OBJECTIVES

: Total hysterectomy is performed for various surgical indications, including endometriosis, abnormal menstruation, benign neoplasms, and malignancy. Hysterectomy may also be performed via several surgical approaches, including open, laparoscopic, vaginal, laparoscopic-assisted vaginal (LAVH), or robotic-assisted surgery (RAS)—currently the fastest-growing hysterectomy approach. We investigated the association of indication with use of RAS; and, among women undergoing RAS, the association of indication with healthcare resource utilization (HRU) and costs.

METHODS

: Using the Premier Healthcare Database, we extracted data on women aged ≥18y undergoing inpatient/observation total hysterectomy between 1-October-2015—31-December-2018. Patients were classified by approach and indication (primary diagnosis). Multivariable generalized estimating equations quantified the association of indication (reference=malignancy) with use of RAS (reference=non-RAS); and, within RAS, the association of indication with operating room time (ORT) and total hospital costs for the surgical admission.

RESULTS

: Study included 127,397 patients undergoing total hysterectomy in 700 hospitals (422, [60.3%] performing RAS in 27,478 [21.6%] patients); 64,099 open, 12,474 laparoscopic, 11,876 vaginal, 11,470 LAVH. The proportion of patients with a malignancy-related indication was: 29.0% RAS, 16.6% open, 9.8% laparoscopic, 5.2% LAVH, 0.9% vaginal. Among RAS, non-malignancy indications included: 25.4% benign neoplasm/24.5% endometriosis/16.8% abnormal menstruation/4.3% ‘other’. After multivariable adjustment, malignancy-related indication was associated with significantly higher odds of employing RAS: odds ratios ranging from 1.85 [95% CI=1.56-2.22] vs. other to 3.03 [95% CI=2.50-3.57] vs. benign neoplasm. Among women undergoing RAS, a malignancy-related indication was associated with longer ORT (215.4 vs. 200.1 minutes, P<0.001) and higher total hospital costs ($14,232 vs. $13,468, P<0.001).

CONCLUSIONS

: RAS appears to be used more frequently for total hysterectomy among patients with malignancy- compared to non-malignancy-related indications. Such patients also appear to be more complex, as evidenced by increased HRU and costs relative to their counterparts. Accounting for these factors in comparisons across approaches or within RAS is critical to the internal validity of future studies.