Why not vaginal?-Nationwide trends and surgical outcomes in low-risk hysterectomies: A retrospective cohort study.

Abstract

Introduction: The rate of vaginal hysterectomies is declining globally. We investigated surgical techniques, outcomes, and costs in a large national cohort of benign hysterectomies with prerequisites for vaginal surgery.

Material and methods: A retrospective register-based cohort study with benign hysterectomies in the Swedish GynOp registry 2014-2023 (n = 17 804). Inclusion criteria were non-prolapse, non-endometriosis with uterus weight <300 g. The cohort was divided into a low-risk and a standard group, with the low-risk group having optimal conditions for vaginal hysterectomy: no previous caesarian section (CS), no previous abdominal surgery, Body Mass Index (BMI) <30, and no nulliparous patients. Surgical outcomes were quantified using crude and adjusted risk ratios (RR, ARR). Costs were calculated and compared between abdominal (AH), laparoscopic (LH), robot-assisted (RH), and vaginal hysterectomies (VH).

Results: The rate of AH and VH decreased during the period studied. RH increased and was the most common surgical technique 2021-2023 (33.2%). VH had the shortest surgical time and was the cheapest method. In the low-risk group, 25.2% of the patients were operated on vaginally. AH had more postoperative complications and longer hospitalization compared to VH in the low-risk group. LH had less severe intraoperative complications, ARR = 0.38 (95% CI 0.17-0.86) but more mild postoperative complications, ARR = 1.24 (95% CI 1.05-1.46) compared to VH in the low-risk group. LH had more conversions, ARR = 1.46 (95% CI 1.00-2.12), longer surgical time, ARR = 2.73 (95% CI 2.46-3.00) and longer hospital stay, ARR = 1.26 (95% CI 1.12-1.43) compared to VH. Mild (ARR = 0.33, 95% CI 0.16-0.66) and severe (ARR = 0.17, 95% CI 0.05-0.58) intraoperative complications and bleeding >500 mL (ARR = 0.12, 95% CI 0.04-0.34) were less common in RH versus VH in the low-risk group. There were no differences between RH and VH regarding postoperative complications and reoperations. Surgical time <45 min was less common in RH versus VH (ARR = 0.47, 95% CI 0.42-0.54) and RH had a significantly longer postoperative hospital stay (ARR = 1.16, 95% CI 1.02-1.33).

Conclusions: A decline of vaginal hysterectomies in Sweden 2014-2023 among patients with prerequisites for vaginal surgery was shown. VH was the cheapest method with few postoperative complications and short hospitalization. Our results support the vaginal route in low-risk hysterectomies.