Reason Behind the Route: Qualitative Investigation of Surgeon’s Decision-making Regarding Route of Benign Hysterectomy

INTRODUCTION: Vaginal hysterectomy rates are decreasing, despite their association with fewer complications and greater cost-effectiveness compared to other minimally invasive techniques. There are many suspected barriers to the performance of vaginal hysterectomy. However, data related to provider decision-making is lacking. Identifying modifiable factors influencing surgeons’ decision-making regarding route of hysterectomy could have substantial public health impact. OBJECTIVE: To identify barriers and facilitators to the performance of vaginal hysterectomy among non-fellowship-trained gynecologic surgeons in the first 10 years of independent practice. METHODS: Semi-structured in-depth interviews were conducted with non-fellowship-trained specialists in general obstetrics and gynecology performing hysterectomies for benign indications within the United States. Participants were required to have performed at least 5 hysterectomies (any route) as the attending surgeon within the last year, completed training within 10 years of the interview, and complete a demographic questionnaire prior to the interview. Interviews were completed over a video-conferencing platform and were recorded, transcribed, and de-identified. Interviewers consisted of 3 fellowship-trained obstetrician–gynecologists (2 urogynecology and reconstructive pelvic surgery, 1 minimally invasive gynecologic surgery). The transcripts were independently coded by 2 coders and analyzed via framework matrix analysis. No interviewers coded their own transcripts. Themes were identified overall, and comparisons were made between two strata: 1) participants who self-identified as being in academic versus non-academic practice; and 2) participants who self-reported completing 0 vaginal hysterectomies in the last year versus participants who completed at least 1 vaginal hysterectomy in the last year. RESULTS: From August 2024 through June 2025, 16 individual in-depth interviews were completed. There were no systematic differences noted in the data based on interviewer or coder. Interviewee characteristics are noted in Table 1. All but one participant endorsed completing 60% or more of their hysterectomies in the last year laparoscopically, and 50% (8/16) indicated that they performed 0 vaginal hysterectomies in the last year. Participant age ranged from 32 to 42 (median 34), and year of residency training completion ranged from 2014 to 2023 (median 2021). Themes related to decisions regarding surgical approach were identified: training experience, patient population, personal confidence, and access to mentorship after completing residency. Barriers to performance of vaginal hysterectomy included: limited exposure during training, perceived lack of appropriate patient candidates in current practice, fear of complications related to decreased visualization or low volume, and that benefits of a vaginal over laparoscopic approach were negligible (Figure 1). Facilitators supporting performance of vaginal hysterectomy included training experiences that involved vaginal hysterectomies performed by general obstetrician–gynecologists and the availability of mentorship, particularly at the beginning of independent practice (Figure 2). Interviewees in the academic strata endorsed barriers, including difficulty teaching vaginal hysterectomy compared to laparoscopic hysterectomy, often related to perceived visualization. Academic providers endorsed feeling it was their duty to perpetuate the practice of vaginal. CONCLUSIONS: Possible barriers to performance of vaginal hysterectomy include volume during residency training, perceived lack of appropriate patient candidates, and fear of complications. Learning vaginal hysterectomy from specialists in general obstetrics and gynecology and mentorship, particularly at the beginning of independent practice, are possible facilitators.Figure 1Table 1