in China. Arch Gynecol Obstet 300(1):153–160. https://doi.org/10.1007/s00404-019-05148-2 Jørgensen SL, Mogensen O, Wu C et al (2019) Nationwide introduction of minimally invasive robotic surgery for early-stage endometrial cancer and its association with severe complications. JAMA Surg 154(6):530–538. https://doi.org/10.1001/jamasurg.2018.5840 Mäenpää MM, Nieminen K, Tomás EI, Laurila M, Luukkaala TH, Mäenpää JU (2016) Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial. Am J Obstet Gynecol 215(5):588.e1-588.e7. https://doi.org/10.1016/j.ajog.2016.06.005 Wang J, Li X, Wu H, Zhang Y, Wang F (2020) A meta-analysis of robotic surgery in endometrial cancer: comparison with laparoscopy and laparotomy. Dis Markers 21(2020):2503753. https://doi.org/10.1155/2020/2503753 Ind T, Laios A, Hacking M, Nobbenhuis M (2017) A comparison of operative outcomes between standard and robotic laparoscopic surgery for endometrial cancer: a systematic review and meta-analysis. Int J Med Robot. 13(4):e1851. https://doi.org/10.1002/rcs.1851 Alexander AL, Strohl AE, Rieder S, Holl J, Barber EL (2019) Examining disparities in route of surgery and postoperative complications in black race and hysterectomy. Obstet Gynecol 133(1):6–12. https://doi.org/10.1097/AOG.0000000000002990 Marshall LM, Spiegelman D, Barbieri RL, Goldman MB, Manson JE, Colditz GA, Willett WC, Hunter DJ (1997) Variation in the incidence of uterine leiomyoma among premenopausal women by age and race. Obstet Gynecol 90(6):967–973. https://doi.org/10.1016/s0029-7844(97)00534-6 Wechter ME, Stewart EA, Myers ER, Kho RM, Wu JM (2011) Leiomyoma-related hospitalization and surgery: prevalence and predicted growth based on population trends. Am J Obstet Gynecol. 205(5):492.e1–5. https://doi.org/10.1016/j.ajog.2011.07.008 Laughlin-Tommaso SK, Jacoby VL, Myers ER (2017) Disparities in fibroid incidence, prognosis, and management. Obstet Gynecol Clin N Am 44(1):81–94. https://doi.org/10.1016/j.ogc.2016.11.007

The authors of this manuscript would like to thank the wonderful staff at the Michigan Surgical Quality Collaborative (MSQC), especially Heather Marshall, Kushal Singh, and Alexander Hallway for their help retrieving data and their guidance in the production of this manuscript. Funding None. Author information Authors and Affiliations Contributions MB conceived of the idea, designed the protocol and wrote the manuscript. MB, AK, and BF organized operative diagnoses, CPT codes, ICD-9 and ICD-10 codes and ensured integrity of codification. KH verified the protocol was methodologically sound and analyzed the data. LC and MA was integral in the design and execution of the project. All authors discussed the final results and contributed to the final manuscript. Corresponding author Ethics declarations Conflict of interest The author declares that they have no conflict of interest. Ethics approval This study was given the determination of not human subjects research by the Ascension St. John Institutional Review Boards (IRB) on 03/02/2022 (Reference #1876078). Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information Below is the link to the electronic supplementary material. Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Baracy, M.G., Kerl, A., Hagglund, K. et al. Trends in surgical approach to hysterectomy and perioperative outcomes in Michigan hospitals from 2010 through 2020. J Robotic Surg 17, 2211–2220 (2023). https://doi.org/10.1007/s11701-023-01631-w Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s11701-023-01631-w