Study finds clinical outcomes and hospital costs favor vaginal hysterectomy

Dr. HanafiTotal vaginal hysterectomy was found to be associated with better postoperative clinical outcomes and lower hospital costs compared to either total abdominal or robotic laparoscopic hysterectomy, according to the results of a retrospective study presented at the 46^th AAGL Global Congress on Minimally Invasive Gynecology.

The single-center study involved 333 patients who underwent hysterectomy between 2008 and 2015, of whom roughly 42% had robotic laparoscopy, 36% abdominal and 22% vaginal hysterectomy. In addition, 230 of the patients completed patient questionnaires.

“Although vaginal hysterectomy is the preferred method among most gynecologists, not all patients are eligible for this method, in part due to previous cesarean section, abdominal surgery, endometriosis and pelvic adhesions,” said lead author Magdi Hanafi, MD, a gynecologist and fertility specialist in private practice in Atlanta, Ga. “Robotic laparoscopic hysterectomy is the second most popular technique because it is minimally invasive. However, some patients cannot undergo either laparoscopic or vaginal hysterectomy, due to the very large size of their tumor. As last resort, abdominal hysterectomy is performed.”

Dr. Hanafi said robotic laparoscopic hysterectomy has “very good postoperative outcomes, with decreased operative blood loss and a shorter hospital stay.” However, vaginal hysterectomy is less expensive, along with a slightly better clinical outcome than laparoscopic and without the need for any abdominal incision.

The study concluded that of the three methods, abdominal hysterectomy ranked the lowest in clinical outcomes. “Patients eventually recover well, but they stay out of work longer and it takes longer for them to regain self-care,” Dr. Hanafi told Contemporary OB/GYN. “These patients take longer before they can pass gas, walk and go to the bathroom, as well as when they can dress themselves, brush their teeth and feed themselves. In contrast, patients undergoing a vaginal or laparoscopic procedure are typically able to resume their daily activities the day after surgery.”

As for hospital cost rankings, vaginal hysterectomy was the least expensive. But as the study period progressed, a laparoscopic procedure became more competitively priced. Abdominal hysterectomy was found to be slightly more expensive overall than the other two methods, primarily because of the longer hospital stay.

The mean total charge for a vaginal hysterectomy was $17,098.41, compared to $23,114.21 for a laparoscopic and $23,295.99 for an abdominal procedure.

“In the beginning, I was surprised that the cost of the robotic surgery was not that much higher than the other two methods, because your first impression of robotics by talking to others is that it is very expensive,” said Dr. Hanafi, chair of gynecology at Emory Saint Joseph Hospital in Atlanta, an affiliate of Emory University.

The average hospital stay for abdominal hysterectomy was 2.8 days versus 1.41 days for either a vaginal or laparoscopic procedure.

On the other hand, laparoscopic surgery had a significantly higher operative time of 194.11 minutes than for vaginal with 119.75 minutes. Abdominal hysterectomy took an average 181.66 minutes.

Estimated blood loss was also highest for abdominal at 194.16 mL, followed by laparoscopic at 105.67 mL and vaginal at 97.11 mL.

Abdominal hysterectomy was also associated with a significantly higher pain level than the other two methods: 6.9 (on a scale of 0 – 10) compared to 5.59 for laparoscopic and 5.47 for vaginal. “Both pain and the duration of pain medication is much less for vaginal and laparoscopic,” Dr. Hanafi says. Mean days of analgesic use were 11.13 for abdominal versus 8.43 for laparoscopic and 7.61 for vaginal.

For patients presenting with a large fibroid tumor close to the xiphisternum, “you have no choice except to perform an abdominal hysterectomy,” said Dr. Hanafi, who performs abdominoplasty at the same time to enhance cosmetic results, without charging more. “Abdominoplasty is easy to do and will increase patient satisfaction.”

Dr. Hanafi observed that there is growing interest in performing robotic laparoscopic hysterectomy because of excellent visualization and superior access to all pelvic spaces. “You can also suture much better and have good control of the bleeding,” he said. “Moreover, you can dissect the ureter and other pelvic organs much easier. Overall, you have better control of the pelvic organ.”

Despite the advantage of robotic surgery, Dr. Hanafi noted there is reluctance among many of his colleagues to embrace the technique. “They feel it will take a long time to learn and/or cost a lot to acquire the technology,” he said. “But that is not true. I think if someone has been performing laparoscopy for a while, they can be easily trained.”

Nonetheless, Dr. Hanafi said he is committed to teaching clinicians to select the method of hysterectomy that is best for their patients.

Commenting on the study, AAGL President Jon I. Einarsson said, “The main problem with studies such as this is that they are comparing apples to oranges. The patients eligible for a vaginal hysterectomy have smaller uteri and they do not have severe pelvic adhesive disease or stage IV endometriosis. This results in easier cases being done transvaginally and this explains the difference in OR time and the difference in cost, at least to a point.”    

Dr. Hanafi reports no relevant financial disclosures.

REFERENCE

Hanafi M. Hysterectomy – Vaginal, Abdominal and Robotic Laparoscopic Study: Clinical Evaluation and Cost Analysis. [AAGL abstract 65]. J Minim Invasive Gynecol. 2017;24(suppl):S25.