Background: Hysterectomy is one of the most common gynecological surgical procedures for benign conditions. In clinical practice, the choice of approach is often influenced by technology availability, leading to selection bias rather than to a decision based on standardized clinical criteria. The study aims to propose a standardized decision-making algorithm, based on objective clinical criteria, for selecting the surgical approach in total hysterectomy. Methods: This is a prospective, observational, analytical study conducted from November 2021 to June 2025, including a cohort of 332 patients who underwent total hysterectomy (LH, VH, AH) for benign gynecological pathology at two major centers in Bucharest. We proposed a decision algorithm based on the results obtained from predictive modelling and the quantified risk factors. Results: The choice of surgical approach is a critical factor in hematological stability, and the presence of comorbidities was associated with the type of approach (p < 0.001). Patients without comorbidities predominantly benefited from laparoscopy (48.85%), but as the anesthetic risk increased (ASA III and IV), the vaginal or abdominal routes were preferred. Conclusions: The convergence of these elements suggests that such a tool can standardize therapeutic decisions and improve the efficiency of interventions, offering a modern and predictable framework for gynecological surgery.

Background: Hysterectomy is a prevalent gynecological procedure and ensuring appropriate use of minimally invasive approaches is essential to enhance the value and quality of care. The aim of this study was to evaluate, for the first time in a Romanian real-world cohort, the factors influencing the final choice of surgical route for hysterectomy and the subsequent impact on postoperative hospitalization. Methods: This is a retrospective analytical observational study conducted over a 4 year period (2021- 2025). The database comprised 961 cases of hysterectomy performed for benign gynecological conditions using laparoscopic (LH), abdominal (AH) and vaginal (VH) approaches in two tertiary centers. Results: The previously developed decision algorithm was implemented in a selected subgroup of approximately 332 (34,54%) patients, while the remaining 629 (65,45%) hysterectomies were performed according to surgeon preference or institutional resource availability. The mean duration of hospitalization of the entire lot was 6.88 days (SD= 2.70). In laparoscopic surgery, deviation was not associated with prolonged hospitalization, with results indicating a null effect, OR 1.08 (95% CI 0.72–1.62). In contrast, in the abdominal cohort, deviation was strongly associated with prolonged LOS, with OR 2.76 (95% CI 1.75–4.40). Conclusions: Patient-related factors shape the theoretical suitability of a surgical approach, but operator and institution-related factors determine whether that option is realistically available. Strengthening training in minimally invasive surgery across all clinics could reduce selection bias.

Background: Hysterectomy is a prevalent gynecological procedure and ensuring appropriate use of minimally invasive approaches is essential to enhance the value and quality of care. The aim of this study was to investigate the gap between algorithm-guided recommendations and routine surgical practice in a Romanian real-world cohort by identifying non-clinical factors associated with deviation from the algorithm, and assessing its impact on postoperative hospitalization. Methods: This is a retrospective analytical observational study conducted over a 4-year period (2021–2025). The database comprised 961 cases of hysterectomy performed for benign gynecological conditions using laparoscopic, abdominal and vaginal approaches in two tertiary centers. Results: The previously developed decision algorithm was implemented in a selected subgroup of approximately 332 (34.54%) patients, while the remaining 629 (65.45%) hysterectomies were performed according to surgeon preference or institutional resource availability. The mean duration of hospitalization of the entire lot was 6.88 days (SD = 2.70). In laparoscopic surgery, deviation was not associated with prolonged hospitalization, with results indicating a null effect, OR 1.08 (95% CI 0.72–1.62). In contrast, in the abdominal cohort, deviation was strongly associated with prolonged LOS, with OR 2.76 (95% CI 1.75–4.40). Conclusions: Patient-related factors shape the theoretical suitability of a surgical approach, but operator- and institution-related factors determine whether that option is realistically available. Strengthening training in minimally invasive surgery across all clinics could reduce selection bias.