Exclusion Criteria: Endometrial > complex hyperplasia Other uterine cancer or suspicion for sarcoma Cervical cancer > 1A1 Ovarian/fallopian tube/primary peritoneal cancer Radical hysterectomy h/o of multiple cones – no cervix available Risk reducing surgery: BRCA+, personal history of breast cancer Emergent hysterectomy Cesarean hysterectomy Adnexal torsion Primarily adnexal indication for surgery or adnexal mass > 4cm Endometriosis Tuboovarian abscess Pelvic kidney Müllerian or uterine anomalies Concomitant antiincontinence procedure Prolapse other than pure uterine Mesh related surgery/excision Planned umbilical hernia repair affecting route choice Clinically indicated appendectomy Planned cholecystectomy Planned bowel surgery

Hysterectomy Algorithm

Hysterectomy indicated This algorithm is not for benign disease appropriate No Yes

Uterine Size ≤12 w (280 g)* Uterine Size 13-16 weeks

And Or Uterine Size ≥ 17 weeks

≤ 1 cesarean section (or laparotomy) Uterine Size ≤ 16 weeks with either

And ≥ 2 cesarean delivery (or laparotomy) Laparoscopic or Robotic Hysterectomy*** Adequate vaginal caliber, mobility, and Or descent in the office Inadequate vaginal access based on Or

caliber/descent/mobility in the office Abdominal Hysterectomy

Yes Vaginal Hysterectomy Exam under Anesthesia*

*Examination under anesthesia protocol: Uterus descends to halfway down the vagina and adequate Office Bimanual Examination Template ~Patient is under anesthesia and in vaginal caliber/access** Uterine size: weeks of gestation (<8 or

stirrups; doesn’t need to be prepped normal, 10, 12, 14, 16, 18, 20, 22 weeks…) No ~Bimanual examination by consultant Vaginal Caliber: narrow or adequate Laparoscopic or Robotic If unsure: Hysterectomy*** Uterine/cervix location: high or normal/prolapsed ~Use weighted speculum, tenaculum on the cervix and provide gentle traction. Uterine mobility: mobile or not mobile

~Dictate the exam in operative note If going to EUA in algorithm State in note if consultant believes vaginal hysterectomy is possible (likely, unlikely, **Or larger uteri when size ***After counseling patient on options or unsure) reduction techniques including of power morcellation and bivalving, coring, and morcellation transabdominal/transvaginal size Less invasive approaches will not be are technically feasible reduction techniques considered protocol deviation