Robotic hysterectomy and hospital performance: nationwide evidence on outcomes, efficiency, and costs in France (2020 to 2024)

Robot-assisted surgery (RAS) has increasingly been adopted for hysterectomy in France, but its impact on hospital performance according to institutional expertise remains incompletely understood. We evaluated clinical outcomes and hospital costs associated with different surgical approaches for hysterectomy using nationwide French data. A retrospective analysis of a French national database identified all total hysterectomies (excluding vaginal hysterectomy) between 2020 and 2024. Procedures were categorized as open, laparoscopic (LH), or robot-assisted (RAH) hysterectomy, and stratified according to center robotic expertise. Outcomes included length of hospital stay (LoS), rates of complicated hospital stays (severity index [SI] 3&4), and direct hospital costs for non-complicated cases (SI 1&2). Overall, 196,050 hysterectomies were evaluated. Minimally invasive surgeries (MIS) were associated with shorter LoS and lower rates of complicated hospital stays than open surgery across both indications. In benign conditions, complicated stays occurred in approximately 1% of MIS versus 4% of open procedures. In malignant conditions, rates were approximately 4% for MIS versus 21.8% for open surgery. Outcomes generally improved with increasing robotic center expertise, with the lowest complication rates observed in multidisciplinary robotic centers. Open hysterectomy was associated with the highest hospital costs, whereas MIS reduced resource utilization. In multidisciplinary robotic centers, RAH demonstrated particularly favorable cost profiles. At a national level, MIS was associated with improved hospital performance compared with open surgery. The observed benefits of RAH appeared greatest in experienced and multidisciplinary centers, suggesting that organizational factors and surgical expertise may be important determinants of clinical and economic outcomes.