Dr Einarsson is Associate Professor of Obstetrics and Gynecology, Harvard Medical School and Director, Division of Minimally Invasive Gynecologic Surgery Brigham and Women’s Hospital, Boston, Massachusetts. He is also a member of the Contemporary OB/GYN editorial board.
Hysterectomy is the most common nonobstetric surgical procedure performed on women, with 1 out of 9 women undergoing it in their lifetime. Recent reports have indicated a sharp decline in the number of hysterectomies performed annually in the United States. According to Wright et al,1 annual hysterectomy volume declined from 681,234 in 2002 to 433,621 cases in 2010. This was based on data from the National Inpatient Sample (NIS), which is the largest publicly available national inpatient care database and represents approximately 20% of discharges from hospitals within the United States. Another study from Desai et al reported further reduction in hysterectomy numbers in 2012, with only 311,820 cases performed that year based on query of data from the NIS.2 According to that report, abdominal hysterectomy (AH) accounted for 52.8% of cases, while vaginal hysterectomy (VH) accounted for 14.7% and laparoscopic hysterectomy (LH) for 32.4% of cases for all nonobstetric indications. The reduction in number of hysterectomies has been attributed to a variety of alternative uterine-sparing treatment options for uterine fibroids and abnormal uterine bleeding, which are the 2 leading indications for hysterectomy.
These estimates, however, may reflect only part of the picture. Databases most commonly used to monitor hysterectomy rates, including those maintained by the federal government such as NIS and privately maintained samples, do not account for hysterectomiesperformed in outpatient surgical centers. A report by Cohen et al in the July issue of Obstetrics & Gynecology sheds some light on this issue.3 The authors queried data from the US Healthcare Cost and Utilization Project State Ambulatory Surgery and Services Database (SASD). Thirty-five states contributed data to the SASD with 16 states reporting all key variables in question for 2011. Based on the observed numbers in those 16 states, extrapolation to nationwide estimates indicates that there are approximately 100,000 to 200,000 hysterectomies performed in an outpatient setting yearly. Furthermore, 81.5% of them are performed laparoscopically or robotically and 16% are performed transvaginally. The SASD administrators confirmed that there was no overlap between these data and the inpatient databases. Although the data were drawn from only 16 of 50 states, they represent 41% of US women aged 18 or older, according to 2010 Census data.
According to this new information, the reduction in number of hysterectomies appears be mainly caused by a shift in surgical venue rather than in absolute numbers. It is admittedly difficult to know the exact numbers of hysterectomies from any of these databases, but there are probably around 500,000 hysterectomies being performed annually in the United States. Further, the mode of access is now predominantly minimally invasive, which represents a significant shift from previous reports.1 If we assume that 150,000 hysterectomies are performed in ambulatory surgical centers with 81.5% of them being done laparoscopically/robotically and 16% transvaginally, then the proportion of mode of access can be estimated as shown in the Table.
These findings highlight the limitations of current understanding of hysterectomy volume and have important implications for resident education as well as medical device development. Although databases that are based on insurance data or hospital discharge information can be useful, they are limited in scope and often lack crucial information such as detailed perioperative outcomes and surgeon characteristics. The data we are looking at now are already several years old and may not accurately reflect current trends and realities. We need a more comprehensive prospective database to better understand what is actually happening in real time in our surgical environment. That would benefit researchers, policy makers, physicians, the US Food and Drug Administration, and medical device manufacturers. The AAGL is currently in the early phases of developing such a database and hopefully it will become a reality in the near future.
The apparent shift of hysterectomy volumes from hospitals to outpatient surgical centers has already impacted resident surgical volumes and will continue to do so. Residency program directors may have to respond by creating rotations at surgical centers, if possible, because it is likely that inpatient hysterectomy volumes will continue to decline. Medical device manufacturers partially base their cost projections and allocation of resources on case volume data. It is generally considered bad business to own a larger share of a shrinking market. The reality that hysterectomy volume is not decreasing as much as previously thought and that most of these cases are done laparoscopically or robotically may shift the attention of medical device companies further towards medical device innovation and development in this sector.
In summary, the total number of hysterectomies performed annually in the United States may have been grossly underestimated. Further, most hysterectomies are currently performed in a minimally invasive fashion – predominantly via the laparoscopic or robotic approach. That has important implications for policy makers, researchers, residency education, and medical device companies. A comprehensive prospective database of surgical procedures in gynecology is urgently needed.
1. Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu Yi-Shiang, Neugut AI, Hershman DL. Obstet Gynecol. 2013 August; 122(201):233-41.
2. Desai VB, Xu X. An update on inpatient hysterectomy routes in the United States. Am J Obstet Gynecol. 2015 Nov; 213(5):742-3.
3. Cohen SL, Ajao MO, Clark NV, Vitonis AF, Einarsson JI. Outpatient hysterectomy volume in the United States. Obstet Gynecol. 2017;130:130-7.