A Swedish population-based evaluation of benign hysterectomy, comparing minimally invasive and abdominal surgery

Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review

OBJECTIVE

To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint.

DATA SOURCES

PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible.

METHODS OF STUDY SELECTION

This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy.

TABULATION, INTEGRATION, AND RESULTS

The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss.

CONCLUSION

Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021233300.

Robotic Surgery in Gynaecology: A Retrospective Evaluation of an Experience at a Single Centre

Objective

The aim of this research was to assess the role of robotics and its outcome in gynaecology both in benign and malignant cases in a single centre and provide a critical evaluation of possible advantages of robot assisted surgeries from surgeons' point of view.

Design

A single centre, retrospective observational study.

Population

All women who underwent robotic gynaecological surgeries between 2015 and 2022.

Methods

The Da Vinci Si™ robotic system was used for these surgeries performed by all surgeons at our quaternary care centre, and data were acquired retrospectively through electronic medical records. Descriptive statistical analysis of data was done. Main outcome measures included operative time, estimated blood loss, hospital stay, complications and conversion rates in all cases. Age was analysed as a demographic data.

Outcome

A total of 211 robotic cases were performed including 172 hysterectomies, 20 myomectomies and 19 cases for other gynaecological indications. The mean operating time or hysterectomy and myomectomy was 113 and 129 min, respectively, and haemoglobin drop was 1.34 and 1.2 g/dl, respectively. No conversions to laparotomy were observed in either of the groups. The surgeries for 19 benign gynaecological conditions included ovarian cystectomy, cesarean scar repair and chronic cornual ectopic.

Conclusion

Robotic surgical system helps accomplish several procedures with exceptional laparoscopic skills. Robotic surgery is safe in all types of gynaecological procedures and is a promising alternative for comprehensive gynaecologic surgical care.

Robotic-assisted benign hysterectomy compared with laparoscopic, vaginal, and open surgery: a systematic review and meta-analysis

The potential benefits and limitations of benign hysterectomy surgical approaches are still debated. We aimed at evaluating any differences with a systematic review and meta-analysis. PubMed, MEDLINE, and EMBASE databases were last searched on 6/2/2021 to identify English randomized controlled trials (RCTs), prospective cohort and retrospective independent database studies published between Jan 1, 2010 and Dec 31, 2020 reporting perioperative outcomes following robotic hysterectomy versus laparoscopic, open, or vaginal approach (PROSPERO #CRD42022352718). Twenty-four articles were included that reported on 110,306 robotic, 262,715 laparoscopic, 189,237 vaginal, and 554,407 open patients. The robotic approach was associated with a shorter hospital stay (p < 0.00001), less blood loss (p = 0.009), and fewer complications (OR: 0.42 [0.27, 0.66], p = 0.0001) when compared to the open approach. The main benefit compared to the laparoscopic and vaginal approaches was a shorter hospital (R/L WMD: - 0.144 [- 0.21, - 0.08], p < 0.0001; R/V WMD: - 0.39 [- 0.70, - 0.08], p = 0.01). Other benefits seen were sensitive to the inclusion of database studies. Study type differences in outcomes, a lack of RCTs for robotic vs. open comparisons, learning curve issues, and limited robotic vs. vaginal publications are limitations. While the robotic approach was mainly comparable to the laparoscopic approach, this meta-analysis confirms the classic benefits of minimally invasive surgery when comparing robotic hysterectomy to open surgery. We also reported the advantages of robotic surgery over vaginal surgery in a patient population with a higher incidence of large uterus and prior surgery.

Quality of Life after Risk-Reducing Hysterectomy for Endometrial Cancer Prevention: A Systematic Review

BACKGROUND

Risk-reducing hysterectomy (RRH) is the gold-standard prevention for endometrial cancer (EC). Knowledge of the impact on quality-of-life (QoL) is crucial for decision-making. This systematic review aims to summarise the evidence.

METHODS

We searched major databases until July 2022 (CRD42022347631). Given the paucity of data on RRH, we also included hysterectomy as treatment for benign disease. We used validated quality-assessment tools, and performed qualitative synthesis of QoL outcomes.

RESULTS

Four studies (64 patients) reported on RRH, 25 studies (1268 patients) on hysterectomy as treatment for uterine bleeding. There was moderate risk-of-bias in many studies. Following RRH, three qualitative studies found substantially lowered cancer-worry, with no decision-regret. Oophorectomy (for ovarian cancer prevention) severely impaired menopause-specific QoL and sexual-function, particularly without hormone-replacement. Quantitative studies supported these results, finding low distress and generally high satisfaction. Hysterectomy as treatment of bleeding improved QoL, resulted in high satisfaction, and no change or improvements in sexual and urinary function, although small numbers reported worsening.

CONCLUSIONS

There is very limited evidence on QoL after RRH. Whilst there are benefits, most adverse consequences arise from oophorectomy. Benign hysterectomy allows for some limited comparison; however, more research is needed for outcomes in the population of women at increased EC-risk.

Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications: A Systematic Review

OBJECTIVE

To identify the incidence, location, etiology, and mortality of major vascular injuries in gynecologic laparoscopy for benign indications.

DATA SOURCES

A systematic review of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and MEDLINE was conducted.

METHODS OF STUDY SELECTION

One thousand ninety-seven studies were screened for inclusion with 147 full-text articles reviewed. Sixty-six studies published between 1978 and 2016 met inclusion criteria, representing 197,062 surgeries. Articles that were included reported the incidence of major vascular injuries during gynecologic laparoscopy for benign indications. Exclusion criteria included surgery for gynecologic malignancy, duplicated data, case series and reports, manuscripts not in English, and studies published only as abstracts.

TABULATION, INTEGRATION, AND RESULTS

Injuries to the aorta, inferior vena cava, iliac (common, external, or internal), and inferior epigastric vessels were recorded, as were injuries denoted as major but not otherwise specified. A total of 179 major vascular injuries were reported with an incidence of 0.09% (95% CI 0.08-0.10). The inferior epigastric vessels were the most commonly injured vessel (0.04%, 95% CI 0.03-0.05), comprising 48% (95% CI 40-55) of all injuries. The majority of injuries occurred during abdominal entry (82%, 95% CI 76-89), and the remainder occurred during surgical dissection (18%, 95% CI 11-24). Most injuries were recognized intraoperatively (93%, 95% CI 87-100), and approximately half (55%, 95% CI 46-63) required laparotomy for repair. Only two of the 179 major vascular injuries resulted in death, for an overall mortality rate from vascular injuries of 0.001% (95% CI 0.000-0.004).

CONCLUSION

The incidence of major vascular injury during gynecologic laparoscopy found in this review is very low, and the vast majority of injuries did not result in death. Laparoscopy remains a safe surgical technique in relation to vascular injuries when performed for benign gynecologic disease.

Consensus on safe implementation of vaginal natural orifice transluminal endoscopic surgery (vNOTES)

STUDY OBJECTIVE

The first ever report of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynaecological was reported in 2012. There has been an exponential uptake of the number of surgeons performing such procedures worldwide with no official guidance to ensure the safe implementation of this technique into gynaecological practice due its recency. The objective of this study is to report an international consensus-based statement to help guide a basis for adopting vNOTES into clinical practice.

STUDY DESIGN

The consensus-based statement was developed amongst 39 international experts using the Delphi methodology over three successive rounds. Consensus was pre-defined as an agreement of 80% or more by the experts. Consensus sought over eight key concepts pertaining to vNOTES including patient selection, perioperative management, surgical technique, instruments, anatomy, training, registries and trials and definition of the surgical technique. Recommendations from an expert anaesthetist and urogynaecologist were also sought to give a broader perspective with respect to the implementation of vNOTES.

RESULTS

Fifty nine international surgeons were invited to participate and 39 (66%) agreed to participate based on being involved in a minimum of 20 vNOTES procedures. They were from 13 countries across 5 continents (Europe, North America, South America, Australia and Asia). Participation was 100% on all three rounds. Overall, consensus was reached in 50 of the 56 questions (89%) with the remaining 6 questions where consensus was not reached pertaining to the domain of patient selection.

CONCLUSION

An international expert based vNOTES statement is presented here to help guide adoption of vNOTES based on the experience of early adopters. Consensus was achieved on most components of this consensus statement. Given the recency of this technique, until high-level evidence becomes available, this statement provides an appropriate guidance to the safe implementation of vNOTES into gynaecological practice.

Assessment of surgeon and hospital volume for robot-assisted and laparoscopic benign hysterectomy in Sweden

INTRODUCTION

The study aims to analyze differences between robot-assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon and hospital volume.

MATERIAL AND METHODS

All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo-oophorectomy from January 1, 2015 to December 31, 2017 (n = 12 386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses.

RESULTS

TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios [aOR] 2.8, 95% CI 1.3-5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2-2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2-25.4), a higher blood loss (200-500 mL aOR 3.5, 95% CI 2.7-4.7; > 500 mL aOR 7.6, 95% CI 4.0-14.6) and a longer operative time (1-2 h aOR 16.7 95% CI 10.2-27.5; >2 h aOR 47.6, 95% CI 27.9-81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4-0.9).

CONCLUSIONS

RATLH led to better perioperative outcome and higher patient satisfaction 1 year after surgery. These outcome differences were slightly more pronounced in very low-volume surgeons but persisted across all surgeon volume groups.

Changes in route of hysterectomy in Norway since introduction of robotic approach

INTRODUCTION

From 2008, several Norwegian Health Trusts have acquired surgical robotic systems, and robotic hysterectomy accounted for 15 % of all hysterectomies performed in Norway in 2018. Robotic assisted hysterectomy is costly, and there is no evidence that the clinical outcome of robotic assisted hysterectomy is superior compared to the outcomes following other minimal invasive hysterectomies such as vaginal and laparoscopic hysterectomies. The objectives of this study were to describe the implementation of robotic hysterectomy and changes in other hysterectomy approaches, such as open abdominal, laparoscopic and vaginal hysterectomy in hospitals with and without robotic systems for hysterectomy.

METHODS

Quantitative study based on hysterectomy data between 2010 to 2018 from the Norwegian Patient Registry.

RESULTS

9 out of 19 health trusts performed robotic assisted hysterectomy during the study period. The rate of abdominal hysterectomies declined during the study period, both in the health trusts with and without available surgical robotic systems. The rate of other minimally invasive hysterectomies also declined in some health trusts after the implementation of robotic assisted hysterectomy.

DISCUSSION

Robotic hysterectomy has been implemented and is increasing in Norway without a thorough evaluation of the effect on patient safety and possible economic consequences. According to our findings, it appears that the implementation of robotic hysterectomy has not had a significant impact on the use of open abdominal hysterectomy. Although associated with increased costs and a lack of evidence of improved clinical outcomes for women, robotic hysterectomy has furthermore to some extent replaced other minimal invasive hysterectomies.

Racial/Ethnic Differences in the Risk of Surgical Complications and Posthysterectomy Hospitalization among Women Undergoing Hysterectomy for Benign Conditions

STUDY OBJECTIVE

Evaluate whether 30- and 90-day surgical complication and postoperative hospitalization rates after hysterectomy for benign conditions differ by race/ethnicity and whether the differences remain after controlling for patient, hospital, and surgical characteristics.

DESIGN

Retrospective cohort study using administrative data. The exposure was race/ethnicity. The outcomes included 5 different surgical complications/categories and posthysterectomy inpatient hospitalization, all identified through 30 and 90 days after hysterectomy hospital discharge, with the exception of hemorrhage/hematoma, which was only identified through 30 days. To examine the association between race/ethnicity and each outcome, we used logistic regression with clustering of procedures within hospitals, adjusting for patient and hospital characteristics and surgical approach.

SETTING

Multistate, including Florida and New York.

PATIENTS

Women aged ≥18 years who underwent hysterectomy for benign conditions using State Inpatient Databases and State Ambulatory Surgery Databases.

INTERVENTIONS

Hysterectomy for benign conditions.

MEASUREMENTS AND MAIN RESULTS

We included 183 697 women undergoing hysterectomy for benign conditions from January 2011 to September 2014. In analysis, adjusting for surgery route and other factors, black race was associated with increased risk of 30-day digestive system complications (multivariable adjusted odds ratio [aOR], 1.98; 95% confidence interval [CI], 1.78-2.21), surgical-site infection (aOR, 1.34; 95% CI, 1.18-1.53), posthysterectomy hospitalization (aOR, 1.31; 95% CI, 1.22-1.40), and urologic complications (aOR, 1.16; 95% CI, 1.01-1.34) compared with white race. Asian/Pacific Islander race was associated with increased risk of 30-day urologic complications (aOR, 1.48; 95% CI, 1.08-2.03), intraoperative injury to abdominal/pelvic organs (aOR, 1.46; 95% CI, 1.23-1.75), and hemorrhage/hematoma (aOR, 1.33; 95% CI, 1.06-1.67) compared with white race. Hispanic ethnicity was associated with increased risk of 30-day posthysterectomy hospitalization (aOR, 1.11; 95% CI, 1.02-1.20) compared with white race. All findings were similar at 90 days.

CONCLUSION

Black and Asian/Pacific Islander women had higher risk of some 30- and 90-day surgical complications after hysterectomy than white women. Black and Hispanic women had higher risk of posthysterectomy hospitalization. Intervention strategies aimed at identifying and better managing disparities in pre-existing conditions/comorbidities could reduce racial/ethnic differences in outcomes.

Regional variation of hysterectomy for benign uterine diseases in Switzerland

Background

Hysterectomy is the last treatment option for benign uterine diseases, and vaginal hysterectomy is preferred over more invasive techniques. We assessed the regional variation in hysterectomy rates for benign uterine diseases across Switzerland and explored potential determinants of variation.

Methods

We conducted a population-based analysis using patient discharge data from all Swiss hospitals between 2013 and 2016. Hospital service areas (HSAs) for hysterectomies were derived by analyzing patient flows. We calculated age-standardized mean procedure rates and measures of regional variation (extremal quotient [EQ], highest divided by lowest rate) and systematic component of variation [SCV]). We estimated the reduction in the variance of crude hysterectomy rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, cultural/socioeconomic factors, burden of disease, and density of gynecologists.

Results

Overall, 40,211 hysterectomies from 54 HSAs were analyzed. The mean age-standardized hysterectomy rate was 298/100,000 women (range 186–456). While the variation in overall procedure rate was moderate (EQ 2.5, SCV 3.7), we found a very high procedure-specific variation (EQ vaginal 5.0, laparoscopic 6.3, abdominal 8.0; SCV vaginal 17.5, laparoscopic 11.2, abdominal 16.9). Adjusted for procedure year, demographic, cultural, and sociodemographic factors, a large share (64%) of the variance remained unexplained (vaginal 63%, laparoscopic 85%, abdominal 70%). The main determinants of variation were socioeconomic/cultural factors. Burden of disease and the density of gynecologists was not associated with procedure rates.

Conclusions

Switzerland has a very high regional variation in vaginal, laparoscopic, and abdominal hysterectomy for benign uterine disease. After adjustment for potential determinants of variation including demographic factors, socioeconomic and cultural factors, burden of disease, and the density of gynecologists, two thirds of the variation remain unexplained.

Effects of Obesity on Peri- and Postoperative Outcomes in Patients Undergoing Robotic versus Conventional Hysterectomy

STUDY OBJECTIVE

To assess if women with obesity have increased complication rates compared with women with normal weight undergoing hysterectomy for benign reasons and if the mode of hysterectomy affects the outcomes.

DESIGN

Cohort study.

SETTING

Prospectively collected data from 3 Swedish population-based registers.

PATIENTS

Women undergoing a total hysterectomy for benign indications in Sweden between January 1, 2015, and December 31, 2017. The patients were grouped according to the World Health Organization's classification of obesity.

INTERVENTIONS

Intraoperative and postoperative data were retrieved from the surgical register up to 1 year after the hysterectomy. Different modes of hysterectomy in patients with obesity were compared, such as open abdominal hysterectomy (AH), traditional laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and robot-assisted laparoscopic hysterectomy (RTLH).

MEASUREMENTS AND MAIN RESULTS

Out of 12,386 women who had a total hysterectomy during the study period, we identified 2787 women with normal weight and 1535 women with obesity (body mass index ≥30). One year after the hysterectomy, the frequency of complications was higher in women with obesity than in women with normal weight (adjusted odds ratio [aOR]) 1.4; 95% confidence interval [CI], 1.1-1.8). In women with obesity, AH was associated with a higher overall complication rate (aOR 1.8; 95% CI, 1.2-2.6) and VH had a slightly higher risk of intraoperative complications (aOR 4.4; 95% CI, 1.2-15.8), both in comparison with RTLH. Women with obesity had a higher rate of conversion to AH with conventional minimally invasive hysterectomy (TLH: aOR 28.2; 95% CI, 6.4-124.7 and VH: 17.1; 95% CI, 3.5-83.8, respectively) compared with RTLH. AH, TLH, and VH were associated with a higher risk of blood loss >500 mL than RTLH (aOR 11.8; 95% CI, 3.4-40.5; aOR 8.5; 95% CI, 2.5-29.5; and aOR 5.8; 95% CI, 1.5-22.8, respectively) in women with obesity.

CONCLUSION

The use of RTLH may lower the risk of conversion rates and intraoperative bleeding in women who are obese compared with other modes of hysterectomy.

Workplace absenteeism amongst patients undergoing open vs. robotic radical prostatectomy, hysterectomy, and partial colectomy

BACKGROUND

There is controversy regarding the widespread uptake of robotic surgery across several surgical disciplines. While it has been shown to confer clinical benefits such as decreased blood loss and shorter hospital stays, some argue that the benefits of this technology do not outweigh its high cost. We performed a retrospective insurance-based analysis to investigate how undergoing robotic surgery, compared to open surgery, may impact the time in which an employed individual returns to work after undergoing major surgery.

METHODS

We identified a cohort of US adults with employer-sponsored insurance using claims data from the MarketScan database who underwent either open or robotic radical prostatectomy, hysterectomy/myomectomy, and partial colectomy from 2012 to 2016. We performed multiple regression models incorporating propensity scores to assess the effect of robotic vs. open surgery on the number of absent days from work, adjusting for demographic characteristics and baseline absenteeism.

RESULTS

In a cohort of 1157 individuals with employer-sponsored insurance, those undergoing open surgery, compared to robotic surgery, had 9.9 more absent workdays for radical prostatectomy (95%CI 5.0 to 14.7, p < 0.001), 25.3 for hysterectomy/myomectomy (95%CI 11.0-39.6, p < 0.001), and 29.8 for partial colectomy (95%CI 14.8-44.8, p < 0.001) CONCLUSION: For the three major procedures studied, robotic surgery was associated with fewer missed days from work compared to open surgery. This information helps payers, patients, and providers better understand some of the indirect benefits of robotic surgery relative to its cost.

Risk Factors for Impaired Patient-Reported Satisfaction and Increased Length of Hospital Stay Following Hysterectomy on Benign Indications in Premenopausal Women: a Study From the Swedish National Register for Gynecological Surgery

Introduction The aims of the study were to evaluate the impact of intra- and postoperative complications on satisfaction one year after hysterectomy for benign conditions, to determine risk factors for low patient satisfaction and to analyze whether complications were associated with the length of hospital stay.

Material and Methods A retrospective study of 27 938 women from the Swedish National Register for Gynecological Surgery undergoing hysterectomy for benign conditions between January 2004 and June 2016. Data were obtained from prospectively collected pre-, peri- and postoperative forms. Statistical analyses were performed using multivariable logistic regression models. Crude and adjusted odds ratios and 95% confidence intervals are presented.

Results More than 90% were satisfied with the hysterectomy. Dissatisfaction was associated with complications. Pelvic pain as indication, preoperatively having less expectations to get rid of symptoms or being alleviated from surgery, and current smoking were also risk factors for low patient satisfaction. Vaginal and abdominal subtotal hysterectomies were associated with high satisfaction. Occurrence of complications intra- and postoperatively before discharge was associated with increased length of hospital stay, as well as occurrence and severity of complications reported after discharge from hospital.

Conclusions Complications were strongly associated with lower patient satisfaction. Preoperative expectations of surgery, indication, mode of surgery and life-style factors had impact on the satisfaction. Patient-centered information to ensure realistic expectations and prevention of complications seem to be essential to gain optimal patient satisfaction with surgery.

Reduced Complications Following Implementation of Laparoscopic Hysterectomy: A Danish Population-based Cohort Study of Minimally Invasive Benign Gynecologic Surgery between 2004 and 2018

STUDY OBJECTIVE

To monitor and report nationwide changes in the rates of and complications after different methods for benign hysterectomy, operative hysteroscopy, myomectomy, and embolization in Denmark. To report the national mortality after benign hysterectomy DESIGN: National prospective, observational cohort study.

SETTING

The Danish Hysterectomy and Hysteroscopy Database.

PATIENTS

Women undergoing surgery for benign gynecologic diseases: 64 818 hysterectomies, 84 175 hysteroscopies, 4016 myomectomies, and 1209 embolizations in Denmark between 2004 and 2018.

INTERVENTIONS

National meetings with representatives from all departments, annual working reports of institutional complication rates, workshops, and national guideline initiative to improve minimally invasive surgical methods.

MEASUREMENTS AND MAIN RESULTS

Rates of the different methods and complications after each method with follow-up to 5 years as recorded by the database directly in the National Patient Registry. Nationwide, a decline in the use of hysterectomy, myomectomy, embolizations, and endometrial ablation. The total short-term complications were 9.8%, 7.5%, 8.9%, and 2.7% respectively, however, with a persistent risk of approximately 20% for recurrent operations within 5 years after endometrial ablation. Initially, we urged for increased use of vaginal hysterectomy, but only reached 36%. From 2010, we urged for reducing abdominal hysterectomies by implementing laparoscopic hysterectomy and reached 72% laparoscopic and robotic procedures. Since 2015, we used coring or contained morcellation for removal of large uterus at laparoscopic hysterectomy. The major and minor complication rates (modified Clavien-Dindo classification) were reduced significantly from 8.1% to 4.1% and 9.9% to 5.7% respectively. Mortality after benign hysterectomy was 0.27‰. The odds ratio for major complications after abdominal hysterectomy was 1.66 (1.52-1.81) compared to minimally invasive hysterectomy independent of the length of stay, high-volume departments, indications, comorbidity, age, and calendar year.

CONCLUSION

Fifteen years with a national database has resulted in a marked quality improvement. Denmark has 85% minimally invasive hysterectomies and has reduced the number of major complications by 50%.