title: Route of hysterectomy and surgical outcomes from a statewide gynecologic oncology population: is there a role for vaginal hysterectomy?
abstract: BACKGROUND
  Recent policy changes by insurance companies have been instituted to encourage vaginal hysterectomy (VH) as the preferred route for removal of the uterus. It is not known if advantages of VH 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 VH for benign indications may not apply to gynecologic cancer patients.
  
  
  METHODS
  We performed a population-based retrospective cohort study of cervical, endometrial, or ovarian/fallopian tube cancer patients treated surgically in Washington State from 2004 through 2013 using the Comprehensive Hospital Abstract Reporting System. Surgery was categorized as abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or VH. We determined rate of surgical approach by year and the association with length of stay, 30-day readmission rate, and perioperative complications.
  
  
  RESULTS
  We identified 10,117 patients who underwent surgery for gynecologic cancer, with 346 (3.4%) VH, 2698 (26.7%) LH, and 7073 (69.9%) AH. Patients undergoing AH had more comorbidities than patients with VH or LH (Charlson Comorbidity Index ≥2: 11.3%, 7.9%, and 8.1%, respectively; P < .001). From 2004 through 2013 AH and VH declined (94.4-47.9% and 4.4-0.8%, respectively; P < .001) while LH increased from 1.2-51.4% in 2013 (P < .001). Mean length of stay was 4.6 days for women undergoing AH and was 1.9 days shorter for VH (95% confidence interval, 1.6-2.3 days) and 2.6 days shorter for LH (95% confidence interval, 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 vs AH.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.
authors.forename: Tiffany L
authors.initials: TL
authors.lastname: Beck
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Morse
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.
authors.forename: Heidi J
authors.initials: HJ
authors.lastname: Gray
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Goff
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.
authors.forename: Renata R
authors.initials: RR
authors.lastname: Urban
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA. Electronic address: johnliao@uw.edu.
authors.forename: John B
authors.initials: JB
authors.lastname: Liao
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005833:Genital Neoplasms, Female / Q000601:surgery*; D006801:Humans; D007044:Hysterectomy / Q000379:methods* / Q000639:trends; D007045:Hysterectomy, Vaginal / Q000706:statistics & numerical data / Q000639:trends; D010535:Laparoscopy / Q000706:statistics & numerical data / Q000639:trends; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D016896:Treatment Outcome; D014861:Washington; D055815:Young Adult
keywords: length of stay; perioperative complication; readmission; vaginal hysterectomy