Value-based assessment of hysterectomy approaches.

Aim By evaluating operative outcomes relative to cost, we compared the value of minimally invasive hysterectomy approaches, including a technique discussed less often in the literature, laparoscopic retroperitoneal hysterectomy (LRH), which incorporates retroperitoneal dissection and ligation of the uterine arteries at their vascular origin. Methods Retrospective chart review of all women (N = 2689) aged greater than or equal to 18 years who underwent hysterectomy for benign conditions from 2011 to 2013 at a high-volume hospital in Maryland, USA. Procedures included: laparoscopic supracervical hysterectomy, robotic-assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total vaginal hysterectomy (TVH), and LRH. Results Total vaginal hysterectomy had the highest intraoperative complication rate (9.6%; P < 0.0001) but the lowest postoperative complication rate (1.8%; P < 0.0001). Robotics had the highest postoperative complication rate (11.4%; P < 0.0001). LRH had the shortest operative time (71.2 min; P < 0.0001) and the lowest intraoperative complication rates (2.1%; P < 0.0001). LRH and TVH were the least costly (averaging $4061 and $6416, respectively), while RALH was the most costly ($9354). Taking both operative outcomes and cost into account, LRH, TVH and laparoscopic-assisted vaginal hysterectomy yielded the highest value scores; total laparoscopic hysterectomy, RALH, and laparoscopic supracervical hysterectomy yielded the lowest. Conclusion Understanding the value of surgical interventions requires an evaluation of both operative outcomes and direct hospital costs. Using a quality-cost framework, the LRH approach as performed by high-volume laparoscopic specialists emerged as having the highest calculated value.