Challenges of Costing a Surgical Procedure in a Lower-Middle-Income Country.

BACKGROUND: It is vital to enquire into cost of health care to ensure that maximum value for money is obtained with available resources; however, there is a dearth of information on cost of health care in lower-middle-income countries (LMICs). Our aim was to develop a reproducible costing method for three routes of hysterectomy in benign uterine conditions: total abdominal (TAH), non-descent vaginal (NDVH) and total laparoscopic hysterectomy (TLH). METHODS: A societal perspective with a micro-costing approach was applied to find out direct and indirect costs. A total of 147 patients were recruited from a district general hospital (Mannar) and a tertiary care hospital (Ragama). Costs incurred from preoperative period to convalescence included direct costs of labour, equipment, investigations, medications and utilities, and indirect costs of out-of-pocket expenses, productivity losses, carer costs and travelling. Time-driven activity-based costing was used for labour, and top-down micro-costing was used for utilities. RESULTS: The total cost [(interquartile range), number] of TAH was USD 339 [(308-397), n = 24] versus USD 338 [(312-422), n = 25], NDVH was USD 315 [(316-541), n = 23] versus USD 357 [(282-739), n = 26] and TLH was USD 393 [(338-446), n = 24] versus USD 429 [(390-504), n = 25] at Mannar and Ragama, respectively. The direct cost of TAH, NDVH and TLH was similar between the two centres, whilst indirect cost was related to the setting rather than the route of hysterectomy. CONCLUSIONS: The costing method used in this study overcomes logistical difficulties in a LMIC and can serve as a guide for clinicians and policy makers in similar settings. TRIAL REGISTRATION: The study was registered in the Sri Lanka clinical trials registry (SLCTR/2016/020) and the International Clinical Trials Registry Platform (U1111-1194-8422) on 26 July 2016.

Value-based assessment of hysterectomy approaches.

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.

Costs and mortality rates of surgical approaches to hysterectomy in Brazil.

OBJECTIVE: To analyze the costs of hysterectomies performed in Brazil due to benign conditions, and to assess its hospital admittance and mortality rates. METHODS: A retrospective cohort was carried out from January 2010 to December 2014, analyzing all hysterectomies (n = 428,346) registered on the DATASUS database between January 2010 and December 2014. Data were collected through a structured questionnaire and analyzed using the SPSS 20.0 for Windows. RESULTS: Hospital admissions were 300,231 for total abdominal hysterectomies, 46,056 for vaginal hysterectomies, 29,959 for subtotal abdominal hysterectomies and 1,522 for laparoscopic hysterectomies. Mortality rates were 0.26%, 0.09%, 0.07% and 0.05% for subtotal, total abdominal, laparoscopic, and vaginal hysterectomies, respectively. Among the procedures studied, total abdominal hysterectomies had the most costs (R$217,802,574.77), followed by vaginal hysterectomies (R$24,173,490.00), subtotal abdominal hysterectomies (R$19.253.300,00) and laparoscopic hysterectomies (R$794,680.40). CONCLUSIONS: Total abdominal hysterectomies had the highest overall costs mainly because it was the most commonly performed technique. Mortality rates were greatest in subtotal abdominal hysterectomies; this, however, may be due to bias related to missing data in our database.

Manchester-Fothergill procedure versus vaginal hysterectomy with uterosacral ligament suspension: an activity-based costing analysis.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is a common diagnosis that imposes high and ever-growing costs to the healthcare economy. Numerous surgical techniques for the treatment of POP exist, but there is no consensus about which is the ideal technique for treating apical prolapse. The aim of this study was to estimate hospital costs for the most frequently performed operation, vaginal hysterectomy with uterosacral ligament suspension (VH) and the uterus-preserving Manchester-Fothergill procedure (MP), when including costs of postoperative activities. METHODS: The study was based on a historical matched cohort including 590 patients (295 pairs) who underwent VH or MP during 2010-2014 owing to apical prolapse. The patients were matched according to age and preoperative prolapse stage and followed for a minimum of 20 months. Data were collected from four national registries and electronic medical records. Unit costs were obtained from relevant departments, hospital administration, calculated, or estimated by experts. The hospital perspective was applied for costing the resource use. RESULTS: Total costs for the first 20 months after operation were 3,514 € per VH patient versus 2,318 € per MP patient. The cost difference between the techniques was 898 € (95% confidence interval [CI]: 818-982) per patient when analyzing the primary operation only and 1,196 € (CI: 927-1,465) when including subsequent activities within 20 months (p < 0.0001). CONCLUSIONS: The MP is substantially less expensive than the commonly used VH from a 20-month time perspective. Healthcare costs can be reduced by one third if MP is preferred over VH in the treatment of apical prolapse.

Hysterectomy costs depending on operational technique.

OBJECTIVES: The aim of the study was to perform a comparative analysis of hysterectomy costs versus the operative technique based on the data of 656 patients operated at the Department of Obstetrics and Gynecology with Gynecological Oncology Subdivision, Brothers Hospitallers of Saint John of God Hospital, Katowice, between 2016 and 2018 (until May 31, 2018). MATERIAL AND METHODS: This retrospective research involved 656 patients who underwent hysterectomy for non-oncological reasons. The patients were subdivided into three groups, depending on the operative method (transabdominal, laparoscopic or transvaginal). Next, treatment costs were compared, including the costs of hospitalization, operating block, operating block materials, drugs, anesthesia, and medical staff. The duration of the operation and the hospital stay were also analyzed as they significantly affected the final result. RESULTS: Data analysis revealed that transvaginal hysterectomy generated the lowest costs. A positive relationship between low costs and the duration of surgery and hospitalization, which is significantly shortened in case of transvaginal hysterectomy, was confirmed. CONCLUSIONS: 1. The transvaginal approach is the most cost-effective technique of hysterectomy. 2. Apart from the financial advantage, transvaginal hysterectomy is also associated with shorter hospitalization and faster recovery. 3. Emphasis should be placed on training physicians in minimally invasive hysterectomies - especially the transvaginal approach - so that the greatest percentage of patients who are deemed eligible for hysterectomy could be operated using this minimally invasive technique.

Costs and mortality rates of surgical approaches to hysterectomy in Brazil

ABSTRACT OBJECTIVE To analyze the costs of hysterectomies performed in Brazil due to benign conditions, and to assess its hospital admittance and mortality rates. METHODS A retrospective cohort was carried out from January 2010 to December 2014, analyzing all hysterectomies (n = 428,346) registered on the DATASUS database between January 2010 and December 2014. Data were collected through a structured questionnaire and analyzed using the SPSS 20.0 for Windows. RESULTS Hospital admissions were 300,231 for total abdominal hysterectomies, 46,056 for vaginal hysterectomies, 29,959 for subtotal abdominal hysterectomies and 1,522 for laparoscopic hysterectomies. Mortality rates were 0.26%, 0.09%, 0.07% and 0.05% for subtotal, total abdominal, laparoscopic, and vaginal hysterectomies, respectively. Among the procedures studied, total abdominal hysterectomies had the most costs (R$217,802,574.77), followed by vaginal hysterectomies (R$24,173,490.00), subtotal abdominal hysterectomies (R$19.253.300,00) and laparoscopic hysterectomies (R$794,680.40). CONCLUSIONS Total abdominal hysterectomies had the highest overall costs mainly because it was the most commonly performed technique. Mortality rates were greatest in subtotal abdominal hysterectomies; this, however, may be due to bias related to missing data in our database.

Cost evaluation, quality of life and pelvic organ function of three approaches to hysterectomy for benign uterine conditions: study protocol for a randomized controlled trial.

BACKGROUND: Hysterectomy is the commonest major gynaecological surgery. Although there are many approaches to hysterectomy, which depend on clinical criteria, certain patients may be eligible to be operated in any of the several available approaches. However, most comparative studies on hysterectomy are between two approaches. There is also a relative absence of data on long-term outcomes on quality of life and pelvic organ function. There is no single study which has considered quality of life, pelvic organ function and cost-effectiveness for the three main types of hysterectomy. Therefore, the objective of this study is to provide evidence on the optimal route of hysterectomy in terms of cost-effectiveness by way of a three-armed randomized control study between non-descent vaginal hysterectomy, total laparoscopic hysterectomy and total abdominal hysterectomy. METHODS: A multicentre three-armed randomized control trial is being conducted at the professorial gynaecology unit of the North Colombo Teaching Hospital, Ragama, Sri Lanka and gynaecology unit of the District General Hospital, Mannar, Sri Lanka. The study population is women needing hysterectomy for non-malignant uterine causes. Patients with a uterus > 14 weeks, previous pelvic surgery, those requiring incontinence surgery or pelvic floor surgery, any medical illness which caution/contraindicate laparoscopic surgery and who cannot read and write will be excluded. The main exposure variable is non-descent vaginal hysterectomy and total laparoscopic hysterectomy. The control group will be patients undergoing total abdominal hysterectomy. The primary outcome is time to recover following surgery, which is the earliest time to resume all of the usual activities done prior to surgery. In total, 147 patients (49 per arm) are needed to have 80% power at α-0.01 considering a loss to follow-up of 20% to detect a 7-day difference between the three routes; TLH versus TAH versus NDVH. The economic evaluation will take a societal perspective and will include direct costs in relation to allocation of healthcare resources and indirect costs which are borne by the patient. A micro-costing approach will be adopted to calculate direct costs from the time of presentation to the gynaecology clinic up to 6 months after surgery. Incremental cost-effectiveness ratios (ICER) will be obtained by calculating the incremental costs divided by the incremental effects (time to recover and QALYs gained) for the intervention groups (NDVH and TLH) over the standard care (TAH) group. DISCUSSION: The cost of the procedure, quality of life and pelvic organ function following the three main routes of hysterectomy are important to clinicians and healthcare providers, both in developed and developing countries. TRIAL REGISTRATION: The study was registered in the Sri Lanka clinical trials registry (SLCTR/2016/020) and the International Clinical Trials Registry Platform ( U1111-1194-8422 ) on 26 July 2016.

Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: a decision analysis.

BACKGROUND: Fallopian tubes are commonly removed during laparoscopic and open hysterectomy to prevent ovarian and tubal cancer but are not routinely removed during vaginal hysterectomy because of perceptions of increased morbidity, difficulty, or inadequate surgical training. OBJECTIVE: We sought to quantify complications and costs associated with a strategy of planned salpingectomy during vaginal hysterectomy. STUDY DESIGN: We created a decision analysis model using TreeAgePro. Effectiveness outcomes included ovarian cancer incidence and mortality as well as major surgical complications. Modeled complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days. We also modeled subsequent benign adnexal surgery beyond the postoperative window. Those whose procedures were converted from a vaginal route were assumed to undergo bilateral salpingectomy, regardless of treatment group, following American College of Obstetricians and Gynecologists guidelines. Costs were gathered from published literature and Medicare reimbursement data, with internal cost data from 892 hysterectomies at a single institution used to estimate costs when necessary. Complication rates were determined from published literature and from 13,397 vaginal hysterectomies recorded in the National Surgical Quality Improvement Program database from 2008 through 2013. RESULTS: Switching from a policy of vaginal hysterectomy alone to a policy of routine planned salpingectomy prevents a diagnosis of ovarian cancer in 1 of every 225 women having surgery and prevents death from ovarian cancer in 1 of every 450 women having surgery. Overall, salpingectomy was a less expensive strategy than not performing salpingectomy ($7350.62 vs $8113.45). Sensitivity analysis demonstrated the driving force behind increased costs was the increased risk of subsequent benign adnexal surgery among women retaining their tubes. Planned opportunistic salpingectomy had more major complications than hysterectomy alone (7.95% vs 7.68%). Major complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days. Therefore, routine salpingectomy results in 0.61 additional complications per case of cancer prevented and 1.21 additional complications per death prevented. A surgeon therefore must withstand an additional ∼3 complications to prevent 5 cancer diagnoses and ∼6 additional complications to prevent 5 cancer deaths. CONCLUSION: Salpingectomy should routinely be performed with vaginal hysterectomy because it was the dominant and therefore cost-effective strategy. Complications are minimally increased, but the trade-off with cancer prevention is highly favorable.

Vaginal hysterectomy versus laparoscopically assisted vaginal hysterectomy for large uteri between 280 and 700 g: a randomized controlled trial.

OBJECTIVE: To compare surgical outcomes, postoperative complications and costs between vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy in cases of large uteri. METHODS: Prospective randomized controlled trial done at Ain Shams University Maternity Hospital, where 50 patients were recruited and divided into two equal groups (each 25 patients). First group underwent vaginal hysterectomy, and the second underwent laparoscopically assisted vaginal hysterectomy. RESULTS: Patient characteristics were similar in both groups. As for surgical outcomes, estimated intraoperative blood loss (P = 0.90), operative time (P = 0.48), preoperative hemoglobin (P = 0.09), postoperative hemoglobin (P = 0.42), and operative complications (P = 1.0) did not differ between the two groups. The hospital costs (converted from Egyptian pound to U.S. dollars) were significantly higher in case of LAVH group [VH: $1060.86 ($180.09) versus LAVH: $1560.5 ($220.57), P value <0.001]. No significant difference exists in the duration of postoperative hospital stay between the two groups [VH: 49.92 h (28.50) versus LAVH: 58.56 (27.78), P = 0.28] or the actual uterine weight measured postoperatively [VH: 350.72 g (71.78) versus LAVH: 385.96 g (172.52), P = 0.35]. CONCLUSION: Both vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy are safe procedures in cases of large uteri with no significant difference between them except in terms of costs as VH appears to be more cost effective. CLINICAL TRIALS.GOV: NCT02826304.

Vaginal vs. robotic hysterectomy for patients with endometrial cancer: A comparison of outcomes and cost of care.

OBJECTIVE: To compare outcomes and cost for patients with endometrial cancer undergoing vaginal hysterectomy (VH) or robotic hysterectomy (RH), with or without lymphadenectomy (LND). METHODS: Patients undergoing planned VH (and laparoscopic LND) or RH (and robotic LND) between January 2007 and November 2012 were reviewed. Patients with stage IV disease, synchronous cancer, synchronous surgery, or treated with palliative intent were excluded. Patients were objectively triaged to LND per institutional protocol based on frozen section. Outcomes were compared between VH and RH groups matched 1:1 on propensity scores. RESULTS: VH was planned in 153 patients; 60 (39%) had concurrent LND while 93 (61%) were low risk and did not require LND. RH was planned in 398 patients; 225 (56%) required concurrent LND and 173 (44%) did not. Among 50 PS-matched pairs without LND, there was no significant difference in complications, length of stay, readmission, or progression free survival. However, median operative time was 1.3h longer and median 30-day cost $3150 higher for RH compared to VH (both p<0.001). Among patients requiring LND, 42 PS-matched pairs were identified. Median operative time was not different when pelvic and para-aortic LND was performed, and 12min longer in the VH group for pelvic LND alone (p=0.03). Median 30-day cost was $921 higher for RH compared to VH when LND was required (p=0.08). CONCLUSION: Utilization of vaginal hysterectomy for endometrial cancer results in similar surgical and oncologic outcomes and lower costs compared to RH and should be considered for appropriate patients with a low risk of requiring LND.

Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy?

STUDY OBJECTIVE: To determine if racial differences exist in receipt of minimally invasive hysterectomy (defined as total vaginal hysterectomy [TVH] and total laparoscopic hysterectomy [TLH]) compared with an open approach (total abdominal hysterectomy [TAH]) within a universally insured patient population. DESIGN: Retrospective data analysis (Canadian Task Force classification II-2). SETTING: The 2006-2010 national TRICARE (universal insurance coverage to US Armed Services members and their dependents) longitudinal claims data. PATIENTS: Women aged 18 years and above who underwent hysterectomy stratified into 4 racial groups: white, African American, Asian, and "other." INTERVENTION: Receipt of hysterectomy (TAH, TVH, or TLH). MEASUREMENTS AND MAIN RESULTS: We used risk-adjusted multinomial logistic regression models to determine the relative risk ratios of receipt of TVH and TLH compared with TAH in each racial group compared with referent category of white patients for benign conditions. Among 33 015 patients identified, 60.82% (n = 20 079) were white, 26.11% (n = 8621) African American, 4.63% (n = 1529) Asian, and 8.44% (n = 2786) other. Most hysterectomies (83.9%) were for benign indications. Nearly 42% of hysterectomies (n = 13 917) were TAH, 27% (n = 8937) were TVH, and 30% (n = 10 161) were TLH. Overall, 36.37% of white patients received TAH compared with 53.40% of African American patients and 51.01% of Asian patients (p < .001). On multinomial logistic regression analyses, African American patients were significantly less likely than white patients to receive TVH (relative risk ratio [RRR], .63; 95% confidence interval [CI], .58-.69) or TLH (RRR, .65; 95% CI, .60-.71) compared with TAH. Similarly, Asian patients were less likely than white patients to receive TVH (RRR, .71; 95% CI, .60-.84) or TLH (RRR, .69; 95% CI, .58-.83) compared with TAH. Analyses by benign indications for surgery showed similar trends. CONCLUSION: We demonstrate that racial minority patients are less likely to receive a minimally invasive surgical approach compared with an open abdominal approach despite universal insurance coverage. Further work is warranted to better understand factors other than insurance access that may contribute to racial differences in surgical approach to hysterectomies.

Impact of body mass index and operative approach on surgical morbidity and costs in women with endometrial carcinoma and hyperplasia.

OBJECTIVE: To assess the impact of body mass index (BMI) and operative approach on surgical morbidity and costs in patients with endometrial carcinoma (EC) and hyperplasia (EH). METHODS: All women with BMI data who underwent surgery for EC or EH from 2008 to 2014 were identified from MarketScan, a healthcare claims database. Differences in 30-day complications and costs were compared between BMI groups and stratified by surgical modality. RESULTS: Of 1112 patients, 35%, 36%, and 29% had a BMI of ≤29, 30-39, and ≥40kg/m2, respectively. Compared to patients with a BMI of 30-39 and ≤29, women with a BMI ≥40 had higher rates of venous thromboembolism (3% vs 0.2% vs 0.3%, p<0.01) and wound infection (7% vs 3% vs 3%, p=0.02). This increase was driven by the subset of patients who had laparotomy and was not seen in those undergoing minimally invasive surgery (MIS). Median total costs for women with a BMI ≥40, 30-39, and ≤29 were U.S. $17.3k, $16.8k, and $16.6k respectively (p=0.53). Costs were higher for patients who had laparotomy than those who had MIS across all BMI groups, with the cost difference being highest in morbidly obese women (≥40: $21.6k vs $14.9k, p<0.01; 30-39: $18.9k vs $16.1k, p=0.01; ≤29: $19.3k vs $15k, p<0.01). Patients who had complications had higher costs compared to those who did not, with a higher cost difference in the laparotomy group ($27.7k vs $16.4k, p<0.01) compared to the MIS group ($19.9k vs $15k, p<0.01). CONCLUSIONS: MIS may increase the value of care by minimizing complications and decreasing costs. This may be most pronounced in morbidly obese women.

Role of concurrent vaginal hysterectomy in the outcomes of mesh-based vaginal pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Hysterectomy is often performed at the time of pelvic organ prolapse (POP) surgery; yet, there is insufficient evidence regarding the specific effect of hysterectomy on outcomes. We sought to determine the outcomes and associated short-term complications of mesh-based POP surgery with and without concurrent hysterectomy. METHODS: We utilized the New York Statewide Planning and Research Cooperation System (SPARCS) database to identify patients under 55 years of age undergoing surgeries for POP with mesh between 2009 and 2014. Patients who had a hysterectomy at the time of mesh-based POP surgery were compared with those who underwent mesh-based POP surgery without hysterectomy. Outcome measures of the patient groups before and after propensity score matching were compared. We assessed the difference Chi-squared tests and log-rank tests in the entire cohort and Mantel-Haenszel stratified Chi-squared tests and Prentice-Wilcoxon tests in the matched cohort. RESULTS: A total of 1,601 women underwent mesh-based POP surgery. 921 patients underwent concurrent hysterectomy, whereas 680 had mesh-based uterine-preserving POP surgery. After propensity score matching, there was no difference in reintervention rates between groups for up to 3 years. Concurrent hysterectomy with mesh-based POP repair was consistently associated with longer hospitalization (20.0% vs 12.8% stayed longer than 2 days) and higher charges (median charges were $22,689 vs $19,273). CONCLUSIONS: Concurrent hysterectomy during mesh-based POP surgery in patients under 55 years led to more expensive charges and a longer stay compared with uterine-preserving mesh surgery. There was no difference in reintervention rates between groups for up to 3 years.

Determining Optimal Route of Hysterectomy for Benign Indications: Clinical Decision Tree Algorithm.

OBJECTIVE: To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy. METHODS: A retrospective postrobot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded the laparoscopic hysterectomy route. A prerobot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated. RESULTS: Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the prerobot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the postrobot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%) robot-assisted; and 136 (11.4%) abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when a vaginal approach was expected. Robotic hysterectomies had longer operations (141 compared with 59 minutes, P<.001) and higher rates of surgical site infection (4.7% compared with 0.2%, P<.001) and urinary tract infection (8.1% compared with 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years. CONCLUSION: When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.

Inpatient Laparoscopic Hysterectomy in the United States: Trends and Factors Associated With Approach Selection.

STUDY OBJECTIVE: To examine utilization patterns of different laparoscopic approaches in inpatient hysterectomy and identify patient and hospital characteristics associated with the selection of specific laparoscopic approaches. DESIGN: Using data from the 2007 to 2012 National (Nationwide) Inpatient Sample (NIS), we identified adult women undergoing inpatient laparoscopic hysterectomy for nonobstetric indications based on International Classification of Diseases, Ninth Revision, Clinical Modification codes. Benign cases were categorized based on laparoscopic approach, classified as total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy (LAVH), or laparoscopic supracervical hysterectomy (LSH). We assessed changes in the use of these approaches during 2007 to 2012, and used multinomial logistic regression to examine the association of patient and hospital characteristics with the choice of laparoscopic approach in 2012. The NIS sample weights were applied to generate nationally representative estimates. DESIGN CLASSIFICATION: Retrospective study (Canadian Task Force classification III). SETTING: Hospital inpatient care nationwide. PATIENTS: Female adult patients in the NIS database who underwent an inpatient laparoscopic hysterectomy between 2007 and 2012. INTERVENTION: Inpatient laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: Of the inpatient laparoscopic hysterectomies performed in 2012, 83.2% were for benign indications. The TLH approach accounted for 48.3% of all laparoscopic hysterectomies, followed by LAVH at 37.3% and LSH at 14.4%. Robotic assistance was reported in 45.0% of all cases and 72.3% of malignant hysterectomies. An examination of temporal trends during 2007 to 2012 demonstrates a shift in the laparoscopic approach from LAVH toward TLH, with a slight decrease in LSH. Patient race/ethnicity, income, indication for hysterectomy, and comorbid conditions, as well as hospital teaching status, urban/rural location, bed size, type of ownership, and geographic region, were significantly associated with the choice of laparoscopic approach. CONCLUSION: Benign laparoscopic hysterectomy is increasingly performed as TLH rather than LAVH. In addition to clinical factors, the selection of laparoscopic approach is influenced by patient socioeconomic and hospital characteristics.

A randomized trial comparing vaginal and laparoscopic hysterectomy vs robot-assisted hysterectomy.

STUDY OBJECTIVE: To investigate the hospital cost and short-term clinical outcome of traditional minimally invasive hysterectomy vs robot-assisted hysterectomy in women primarily not considered candidates for vaginal surgery. DESIGN: Randomized controlled trial (Canadian Task Force classification I). SETTING: University Hospital in Sweden. PATIENTS: One hundred twenty-two women with uterine size ≤ 16 gestational weeks scheduled to undergo minimally invasive hysterectomy because of benign disease. INTERVENTIONS: Robot-assisted hysterectomy or traditional vaginal or laparoscopic minimally invasive hysterectomy. MEASUREMENTS AND MAIN RESULTS: All women underwent surgery as randomized. There were no demographic differences between the 2 groups. Vaginal hysterectomy was possible in 41% in the traditional minimally invasive group, at a mean hospital cost of $4579 compared with $7059 for traditional laparoscopic hysterectomy. This was reflected in a mean hospital cost of $993 more per robotic-assisted hysterectomy than for traditional minimally invasive hysterectomy when the robot was a preexisting investment. This hospital cost increased by $1607 when including investments and cost of maintenance. A per-protocol subanalysis comparing laparoscopy and robotics demonstrated similar hospital cost when the robot was a preexisting investment ($7059 vs $7016). Robotic-assisted hysterectomy was associated with less blood loss and fewer postoperative complications. CONCLUSION: A similar hospital cost can be attained for laparoscopy and robotics when the robot is a preexisting investment. From the perspective of hospital costs, robotic-assisted hysterectomy is not advantageous for treating benign conditions when a vaginal approach is feasible in a high proportion of patients.

Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology.

Vaginal hysterectomy fulfills the evidence-based requirements as the preferred route of hysterectomy for benign gynecologic disease. Despite proven safety and effectiveness, the vaginal approach for hysterectomy has been and remains underused in surgical practice. Factors associated with underuse of vaginal hysterectomy include challenges during residency training, decreasing case numbers among practicing gynecologists, and lack of awareness of evidence supporting vaginal hysterectomy. Strategies to improve resident training and promote collaboration and referral among practicing physicians and increasing awareness of evidence supporting vaginal hysterectomy can improve the primary use of this hysterectomy approach.

A systematic review and cost analysis of robot-assisted hysterectomy in malignant and benign conditions.

In order to assess the effectiveness and costs of robot-assisted hysterectomy compared with conventional techniques we reviewed the literature separately for benign and malignant conditions, and conducted a cost analysis for different techniques of hysterectomy from a hospital economic database. Unlimited systematic literature search of Medline, Cochrane and CRD databases produced only two randomized trials, both for benign conditions. For the outcome assessment, data from two HTA reports, one systematic review, and 16 original articles were extracted and analyzed. Furthermore, one cost modelling and 13 original cost studies were analyzed. In malignant conditions, less blood loss, fewer complications and a shorter hospital stay were considered as the main advantages of robot-assisted surgery, like any mini-invasive technique when compared to open surgery. There were no significant differences between the techniques regarding oncological outcomes. When compared to laparoscopic hysterectomy, the main benefit of robot-assistance was a shorter learning curve associated with fewer conversions but the length of robotic operation was often longer. In benign conditions, no clinically significant differences were reported and vaginal hysterectomy was considered the optimal choice when feasible. According to Finnish data, the costs of robot-assisted hysterectomies were 1.5-3 times higher than the costs of conventional techniques. In benign conditions the difference in cost was highest. Because of expensive disposable supplies, unit costs were high regardless of the annual number of robotic operations. Hence, in the current distribution of cost pattern, economical effectiveness cannot be markedly improved by increasing the volume of robotic surgery.

Cost differences among robotic, vaginal, and abdominal hysterectomy.

OBJECTIVE: To compare the costs of vaginal and abdominal hysterectomy with robotically assisted hysterectomy. METHODS: We identified all cases of robotically assisted hysterectomy, with or without bilateral salpingo-oophorectomy, treated at the Mayo Clinic (Rochester, Minnesota) from January 1, 2007, through December 31, 2009. Cases were propensity score-matched (one-to-one) to cases of vaginal and abdominal hysterectomy, selected randomly from January 1, 2004, through December 31, 2006 (before acquisition of the robotic surgical system). All billed costs were abstracted through the sixth postoperative week from the Olmsted County Healthcare Expenditure and Utilization Database and compared between cohorts with a generalized linear modeling framework. Predicted costs were estimated with the recycled predictions method. Costs of operative complications also were estimated. RESULTS: The total number of abdominal hysterectomies collected for comparison was 234 and the total number of vaginal hysterectomies was 212. Predicted mean cost of robotically assisted hysterectomy was $2,253 more than that of vaginal hysterectomy ($13,619 compared with $11,366; P<.001), although costs of complications were not significantly different. The predicted mean costs of robotically assisted compared with abdominal hysterectomy were similar ($14,679 compared with $15,588; P=.35). The costs of complications were not significantly different. CONCLUSIONS: Overall, vaginal hysterectomy was less costly than robotically assisted hysterectomy. Abdominal hysterectomy and robotically assisted hysterectomy had similar costs. LEVEL OF EVIDENCE: II.

Cost effectiveness of enhanced recovery after surgery programme for vaginal hysterectomy: a comparison of pre and post-implementation expenditures.

Enhanced Recovery After Surgery programmes were first conceived to optimise perioperative patient care and have been delivered by surgical specialities in the UK for over a decade. Although their safety and acceptability have been ratified in many surgical fields including gynaecology and colorectal surgery, the cost effectiveness of its implementation in benign vaginal surgery remains unclear. In this case-control study, the perioperative expenditure for 45 women undergoing vaginal hysterectomy at a North London teaching hospital after implementation of an enhanced recovery pathway was compared with 45 matched controls prior to implementation. Frequency of catheter use (84.4% vs. 95.6%) and median length of stay (23.5 vs. 42.9 h) were significantly lower following implementation of pathway (both p < 0.05). Although enhanced recovery patients were more likely to attend the accident and emergency department for minor symptoms following discharge (15.6% vs. 0%, p < 0.05), the inpatient readmission rate (6.7% vs. 0.0%, p > 0.05) was similar in both groups. Establishing the programme incurred additional expenditures including delivering a patient-orientated gynaecology 'school' and employing a specialist enhanced recovery nurse, but despite these, we demonstrated a saving of 15.2% (or £164.86) per patient. The cost efficiency savings, coupled with increased satisfaction and no rise in morbidity, offers a very attractive means of managing women undergoing vaginal hysterectomy. We believe that our data can be reproduced in other centres and recommend that the pathway be used routinely in women undergoing these procedures.