Objective
The objective of the study was to describe trends in hysterectomy route at a large tertiary center.
Study Design
We reviewed all hysterectomies performed at Magee-Womens Hospital from 2000 to 2010. This database was chosen over larger national surveys because it has been tracking laparoscopic procedures since 2000, well before laparoscopic hysterectomy International Classification of Diseases , ninth revision (ICD-9) procedure codes were developed.
Results
There were 13,973 patients included who underwent hysterectomy at Magee-Womens Hospital. In 2000, 3.3% were laparoscopic (LH), 74.5% abdominal (AH), and 22.2% vaginal hysterectomy (VH). By 2010, LH represented 43.5%, AH 36.3%, VH 17.2%, and 3.0% laparoscopic converted to open (LH→AH). Hysterectomies performed for gynecological malignancy represented 24.4% of cases. The average length of stay for benign LH and VH, 1.0 ± 1.0 and 1.6 ± 1.0 days respectively, was significantly shorter than the average 3.1 ± 2.3 day stay associated with AH ( P < .001). The average patient age was 46.9 ± 10.9 years for LH, 51.5 ± 12.1 years for AH, and 51.7 ± 14.1 years for VH, and over the study period there was a significant trend of increasing patient age (b1 = 0.517, 0.583, and 0.513, respectively [ P < .001 for all]).
Conclusion
The percentage of LH increased over the last decade and by 2010 had surpassed AH. The 43.4% LH rate in 2010 is much higher than previously reported in national surveys. This likely is due to an increase in the number of laparoscopic procedures being performed over the last few years as well as the ability of our study to capture LH prior to development of appropriate ICD-9 procedure codes. Our unique ability to determine hysterectomy route, which predates appropriate coding, may provide a more accurate characterization of hysterectomy trends.
Approximately 494,000 hysterectomies are performed annually in the United States, making this procedure one of the most commonly performed in women of reproductive age. Over the last 3 decades, technological advances in surgical equipment and training have allowed for minimally invasive approaches to hysterectomy. The first case of laparoscopic-assisted hysterectomy was published by Reich et al in 1989. Since that time, practice patterns have changed as laparoscopic approaches to hysterectomy have increased throughout the world.
Laparoscopic and vaginal approaches to hysterectomy are preferred to abdominal approaches because they result in shorter hospital stays, faster return to normal activities, and fewer infections. Laparoscopic-assisted vaginal, total laparoscopic, and robotically assisted laparoscopic hysterectomies are being performed more commonly as surgeons become trained with the necessary surgical skills and as the technology becomes more widely accessible. Laparoscopic hysterectomy has been associated with a higher risk of urinary tract injury compared with abdominal and vaginal procedures, and the risks of these minimally invasive approaches must be balanced with the benefits.
Over the last 20 years, the proportion of laparoscopically performed hysterectomies has increased, whereas abdominal hysterectomies have decreased. The reported rate of laparoscopic hysterectomy in 1990 was only 0.3%, whereas the abdominal and vaginal approaches represented 73.6% and 24.4% of cases, respectively. In the 2005 Nationwide Inpatient Sample, 14% of hysterectomies were laparoscopic, 64% abdominal, and 22% vaginal. These data, however, are limited by the fact that the code for a total laparoscopic hysterectomy was not in use until 2006.
Although laparoscopic hysterectomies have been performed for many years, International Classification of Diseases , ninth revision (ICD-9) procedure codes have only recently become available ( Table 1 ). Coding for laparoscopic-assisted vaginal hysterectomy has been available since 1996, whereas the code for total laparoscopic hysterectomy was not developed until 2006. Prior studies have described trends in gynecological surgical procedures using large databases, such as the National Hospital Discharge Survey or the Nationwide Inpatient Sample; however, these databases provide limited information on surgical approach to hysterectomy because many of the laparoscopic codes were not yet developed.
| Code | Procedure | Effective date a | Previous code |
|---|---|---|---|
| 68.31 | Laparoscopic supracervical hysterectomy | 2003 | 68.3 |
| 68.39 | Subtotal abdominal hysterectomy | 2003 | 68.3 |
| 68.41 | Laparoscopic total abdominal hysterectomy | 2006 | 68.4 |
| 68.49 | Total abdominal hysterectomy | 2006 | 68.4 |
| 68.51 | Laparoscopically assisted vaginal hysterectomy | 1996 | 68.5 |
| 68.59 | Total vaginal hysterectomy | 1996 | 68.5 |
| 68.61 | Laparoscopic radical abdominal hysterectomy | 2006 | 68.6 |
| 68.69 | Modified radical abdominal hysterectomy | 2006 | 68.6 |
| 68.71 | Laparoscopic radical vaginal hysterectomy | 2006 | 68.7 |
| 68.79 | Radical vaginal hysterectomy | 2006 | 68.7 |
| 17.42 | Robotic-assisted procedure | 2008 | None |
| V64.41 | Laparoscopic procedure converted to open | 2004 | None |
Magee-Womens Hospital, a tertiary care hospital with a combination of academic and private gynecologists and an active minimally invasive gynecologic surgery division, had been tracking laparoscopic procedures via intraoperative reports prior to the development of ICD-9 procedure codes for laparoscopic procedures. Given the availability of this information in our institution’s database, the aim of this study was to assess changes in hysterectomy route over time and identify differences in characteristics of patients undergoing laparoscopic hysterectomy compared to abdominal or vaginal routes.
Materials and Methods
Deidentified data were obtained from the University of Pittsburgh Medical Center, Magee-Womens Hospital, coding department for the years 2000-2010. All women with an ICD-9 procedure code indicating that a hysterectomy was performed during a hospital admission were included in this study. Additional data and associated information including patient date of birth, race, marital status, insurance type, date of admission and discharge, discharge diagnoses, and concomitant procedures were collected. Because this database did not contain personal identifiers, this analysis was considered exempt by the University of Pittsburgh Institutional Review Board.
Exclusion criteria included missing data and hysterectomy associated with either cesarean delivery or pelvic exenteration because both can be performed only with abdominal approaches. Using pregnancy-specific V27 ICD-9 procedure codes, 118 hysterectomies performed at the time of delivery were excluded from the dataset. Pelvic exenteration (ICD-9 procedure code 68.8) was not included in the initial hysterectomy data obtained from the coding department. Sixteen patients lacked laparoscopic hospital coding data and had 3-digit ICD-9 procedure codes making determination of the route of hysterectomy impossible and were thus excluded.
The initial sample included 14,107 women. After excluding those with unidentifiable hysterectomy routes and those undergoing cesarean hysterectomy or exenteration, the total number of women in the study was 13,973 ( Figure 1 ). Subjects with code v64.41 (154 patients), indicating that a procedure was converted from laparoscopic to open, were analyzed separately. ICD-9 procedure codes for hysterectomy have changed over time from 3-digit codes to 4-digit codes, with those ending in 1 indicating laparoscopic procedures and those ending in 9 indicating open or vaginal procedures. When 4-digit laparoscopic ICD-9 procedure codes were available, these were used to categorize hysterectomies as laparoscopic, open, or vaginal and were used to confirm Magee-Womens Hospital (MWH) laparoscopic coding records.
In our study period, many of the procedures were performed prior to the development of laparoscopic ICD-9 procedure codes. When only 3-digit procedure codes were available, the route of hysterectomy was differentiated by the MWH laparoscopic code (5409 subjects). The 4-digit ICD-9 procedure code was used to identify hysterectomy route for 8264 patients. There were 146 subjects with discrepancies between the 4-digit ICD-9 procedure codes and the MWH laparoscopic codes. Figure 1 demonstrates how these discrepant codes were analyzed.
Patients were categorized into 4 groups based on ICD-9 and MWH procedure codes: abdominal (AH), vaginal (VH), laparoscopic (LH), and laparoscopic converted to abdominal (LH→AH). ICD-9 procedure codes used were as follows: AH (68.39, subtotal abdominal hysterectomy; 68.49, total abdominal hysterectomy; 68.69, radical abdominal hysterectomy); VH (68.59, total vaginal hysterectomy; 68.79, radical vaginal hysterectomy); LH (68.31, laparoscopic supracervical hysterectomy; 68.41, total laparoscopic hysterectomy; 68.51, laparoscopic-assisted vaginal hysterectomy; 68.61, laparoscopic radical hysterectomy; 68.71, laparoscopic radical vaginal hysterectomy); and LH→AH (v64.41, laparoscopic converted to open). Robotic hysterectomies were considered laparoscopic cases and were not analyzed separately because Magee-Womens Hospital did not acquire a robot until late 2009. Subjects who sustained a bladder or ureteral injury at the time of surgery were identified by ICD-9 procedure codes (nonobstetric bladder injury: 57.81, 57.82, and 57.89; ureteral injury: 56.74, 56.75, 56.79, 56.82-86, and 56.89).
The primary indication for the hysterectomy was considered to be the first diagnosis code. These ICD-9 diagnosis codes were grouped into the following categories: dysfunctional uterine bleeding (626), dysmenorrhea (625.0, 625.3, 625.5), endometriosis (617), fibroids (218), gynecologic malignancy (179-184, 630, 233, 621.3), pelvic organ prolapse/incontinence (618, 625.6, 788), and other. Procedures performed concomitantly at the time of hysterectomy included anterior/posterior repair (70.5), colpopexy (70.77-78), cystoscopy (57.32), salpingo-oophorectomy–bilateral or unilateral (65), and urethral suspension including traditional pubovaginal and midurethral slings (59.4-5). Obesity diagnosis codes (278.00-02) were also analyzed.
Continuous variables were compared using a Mann-Whitney U test or a Kruskal-Wallis test. Variables with counts were compared using a χ 2 test. Linear trends of rates, age, and average length of stay (LOS) during the study period were tested using linear regression models. Outcomes with P < .05 were considered significant. All analyses were conducted with SPSS (version 17; SPSS Inc, Chicago, IL).
Results
During 2000-2010, 13,973 women underwent hysterectomy at University of Pittsburgh Medical Center, Magee-Womens Hospital, which met our inclusion criteria. The demographics of this population are listed in Table 2 . In 2000, 3.3% were LH, 74.5% were AH, and 22.2% were VH. By 2010, LH represented 43.5%, AH 36.3%, VH 17.2%, and LH→AH 3.0%. The majority of hysterectomies were performed for the primary diagnosis of fibroids (29.5%) followed by gynecological cancer (24.4%) and pelvic organ prolapse (14.4%). Uterine fibroids were the most common diagnosis for hysterectomies performed laparoscopically (27.4%), whereas pelvic organ prolapse/incontinence was the most common indication for the vaginal approach (49.4%). Gynecological malignancy and fibroids were the most common primary diagnoses for AH (32.5% and 32.8%, respectively). For procedures converted from laparoscopic to open, gynecological malignancy was the most common primary diagnosis (37.7%).
| Characteristic | Laparoscopic (n = 2839) | Open (n = 8611) | Vaginal (n = 2769) | Laparoscopic converted to open (n = 154) |
|---|---|---|---|---|
| Mean age ± SD, y | 46.9 ± 10.9 | 51.5 ± 12.1 | 51.7 ± 14.1 | 51.8 ± 10.6 |
| Race, % | ||||
| White | 86.6 | 82.4 | 85.7 | 83.1 |
| Black | 9.5 | 13.7 | 11.3 | 15.6 |
| Other | 1.6 | 1.0 | 0.7 | 1.3 |
| Marital status, % | ||||
| Single | 18.8 | 20.9 | 13.5 | 24.7 |
| Married | 67.0 | 60.0 | 64.0 | 59.7 |
| Divorced | 8.6 | 8.3 | 9.9 | 6.5 |
| Other | 5.6 | 10.8 | 12.6 | 9.1 |
| Indication | ||||
| Benign, n (%) | 2316 (21.9) | 5541 (52.4) | 2615 (24.7) | 96 (0.9) |
| Malignancy, n (%) | 523 (15.4) | 2670 (78.4) | 154 (4.5) | 58 (1.7) |
Because different factors are considered when planning the surgical route of hysterectomy for gynecological malignancy and benign disease, separate trends were examined for these 2 diagnostic categories. For benign conditions (n = 10,568) in the year 2000, 3.3% cases were LH, 69.7% AH, and 27% VH. By the year 2010, 46.2% of cases were LH, 28.6% AH, 23.1% VH, and 2.1% LH→AH ( Figure 2 ). For gynecological malignancy (n = 3405) in the year 2000, 3.4% cases were LH, 93.1% AH, and 3.4% VH. In the year 2010, 36.8% of cases were LH, 55.2% AH, 2.8% VH, and 5.1% LH→AH ( Figure 3 ).
