OBJECTIVES : To analyze adoption of different surgical approaches to treat benign hysterectomy in cases with high surgical complexity in the United States outpatient setting.

METHODS : A retrospective cohort analysis was performed among adult females who underwent elective outpatient hysterectomy for benign conditions from January 1, 2017 to December 31, 2019 in the Premier Hospital Perspective Database®. Patients with missing or extreme costs below first and above 99^th percentile and hysterectomies related to obstetric procedures were excluded from the analysis. Proportions of patients who received open (OH), vaginal (VH), laparoscopic (LH) and robotic (RH) assisted hysterectomies were calculated for patients with and without complex surgical conditions (e.g., obesity BMI≥ 30, pelvic adhesions, large uterus weight >250 gm and prior history of pelvic surgery or C-section), respectively.

RESULTS : The study included 185,267 patients who underwent hysterectomy for benign conditions in the hospital outpatient setting in 2017 to 2019. Among those without surgical complexity, proportions of LH and RH were 44.5% and 35.8% respectively, followed by 18.7% VH and 1.0% OH. We observed an increased rate of RH approach for cases with at least one surgical complexity: obesity (46.9%), pelvic adhesions (50.0%), large uterus weight (47.8%), and patients with history of surgery or C-section (48.4%); while the rate of VH was lower for complex cases: obesity (9.7%), pelvic adhesions (3.2%), large uterus weight (5.0%), and patients with history of surgery or C-section (9.5%) and the rate of LH remained steady. Moreover, for patients with two and three or more surgical complexities, the rate of RH further increased to up to 51.9% and 57.8%, respectively, accompanied by reduced rate of LH and VH.

CONCLUSIONS : Higher proportions of robotic assisted hysterectomies was observed to treat complex benign cases in the outpatient hospital setting compared to other surgical approaches.