Minimally Invasive Versus Open Total Hysterectomy: From Practice Variability to a Decision Algorithm

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.