uterine-morcellators-78958-157209The preferred route for a hysterectomy is vaginal. This means the entire surgery is done through the vagina with no incisions in the abdomen of any kind. The joke among surgeons is that it is a bit like taking a car apart through the muffler. While doing surgery entirely through the vagina may sound highly complex, it’s really just like any surgery. A vaginal hysterectomy done correctly it is an elegant, neat procedure with excellent safety and very quick recovery. If I needed a hysterectomy and I was a candidate (most women are) I would choose a vaginal hysterectomy.

But don’t take my word for it. The American Congress of Obstetricians and Gynecologists (ACOG) also says that vaginal hysterectomy is the route of choice (for non cancer surgery). They also agree with the science that says not only is it the safest (or as safe) as any other route but also the least expensive. Most patients who have vaginal hysterectomy are able to go home the next day and the recovery is typically very smooth. In my personal experience patients are amazed at how quickly they recover.

Despite the mountain of evidence based medicine supporting vaginal hysterectomy and the recommendations from ACOG many hysterectomies are not performed this way. A lot of surgeons opt for the far more expensive approach using laparoscopic surgery (operating telescopes), some also use a robot to assist with their laparoscopic technique (even more expensive), and a few still opt for traditional open surgery (think big scar, like a c-section).

Why would surgeons choose a more expensive and not better by any medical metric approach?

Some of it is because they were swayed by the manufacturers of laparoscopic equipment or the DaVinci gang (the laparoscopic robot folks). Once you exclusively do a surgery one way for many years you lose skills.

Some doctors never learn to do vaginal hysterectomies. Don’t really know why that happens, but it’s probably a failing of many residencies. I had done far more than 100 when I finished my 5 year residency, today’s graduates (for a variety or reasons) are probably lucky to have done 10. Most urogynecologists (gynecologists who do an additional 3 years of training) are very skilled in vaginal hysterectomy.

Some doctors never master laparoscopic surgery without the aid of the robot and often these surgeons never mastered vaginal surgery either or they abandoned vaginal surgery because they were desperate to accumulate laparoscopic cases to practice with the robot.

Some (most) hospitals push their robot, after all they have to pay for it. Robots add a lost of expense to gynecologic surgery with zero return. But hey, marketing departments loooove robots. They are so cool. And a lot of doctors start to believe their own hype that robots + them = awesome.

Some doctors erroneously think that leaving behind the cervix after a hysterectomy confers some health advantages (the cervix has to come out with a vaginal hysterectomy). Sigh.

What ever the reason for not being able to do a vaginal hysterectony, skills or a failure to understand the medical evidence or the lure of cool toys or fancy marketing, some surgeons don’t want to refer to a surgeon who can do a vaginal hysterectomy because of lost money or a perceived loss of prestige.

It really doesn’t surprise me that UnitedHealth announced they plan to preferentially pay for vaginal hysterectomies which are less expensive and at least as good if not better than other approaches. A hysterectomy not done vaginally after April 6th under their health plan will require prior authorization. How smoothly that will go remains to be seen.

Some of this may be a backlash against power morcellators (devices that used through an operating telescope that chop the uterus into tiny pieces so it can be removed laparscopically), but regardless of the reason I applaud the decision (and am frankly a little surprised that it took this long). If your surgeon won’t or can’t do the recommended technique (vaginal hysterectomy) she or he should have to explain why the procedure requires a non vaginal route. Some reasons are legitimate (for example, a uterus the size of a 30 week pregnancy can’t really be done vaginally), however, if you take cancer out of the picture more often than not a hysterectomy can be done vaginally by a surgeon who is well-trained to do the procedure.

If gynecologists can’t do the right thing and their professional society can’t convince them to do the right thing they should not be surprised when a third party steps in and helps to point them in the right direction.

It’s just a sad day for gynecology when doing the right thing requires nudging from an insurance company.

Join the Conversation


  1. Yes it is a sad day but we need more of them! As much as I hate insurance companies, someone has to put the brakes on “The DaVinci Gang.” (Nice coinage by the way, may I steal it?). Medical “technology” is the biggest driver of cost increases, but, more importantly, often adds no benefit and causes some harm. Finding skilled surgeons who can do something without a robot or laparoscope is becoming more difficult by the day.

    Thanks for the enlightenment on vaginal hysterectomies.

    Dr. Nick

  2. I thought about getting a vaginal hysterectomy before I decided on the da Vinci. Dr. Jen, is it possible you could write some of the pros & cons of vaginal hyst and da Vinci (besides cost)?

    1. I am an Ob/Gyn trained and experienced in vaginal surgery (TVH, sacrospinous ligament suspension, paravaginal repair, etc.). I agree with Dr Gunter on this. Other cons besides cost to robots? They involve 5 incisions that, when added up, total more incision than an abdominal hysterectomy. Recovery is usually quicker with vaginal and robots don’t decrease recovery time significantly compared with abdominal (outside of biased studies). Robotics place the patient at a deeper angle than standard laparoscopy; coupled with taking longer to do, this deep angle (deep Trendelenburg) may expose the central nervous system to risk and problems. I have seen it in surgery done by colleagues. The light on a robotic is hotter than the fiberoptic on a standard laparoscopy and is more likely to cause bowel injury. The vaginal cuffs are more likely to dehisce (fall apart), resulting in bowels coming out through the vagina. I have this happen to wives of friends who opted for the almighty robot and it’s reported in literature. The least likely complication rates for hysterectomy are abdominal, vaginal, laparoscopic assisted vaginal, total laparoscopic and robotic… in that order. Does all this suffice for reasons besides cost?

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