In this randomized controlled trial, postoperative visit satisfaction of patients evaluated via telehealth was noninferior to the satisfaction of patients seen in the clinic 4 weeks after minimally invasive hysterectomy. Unplanned clinic visits and ED visits did not differ between groups, nor did 90-day postoperative complications.

Historically, the pelvic exam was considered to be an essential component of the postoperative visit, in theory to detect asymptomatic vaginal cuff dehiscence. However, Caskey et al. demonstrated in a retrospective cohort that vaginal cuff exam after laparoscopic hysterectomy was neither predictive of nor protective against the risk of future vaginal cuff dehiscence, obviating this indication for a postoperative pelvic exam [17]. Some surgeons performing prolapse repair at the time of hysterectomy may still choose to do a postoperative pelvic exam to establish a new baseline POP-Q in case a patient returns with recurrent prolapse concerns in the future. However, while this information may provide a data point for the surgeon analyzing the outcome of their repair, even rapidly recurrent prolapse does not prompt any action in the immediate postoperative period. Given that approximately 30% of patients may eventually require future surgery for recurrent prolapse, which should be determined by patient symptoms rather than by physician assessment of POP-Q, subjecting patients to a postoperative pelvic exam is a futile endeavor by surgeons [18].

This debunking of the necessity of the postoperative pelvic exam raised questions about the necessity of an in-person postoperative visit, which prompted the development of this trial. In our investigation, we found no significant differences in overall patient satisfaction between the telehealth and clinic groups. Patients in both groups reported high levels of satisfaction with their postoperative visits, which aligns with previous research indicating comparable levels of satisfaction between telehealth and in-person care across various medical specialties. These findings suggest that telehealth may offer a satisfactory alternative for postoperative care after minimally invasive hysterectomy, providing patients with greater convenience without compromising satisfaction.

Furthermore, our study revealed no difference in postoperative complication rates and no clinically significant differences in unplanned events. The low rates of postoperative complications observed in both groups underscore the rarity of adverse outcomes after minimally invasive hysterectomy and the safety and effectiveness of telehealth for monitoring patients when counseled appropriately. Interestingly, the majority of patients had at least one unplanned encounter after hysterectomy, regardless of their type of postoperative visit. This is consistent with prior findings from Lua-Mailland et al., who noted that 75% of patients had at least one unplanned encounter within 6 weeks of apical prolapse repair [19]. The vast majority of unplanned encounters in our study were patient calls or EMR messages. While all patients are provided with comprehensive discharge instructions, which include recommended medication schedules, information about wound care, common benign symptoms after hysterectomy, and reasons to call the clinic or report to the emergency department, we found that most calls and EMR messages were related to information covered in the discharge instructions. This may indicate a lack of clarity, a lack of patient comprehension, or distrust in the information provided. Further research is needed to elucidate whether an improved method of conveying postoperative information to patients might reduce healthcare utilization. Additionally, further guidance on patient symptoms necessitating in-person evaluation would help standardize postoperative care when implementing a telehealth-based care plan.

Of note, the largest standard deviations in the satisfaction survey were observed in response to whether patients would have preferred the opposite type of visit than the one they were assigned. Patients in both groups were nearly equally unlikely to prefer the other type of appointment, demonstrating the general acceptability of both types of postoperative visit, but the large standard deviations indicate that some patients in each group would have preferred the opposite visit type. This highlights the important point that patients may have a variety of personal reasons for their visit preferences, which may include travel time, availability of transportation, mental health concerns, lack of support, reluctance or embarrassment about pelvic exams, a desire for reassurance from a surgeon, or any number of other rationales. In our experience, patients who feel strongly about the type of postoperative visit they prefer will make it clear to their surgeon and those patients should be accommodated, even in a practice that defaults to a different type of postoperative visit. In this study, two patients from each group switched to the other type of postoperative visit prior to their appointment, suggesting that patients have reasons that may drive them toward either visit type.

Strengths of this study include its randomized controlled design, the racially and socioeconomically diverse patient population, and the range of approaches and indications for hysterectomy, including pelvic organ prolapse, abnormal uterine bleeding, fibroids, and gender incongruence. Another strength is the survey questions utilized, which were targeted specifically to patient experience with postoperative visits and written at a reading level accessible to patients with lower health literacy. Limitations include recruitment from a single academic medical center, the exclusion of non-English-speaking patients, the use of non-validated survey questions, and the fact that only one quarter of participants were aged 50 or older, which may limit the generalizability of the findings to older patients.

Future research in this area might explore the cost effectiveness of telehealth, methods of improving telehealth for non-English speaking patients, and further inquiry about postoperative patient communication. Interesting research from the Netherlands has demonstrated the value of eHealth programs in reducing pain and time to return to work in patients who underwent gynecologic surgery [20]. These promising results may herald a future where eHealth applications are used to facilitate personalized postoperative communication with patients without clinic staff involvement. Additionally, qualitative studies could provide valuable insights into patients’ perceptions and experiences of telehealth in the postoperative setting, informing the development of tailored interventions to optimize patient-centered care delivery. Finally, it would be prudent to develop a validated postoperative satisfaction questionnaire given the inadequacy of available validated tools to assess patient experience with postoperative care.

In conclusion, this study demonstrates that postoperative telehealth visits are a viable alternative to clinic visits for appropriate patients. Our findings contribute to a growing body of evidence on the role of telehealth in gynecologic surgery and provide valuable insights into patient experience with telehealth visits. Embracing telehealth in surgical care delivery has the potential to enhance patient satisfaction, improve healthcare accessibility, and optimize resource utilization in the postoperative period.