OBJECTIVE To examine the use of inpatient hysterectomy and explore changes in the use of various routes of hysterectomy and patterns of referral. METHODS The Nationwide Inpatient Sample was used to identify all women aged 18 years or older who underwent inpatient hysterectomy between 1998 and 2010. Weighted estimates of national trends were calculated and the number of procedures performed estimated. Trends in hospital volume and across hospital characteristics were examined. RESULTS After weighting, we identified a total 7,438,452 women who underwent inpatient hysterectomy between 1998 and 2010. The number of hysterectomies performed annually rose from 543,812 in 1998 to a peak of 681,234 in 2002; it then declined consistently annually and reached 433,621 cases in 2010. Overall, 247,973 (36.4%) fewer hysterectomies were performed in 2010 compared with 2002. From 2002 to 2010 the number of hysterectomies performed for each of the following indications declined: leiomyoma (−47.6%), abnormal bleeding (−28.9%), benign ovarian mass (−63.1%), endometriosis (−65.3%), and pelvic organ prolapse (−39.4%). The median hospital case volume decreased from 83 procedures per year in 2002 to 50 cases per year in 2010 (P<.001). CONCLUSION The number of inpatient hysterectomies performed in the United States has declined substantially over the past decade. The median number of hysterectomies per hospital has declined likewise by more than 40%. LEVEL OF EVIDENCE III

YSTERECTOMY FOR BENIGN gynecologic disease is one of the most commonly performed procedures for women. Overall, 1 in 9 women in the United States will undergo the procedure during her lifetime. 1-3 While hysterectomy has traditionally been performed abdominally via laparotomy, vaginally, or by laparoscopy, robotically assisted hysterectomy has been introduced as an alternative minimally invasive approach to hysterectomy. 1,2 The robotic surgical platform received approval from the US Food and Drug Administration in 2005 for the performance of gynecologic procedures and allows a surgeon to perform the procedure at a remote console. 3 Potential benefits of robotic surgery include increased range of motion with the instrumentation, 3-dimensional stereoscopic visualization, and improved ergonomics for the operating surgeon. 3,4 Unlike other procedures such For editorial comment see p 721.

Retrorectal tumors remain a diagnostic and therapeutic challenge. Pain, male gender, and advanced age increase the likelihood of malignancy. Various imaging modalities are useful for planning resection but cannot establish a definitive diagnosis. Whereas benign retrorectal tumors can be completely resected, curative resection of malignant retrorectal tumors remains difficult.

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