Current Commentary Considerations to Improve the Evidence-Based Use of Vaginal Hysterectomy in Benign Gynecology Michael Moen, MD, Andrew Walter, MD, Oz Harmanli, MD, Jeffrey Cornella, MD, Mikio Nihira, MD, MPH, Rajiv Gala, MD, Carl Zimmerman, MD, and Holly E. Richter, PhD, MD, for the Society of Gynecologic Surgeons Education Committee Vaginal hysterectomy fulfills the evidence-based require- ments as the preferred route of hysterectomy for benign gynecologic disease. Despite proven safety and effec- tiveness, the vaginal approach for hysterectomy has been and remains underused in surgical practice. Factors associated with underuse of vaginal hysterectomy include challenges during residency training, decreasing case numbers among practicing gynecologists, and lack of awareness of evidence supporting vaginal hysterec- tomy. Strategies to improve resident training and pro- mote collaboration and referral among practicing physicians and increasing awareness of evidence sup- porting vaginal hysterectomy can improve the primary use of this hysterectomy approach. (Obstet Gynecol 2014;124:585–8) DOI: 10.1097/AOG.0000000000000398 F or more than a century, the two basic approaches for hysterectomy were vaginal and abdominal, with vaginal hysterectomy offering several advantages over the abdominal approach (total abdominal hysterectomy [TAH]) in terms of morbidity. During the past 25 years, various alternative endoscopic techniques for minimally invasive hysterectomy have been introduced, including laparoscopically assisted vaginal hysterectomy, total lap- aroscopic hysterectomy, and laparoscopic supracervical hysterectomy. Most recently, microprocessor-based remote-controlled endoscopic assistance (commonly referred to as “robotics”) has been introduced, leading to the performance of robotic hysterectomy. Recent statistics indicate significant increases in the use of lap- aroscopic hysterectomy and robotic hysterectomy in treating benign gynecologic disease. 1 However, it must be recognized that the use of laparoscopic and robotic technologies has not been entirely evidence-based and has been associated with significant industry marketing. Improved visualization with endoscopic techniques has been claimed to be an important benefit of laparoscopic hysterectomy and robotic hysterectomy. However, there is level 1 evidence that in many, if not most, hysterectomies, the increased visualization with endoscopic ap- proaches offers no benefit and increases cost com- pared with vaginal hysterectomy. 2 Total laparoscopic hysterectomy, for example, costs on average $3,500 more per case and robotic hysterectomy more than $5,000 more per case than vaginal hysterectomy. 3 From an evidence-based perspective, vaginal hys- terectomy is the least invasive approach and is associated with shorter recovery time, fewer complica- tions, less cost, and better cosmetic results than other types of hysterectomy. 3,4 Position statements from the American College of Obstetricians and Gynecologists and the American Association of Gynecologic Laparos- copists endorse vaginal hysterectomy as the preferred route of hysterectomy for benign disease. 5,6 Despite the supporting scientific evidence, improved patient safety, and favorable economic From the Advocate Lutheran General Hospital, Park Ridge, Illinois; Kaiser Permanente–North Valley, Roseville, California; Tufts University School of Medicine, Boston, Massachusetts; the Mayo Clinic, Scottsdale, Arizona; the Uni- versity of Oklahoma College of Medicine, Oklahoma City, Oklahoma; the Uni- versity of Queensland Ochsner Clinical School, New Orleans, Louisiana; Vanderbilt University School of Medicine, Nashville, Tennessee; and the Depart- ment of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama. Corresponding author: Michael Moen, MD, 1875 Dempster Street, #665, Park Ridge, IL 60068; e-mail: michael.moen@advocatehealth.com. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14 VOL. 124, NO. 3, SEPTEMBER 2014 OBSTETRICS & GYNECOLOGY 585