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Objective: To identify and evaluate surgical management of women with uterine fibroids. Design: Retrospective analysis of mandatory surgical data sent to the Institute for Quality Assurance. Setting: Data collection from 1998 to 2004 in Hesse, Germany. Patient(s): 34,814 women who underwent surgery for uterine fibroids. Intervention(s): Patients were treated with either myomectomy or hysterectomy. Main Outcome Measure(s): Statistical analysis of mandatory surgical parameters. Result(s): Altogether, 4975 (14.3%) women had myomectomies, and 29,839 (85.7%) had hysterectomies. Age was an important determinant of surgical procedure; hysterectomy was preferred for patients over 40 (odds ratio 4.3; 95% confidence interval: 4.1–4.5). Laparoscopic myomectomy rates increased from 25.9% in 1998 to 41.9% in 2004; during the same period, the proportion of conversion procedures and abdominal approaches fell from 15.6% to 2.9% and 38.9% to 30.9%, respectively. Intraoperative complication rates were similar for myomectomy (1.1%) and hysterectomy (1.0%), but postoperative complication rates were higher for hysterectomy (5.8%) than myomectomy (3.2%). Conclusion(s): The increasing use of endoscopic procedures was an important feature in this series and appeared to be safe. The reduction of conversion rates and intraoperative complications might be related to improvements in surgical skill. Acceptance of the benefits of endoscopic approaches seems to have promoted its steady growth as a primary surgical approach. [Copyright &y& Elsevier]