Route of hysterectomy and surgical outcomes from a state-wide gynecologic oncology population

Abstract: Route of hysterectomy and surgical outcomes from a state-wide gynecologic oncology population: is there a role for vaginal hysterectomy? 
 

BACKGROUND:

Recent policy changes by insurance companies have been instituted to encourage vaginal hysterectomy as the preferred route for removal of the uterus. It is not known if advantages of vaginal hysterectomy for benign indications apply to women with gynecologic cancer.

OBJECTIVE:

The goal of this study was to assess trends in surgical approach to hysterectomy among gynecologic cancer patients and to evaluate outcomes by approach. We hypothesized that, among gynecologic oncology patients, postoperative complications and hospital stay would differ by surgical approach, and that advantages of vaginal hysterectomy for benign indications may not apply to gynecologic cancer patients.

STUDY DESIGN:

We performed a population-based retrospective cohort study of cervical, endometrial, or ovarian/fallopian tube cancer patients treated surgically in Washington State from 2004 to 2013 using the Comprehensive Hospital Abstract Reporting System (CHARS). Surgery was categorized as abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or vaginal hysterectomy (VH). We determined rate of surgical approach by year and the association with length of stay (LOS), 30-day readmission rate, and perioperative complications.

RESULTS:

We identified 10,117 patients who underwent surgery for gynecologic cancer, with 346 (3.4%) VH, 2,698 (26.6%) LH, and 7,073 (69.9%) AH. Patients undergoing AH had more comorbidities than VH or LH (CCI ≥2 11.3%, 7.9% and 8.1% respectively, P<.001). From 2004 to 2013 AH and VH declined (94.4% to 47.9% and 4.4% to 0.8% respectively; P<.001) while LH increased from 1.2% to 51.4% in 2013 (P<.001). Mean LOS was 4.6 days for women undergoing an AH and was 1.9 days shorter for VH (95% CI, 1.6-2.3 days) and 2.6 days shorter for LH (95% CI, 2.4-2.7 days) (P<.001). Risk of 30-day readmission for patients undergoing LH was 40% less likely compared to AH but not different for VH versus AH.

CONCLUSION:

AH and LH remain the preferred routes for hysterectomy in gynecologic oncology. Over the past decade, there has been a significant shift to LH with lower 30-day readmission and complication rates. There may be a limited role for VH in select patients. Current efforts to standardize the surgical approach to hysterectomy should not apply to patients with known or suspected gynecologic cancer.