title: The impact of different surgical modalities for hysterectomy on satisfaction and patient reported outcomes.
abstract: BACKGROUND
  There is an ongoing debate regarding the cost-benefit of different surgical modalities for hysterectomy. Studies have relied primarily on evaluation of clinical outcomes and medical expenses. Thus, a paucity of information on patient-reported outcomes including satisfaction, recovery, and recommendations exists.
  
  
  OBJECTIVE
  The objective of this study was to identify differences in patient satisfaction and recommendations by approach to a hysterectomy.
  
  
  METHODS
  We recruited a large, geographically diverse group of women who were members of an online hysterectomy support community. US women who had undergone a benign hysterectomy formed this retrospective study cohort. Self-reported characteristics and experiences were compared by surgical modality using chi-square tests. Outcomes over time were assessed with the Jonkheere-Terpstra trend test. Logistic regression identified independent predictors of patient satisfaction and recommendations.
  
  
  RESULTS
  There were 6262 women who met the study criteria; 41.74% (2614/6262) underwent an abdominal hysterectomy, 10.64% (666/6262) were vaginal, 27.42% (1717/6262) laparoscopic, 18.94% (1186/6262) robotic, and 1.26% (79/6262) single-incision laparoscopic. Most women were at least college educated (56.37%, 3530/6262), and identified as white, non-Hispanic (83.17%, 5208/6262). Abdominal hysterectomy rates decreased from 68.2% (152/223) to 24.4% (75/307), and minimally invasive surgeries increased from 31.8% (71/223) to 75.6% (232/307) between 2001 or prior years and 2013 (P<.001 all trends). Trends in overall patient satisfaction and recommendations showed significant improvement over time (P<.001).There were differences across the surgical modalities in all patient-reported experiences (ie, satisfaction, time to walking, driving and working, and whether patients would recommend or use the same technique again; P<.001). Significantly better outcomes were evident among women who had vaginal, laparoscopic, and robotic procedures than among those who had an abdominal procedure. However, robotic surgery was the only approach that was an independent predictor of better patient experience; these patients were more satisfied overall (odds ratio [OR] 1.31, 95% CI 1.13-1.51) and on six other satisfaction measures, and more likely to recommend (OR 1.64, 95% CI 1.39-1.94) and choose the same modality again (OR 2.07, 95% CI 1.67-2.57). Abdominal hysterectomy patients were more dissatisfied with outcomes after surgery and less likely to recommend (OR 0.36, 95% CI 0.31-0.40) or choose the same technique again (OR 0.29, 95% CI 0.25-0.33). Quicker return to normal activities and surgery after 2007 also were independently associated with better overall satisfaction, willingness to recommend, and to choose the same surgery again.
  
  
  CONCLUSIONS
  Consistent with other US data, laparoscopic and robotic hysterectomy rates increased over time, with a concomitant decline in abdominal hysterectomy. While inherent shortcomings of this retrospective Web-based study exist, findings show that patient experience was better for each of the major minimally invasive approaches than for abdominal hysterectomy. However, robotic-assisted hysterectomy was the only modality that independently predicted greater satisfaction and willingness to recommend and have the same procedure again.
authors.affiliation: Newark Beth Israel Medical Center, Minimally Invasive & Gynecologic Robotic Surgery, Newark, NJ, United States. mptmd@aol.com.
authors.forename: Michael C
authors.identifier: http://orcid.org/0000-0003-4057-7288
authors.initials: MC
authors.lastname: Pitter
authors.forename: Christopher
authors.identifier: http://orcid.org/0000-0001-6294-0741
authors.initials: C
authors.lastname: Simmonds
authors.forename: Usha
authors.identifier: http://orcid.org/0000-0002-4215-3158
authors.initials: U
authors.lastname: Seshadri-Kreaden
authors.forename: Helen B
authors.identifier: http://orcid.org/0000-0002-3079-437X
authors.initials: HB
authors.lastname: Hubert
keywords: Internet; hysterectomy; laparoscopy; patient outcomes assessment; patient satisfaction; robotics; vaginal hysterectomy