Hysterectomy trends and outcomes: an ambispective audit from a tertiary institute in Northern India.

Hysterectomy refers to the surgical removal of the uterus, performed for a range of gynecological or obstetric reasons. Globally, it ranks as one of the most performed major surgical procedures for women, second only to cesarean sections [ 1 ]. According to the World Health Organization, an estimated 1,540,000 women worldwide underwent hysterectomies in 2016 [ 2 ]. In the USA, around 600,000 hysterectomies are carried out each year, making it the most frequently performed non-obstetric surgery among women [ 3 ]. Hysterectomy rates differ worldwide, with countries such as Australia and the USA reporting higher incidences compared with Scandinavian nations [ 4 ]. In India, the overall prevalence of hysterectomy was 11.35%, with 3.3% of women aged 15-49 years having undergone the procedure. However, prevalence rates varied considerably across different states and union territories [ 5 ]. The southern region, particularly Andhra Pradesh (8.7%) and Telangana (8.2%), exhibits a notably higher prevalence of hysterectomies, followed by Bihar (6.0%) and Gujarat (4.0%). Conversely, the Northeastern region records the lowest prevalence at 1.2%. Interestingly, 69.6% of hysterectomies nationwide are conducted in private healthcare facilities. However, in the Northeastern region, most of these procedures (73.0%) are performed in public healthcare facilities, with only 26.7% carried out in private settings. Several sociodemographic factors, including age, urban or rural residence, religion, caste, education level, geographic region, economic status, parity, and age at first cohabitation, are statistically associated with the probability of undergoing hysterectomy in India. The procedure is most frequently attributed to excessive menstrual bleeding or pain, with fibroids or cysts being the next most common reasons [ 5 ]. Hysterectomy is electively performed for a variety of gynecological conditions, whether benign or malignant [ 6 ]. These commonly include benign uterine disorders such as fibroids, endometriosis, prolapse, adenomyosis, and persistent pelvic pain [ 7 ]. Hysterectomy may also be carried out for obstetric reasons, including conditions such as placenta accreta spectrum, abruptio placentae, atonic or traumatic postpartum hemorrhage unresponsive to medical or surgical treatment, uterine rupture, and puerperal sepsis [ 8 ]. This study was conducted to assess the various indications, surgical approaches, outcomes, and clinicopathological findings associated with hysterectomies performed at our institution over the past 8 years.

The study included a total of 1,083 cases of abdominal, laparoscopic, vaginal, and robotic hysterectomies. A total of 22 cases were excluded from the study due to incomplete data from the medical records department for the retrospective analysis. The average age of the participants in the study was 46.56±9.7 years ( Table 1 ). Of the study population, 783 (72.30%) patients were aged 41 years or older, while 300 (27.70%) were younger than 40 years. The largest proportion of participants came from the upper-lower socioeconomic class, with the fewest belonging to the upper class. Regarding education, 11.26% of patients were graduates, while 9.97% were illiterate. Most participants (62.61%) resided in rural areas, with the remaining 37.39% from urban areas. Regarding the type of hysterectomy, 912 (84.21%) procedures were performed for benign conditions, while 171 (15.79%) were for malignant cases. Abdominal hysterectomy was the most common approach (44.41%), followed by robotic (39.52%), vaginal (12.00%), and laparoscopic (4.07%) hysterectomy. Significant differences were observed across the four groups for various diagnoses ( Table 2 ). Fibroid uterus was the most common indication for hysterectomy across all routes except vaginal hysterectomies (VH), accounting for 33.69% of total abdominal hysterectomies (TAH), 47.73% of total laparoscopic hysterectomies (TLH), and 48.36% of total robotic hysterectomies (TRH). The type of anesthesia used also varied across the four surgical procedures. For TAH, 11.43% of patients received spinal anesthesia, 40.96% received general anesthesia (GA), 29.11% received GA combined with epidural, and 18.50% received spinal combined with epidural. In contrast, TLH and TRH primarily used GA (97.73% and 99.53%, respectively), with no cases of spinal or spinal-epidural anesthesia. VH, however, predominantly used spinal anesthesia (78.46%), with minimal reliance on GA (5.39%) or combined anesthesia methods. TRH had the highest percentage of surgeries under 60 minutes (3.27%) and 60-120 minutes (88.55%), while TAH was most common for 121-180 minutes (40.75%) and over 180 minutes (11.44%). TRH had the highest percentage of cases with blood loss ≤100 mL (90.65%), while TAH had the most cases with blood loss >300 mL ( Table 3 ). Significant differences were observed among all procedures ( P <0.0001). TAH had the highest median blood loss (300 mL), while TRH had the lowest (52.5 mL), indicating its minimal invasiveness. Multivariable logistic regression demonstrated that, after adjustment for age and diagnosis, minimally invasive hysterectomy routes remained independently associated with significantly lower odds of blood loss >300 mL compared with abdominal hysterectomy. Robotic hysterectomy showed the greatest reduction (aOR, 0.03; 95% CI, 0.015-0.064; P <0.001), followed by laparoscopic hysterectomy (aOR, 0.08; 95% CI, 0.02-0.33; P =0.001) and vaginal hysterectomy (aOR, 0.60; 95% CI, 0.37-0.97; P =0.036). Malignant diagnosis was independently associated with increased odds of higher blood loss (aOR, 3.42; P <0.001). The study also examined the need for blood transfusions across different hysterectomy routes. Intra-operative blood transfusion: among the surgical approaches, TAH had the highest transfusion requirement (18.71%), likely due to its use in more complex cases, whereas minimally invasive techniques such as TRH had significantly lower rates (0.47%) with no cases in TLH. The differences were statistically significant between TAH and all other procedures, indicating a higher need for transfusions in more complex cases typically managed via the abdominal route. TRH had a significantly lower transfusion requirement compared with VH, while differences between TLH and TRH, as well as TLH and VH, were not statistically significant. Post-operative blood transfusion: TAH had the highest post-operative blood transfusion rate (13.30%), followed by VH (13.07%), TLH (6.82%), and TRH (1.40%). Statistically significant differences were found between TRH and TAH ( P <0.0001), TRH and TLH ( P =0.043), and TRH and VH ( P <0.0001), with TRH showing a significantly lower need for transfusions. No significant differences were noted between TAH and TLH ( P =0.342), TAH and VH ( P =0.579), or TLH and VH ( P =0.568). The study also analyzed intra-operative complications across different hysterectomy routes: 1) bladder injury: the highest incidence was in TAH (2.70%), followed by TLH (2.27%), VH (1.54%), and TRH (0.70%), but differences were not statistically significant ( P =0.081). 2) Bowel injury: most incidents occurred in TAH (2.9%), followed by TLH (2.27%), TRH (0.47%), and one case in VH. Statistically significant differences were found between TAH and TRH ( P =0.004) and TAH and VH ( P =0.048). 3) Ureteric injury: the highest incidence was in TAH (1.66%), followed by TRH (0.23%), with no cases in TLH or VH. Differences were not statistically significant ( P =0.084). 4) Major vascular injuries: only TAH had major vascular injuries (0.62%), with no cases in TLH, TRH, or VH, and no significant differences ( P =0.433).

Hysterectomy may be performed via various surgical routes, abdominal, vaginal, laparoscopic, robotic, and vaginal natural orifice transluminal endoscopic surgery based on uterine characteristics, pathology extent, patient comorbidities, surgeon experience, and facility resources. Globally, trends are shifting toward minimally invasive techniques, with robotic hysterectomy gaining popularity due to its precision and improved outcomes [ 8 ]. In our study, the mean patient age was 46.56±9.7 years, with the majority aged 41-50 years, similar to findings by Pandey et al. [ 9 ] and Sivapragasam et al. [ 10 ]. Rural residents comprised 62.61% of cases, aligning with Rout et al. [ 11 ] and Desai et al. [ 12 ], who reported a higher prevalence of hysterectomy in rural populations, likely due to delayed care-seeking, limited access to conservative treatments, and earlier childbirth. Fibroid uterus was the leading indication, consistent with prior studies in India and abroad [ 9 , 13 - 16 ]. While our incidence was lower than the 84.1% reported by Chale et al. [ 17 ] in Tanzania, it remains the most frequent pathology leading to hysterectomy in many regions. Abdominal hysterectomy was the most common route (44.4%), followed by robotic (39.52%), vaginal (12.00%), and laparoscopic (4.7%). These trends mirror those reported by Pandey et al. [ 9 ] and Rajora and Bhatti [ 18 ], although studies like Panda et al. [ 19 ] highlight a higher prevalence of vaginal approaches elsewhere. In our study, vaginal hysterectomy was primarily used for uterine prolapse (83.1%). A Cochrane review supports VH as the preferred approach when feasible, followed by laparoscopy to avoid laparotomy [ 20 ]. An important observation in our study was the relatively high proportion of robotic hysterectomies compared with conventional laparoscopic procedures. This distribution reflects the institutional surgical practices and resource availability at our tertiary referral center, where robotic surgery has been increasingly adopted for both benign and malignant gynecological conditions due to the availability of a dedicated robotic platform and surgeons trained in robotic gynecologic oncology procedures. Additionally, many complex oncological cases requiring staging procedures were preferentially managed robotically rather than through conventional laparoscopy. Conventional laparoscopic hysterectomy was comparatively less frequent, partly due to evolving institutional preference toward robotic-assisted minimally invasive surgery during the study period. This pattern may represent a center-specific practice trend and introduces potential selection bias, which should be considered while interpreting the comparative outcomes across surgical routes. Mean operative time was longest for TAH (140.3±50.5 minutes), followed by VH, TLH, and TRH-the latter having the shortest duration (92.1±21.2 minutes). A study by Panda et al. [ 19 ] in India also supports shorter durations for minimally invasive surgeries. While some TRH cases involved staging, improved visualization and precision may contribute to reduced operative times. Blood loss was highest in TAH and lowest in TRH, with the majority of robotic cases experiencing losses under 100 mL. Our findings align with studies by van Weelden et al. [ 21 ] and Clarke-Pearson and Geller [ 22 ], who demonstrated significantly lower blood loss in minimally invasive approaches. Blood transfusion rates were also highest in TAH, likely due to its use in complex cases, such as malignancies. The association between minimally invasive approaches and reduced blood loss remained significant even after adjustment for available confounding variables, suggesting that the observed differences were not solely attributable to baseline case selection. In the overall study population, bladder injury (1.75%), bowel injury (1.57%), and ureteric injury (0.83%) were the most frequent intraoperative complications, with the highest proportions observed in the TAH group. Ureteric injury rates were lower than the 1.2% reported by Ravlo et al. [ 23 ]. TRH had the fewest complications, supporting its safety profile, though cost remains a barrier to wider implementation. Histopathologically, leiomyoma (35.0%) and adenomyosis (12.9%) were the most common findings, consistent with other Indian studies by Wankhade and Dawande [ 24 ] in 2023 and Gupta et al. [ 25 ]. Correlation between preoperative and histopathological diagnoses was observed in 77.7% of cases. Pathology differed in 13.15% of cases, highlighting the value of histopathology in refining postoperative management. Similar correlation rates were reported by Pandey et al. [ 1 ] and Siwatch et al. [ 26 ]. Hysterectomy continues to raise important concerns regarding its appropriateness, especially when conservative options are available. Magon et al. [ 27 ] emphasized its historical overuse and underuse. While often life-enhancing, or even lifesaving, it must be approached with clinical judgment and patient-centered counseling, especially in benign conditions where less invasive alternatives exist. This audit benefits from a large sample size and ambispective design, enabling robust comparison of surgical techniques and outcomes. However, limitations include the single-center setting, non-randomized design, and reliance on retrospective data for part of the study, which may introduce selection and documentation bias. Additionally, the follow-up period was limited to 30 days, preventing assessment of long-term outcomes. Although multivariable adjustment was performed, residual confounding may persist due to unavailable variables such as body mass index, detailed uterine size measurements, and extent of adhesions. This audit highlights the importance of promoting minimally invasive techniques, improving surgical documentation, and integrating audit findings into clinical training and decision-making to optimize outcomes. In conclusion, minimally invasive hysterectomy techniques, especially laparoscopic and robotic, offer clear benefits in reducing blood loss and operating time compared with abdominal and vaginal routes. While vaginal hysterectomy remains a time-efficient option, it tends to result in slightly higher blood loss compared with laparoscopic or robotic procedures. Our findings support the need to prioritize minimally invasive techniques where feasible, given their superior safety profile. It is crucial to ensure that all hysterectomy cases are systematically documented, allowing audit findings to enhance healthcare standards.

This ambispective study was carried out from February 2016 to May 2024. We retrospectively gathered patient data from the medical records section for the period between February 2016 and June 2022, followed by prospective data collection from July 2022 to May 2024. The study was approved by the Institutional Ethical Committee (IEC number: AIIMS/IEC/22/603). Eligible patients for the study included women who underwent hysterectomy for benign or malignant gynecological conditions or obstetric emergencies, via elective or emergency procedures. Women who underwent hysterectomy elsewhere or had incomplete records were excluded from the study. For retrospective cases, patient data were accurately retrieved from hospital medical records. This included demographic information, medical history, indications for hysterectomy, the surgical approach, surgical details, and perioperative outcomes. Data were gathered by reviewing electronic medical records and physical case files to ensure completeness and accuracy. For prospective cases, after obtaining informed consent, patients’ demographic information, chief complaints, and comprehensive menstrual, obstetric, medical, and surgical histories were recorded. A thorough general physical examination, along with systemic abdominal and pelvic assessments, was conducted. The indications for hysterectomy, the type and route of surgery, operative findings, perioperative parameters, complications, and postoperative outcomes were documented. Patients were monitored during follow-up visits in the outpatient department for up to 30 days postoperatively. The surgical and perioperative characteristics among the study population were compared among the various routes of hysterectomy. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) software, version 25.0 (IBM Corp., Armonk, NY, USA). Data normality was assessed using the Shapiro-Wilk test. For data that did not follow a normal distribution, nonparametric tests were employed. Quantitative variables were compared using normally distributed data and the Kruskal-Wallis test for non-normally distributed data. Qualitative variables were compared using the chi-square test/Fisher’s exact test. A P-value of less than 0.05 was considered statistically significant. In addition to univariate comparisons, multivariable logistic regression analysis was performed to evaluate the independent association between route of hysterectomy and perioperative blood loss (>300 mL), adjusting for age and diagnosis (benign vs. malignant). Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated.