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Laparoscopic and Robotic-Assisted Hysterectomy for Uterine Leiomyomas: A Comparison of Complications and Costs
Abstract
Objective:
Robotic surgery is increasingly being used for treatment of malignant and benign gynaecologic diseases. The purpose of our study is to compare patient perioperative complications and costs of laparoscopic versus robotic-assisted hysterectomy for uterine leiomyomas.
Methods:
A retrospective cohort study using the Nationwide Inpatient Sample database from the United States was conducted, comparing patients who underwent robotic-assisted hysterectomy and laparoscopic hysterectomy (total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy) for uterine fibroids between 2008 and 2012. Baseline characteristics were compared between the two groups, and logistic regression was used to compare postoperative outcomes between laparoscopic and robotic approaches. Direct costs were compared between the two groups using linear regression models.
Results:
Over a five-year period, the total number of hysterectomies performed increased. Patients undergoing robotic hysterectomy were older and had more comorbidities. In adjusted analyses, women who underwent robotic surgery were more likely to have respiratory failure (0.71% vs. 0.39%; P < 0.0108), postoperative fever (1.05% vs. 0.67%, P < 0.0002), and ileus (1.76% vs. 1.3%; P < 0.0060), and less likely to require transfusions (3.4% vs. 3.96%; P < 0.0037). Robotic surgery was consistently more expensive, with a median cost of 23 753.00 for laparoscopic hysterectomy.
Conclusion:
While there are only slight differences in postoperative complications between laparoscopic-assisted hysterectomy and robotic-assisted hysterectomy, robotic-assisted hysterectomy is associated with considerably greater direct costs. Unless specific indications for robotic-assisted hysterectomy exist, laparoscopic-assisted hysterectomy should be the preferred approach for minimally invasive surgical treatment of leiomyomas.
... Early postoperative complications were mainly wound and urinary tract infections, while long-term postoperative complications included lymphatic drainage disorders [19]. Meanwhile, Ngan et al. suggest that some postoperative complications, such as respiratory failure, are higher in RH patients due to higher risks of facial and upper-airway edema resulting from longer OT in the steep Trendelenburg position [32]. ...
... The widespread use of RH has been limited by expense [34]: increased costs are attributable to the price of robotic instruments, instrument sterilization and maintenance, use of disposable instruments, patient and robot draping, and the OT [30]. RH remains 1.43 times more costly, with a median difference of $12,893, even after adjustment for age, LOH, and conversion to laparotomy [32]. However, RH proved to be more profitable in complex procedures, obese patients, and in uterine weights >750 g [30,31]. ...
Hysterectomy is a commonly performed gynecologic surgery that can be associated with significant morbidity and mortality. However, the evolution of the surgical approach, from open to minimally invasive gynecologic surgery (MIGS), has substantially improved patient outcomes by reducing perioperative complications, pain, and length of hospitalization. The evident advantages and the approval of the da Vinci Surgical System by the Food and Drug Administration led to the exponential rise in the use of MIGS. In particular, robotic hysterectomy (RH) witnessed unparalleled popularity compared to other MIGS despite the lack of strong evidence demonstrating its superiority. Therefore, we conducted a systematic review of the literature to evaluate and compare various patient and surgical outcomes of RH with conventional laparoscopic hysterectomy (CLH), including operating time, estimated blood loss, length of hospitalization, overall complications, survival, and cost. Overall, the outcomes were comparable between RH and CLH except concerning cost. RH is significantly more expensive than CLH due to the higher costs of robotic equipment, including disposable instruments, equipment maintenance, and sterilization. Although RH demonstrated comparable outcomes and higher costs, its technical advantages such as improved ergonomics, three-dimensional view, a wider range of wristed mobility, mechanical lifting of robot's hand, and greater stability might benefit patient subsets (e.g., obesity, large uterine weights >750 g). Therefore, large and multicentered randomized control trials are imperative to determine the most effective surgical approach between RH and other MIGS for different patient subsets.
... In all cases, it was confirmed that the ureteral wall was weakened, not perforated or cut; therefore, it was resolved by inserting a double-J catheter into the ureter. Several studies have reported major complications in RH such as respiratory arrest; however, no other major complications occurred after hysterectomy in this study [26,28]. ...
Hysterectomy is commonly performed for benign gynecological diseases. Minimally invasive surgical approaches offer several advantages. Unfortunately, few studies have compared the outcomes of different types of minimally invasive surgeries. Therefore, this study aimed to compare the surgical outcomes of robotic hysterectomy (RH) and conventional laparoscopic hysterectomy (CLH) in benign gynecologic diseases. We performed a retrospective cohort study at a single center between January 2014 and July 2022. A total of 397 patients (RH: 197 and CLH: 200) who underwent minimally invasive hysterectomy for benign diseases with uterine size exceeding 250 g were enrolled, and factors related to the surgical outcomes were compared. The median age was 46 (range, 35–74) years, and the median uterine weight was 400 (range, 250–2720) g. There were no significant differences between the two groups regarding age, body mass index, uterine weight, hospital stay, estimated blood loss, or operating time. Intraoperative and postoperative complication rates were not significantly different between the two groups. RH was not inferior to CLH in terms of perioperative and immediate postoperative outcomes in our study.
... Moreover, research has been conducted revealing that patients who underwent UAE experienced considerably less blood loss than people who underwent a hysterectomy. Minor problems, such as fever, discomfort, and vaginal discharge, were observed to become increasingly prevalent in women undergoing UAE in comparison to others who underwent a hysterectomy [12]. The occurrence of so-called severe consequences such as pulmonary embolism and sepsis is quite low. ...
Uterine fibroids are a prevalent disease that most commonly affects women of reproductive age group and causes symptoms such as abnormal uterine bleeding that can have a detrimental impact on their quality of life. Being in the reproductive age group, fertility-conserving modalities in the form of hormonal therapy, myomectomy, hysterectomy, and uterine artery embolization (UAE) remain the main treatment options. Uterine artery embolization is one of the treatment options for select cases of fibroid uterus. Here, we present the case of a 36-year-old woman diagnosed with cervical leiomyoma who presented with uncontrollable uterine bleeding, severe anemia, and many failed medical therapies. Although the case did not fit within the usual UAE guidelines, the treatment was done to tide over the crisis as a temporary method to control severe hemorrhage. Bleeding was controlled immediately and the patient was getting prepared for major surgery with the correction of severe anemia. However, seven days after UAE, the fibroid spontaneously expelled itself, resulting in improved symptoms and the avoidance of surgery. The patient is currently symptomless and has improved sexual life, self-esteem, and quality of life.
... However, it is known that African Americans' experience of racism is a key determinant of quality of life through several mechanisms that impact income, and therefore affordability. [20,31,33,39] Thus, it is important to determine at what specific points these mechanisms impact health seeking and utilization among African American women, who experience racism, especially from their own perspectives. The issue of employability may be a significant factor in the employment rates identified by the U.S. Census Bureau. ...
Uterine gynecological procedure cost differences are important components of considerations for affordability, care access and quality. To achieve affordability, equity, and inclusion, reducing disparities, care distribution and cost correlates are important considerations for decision-making. This study determines and compares the
distribution, cost and correlates, of Uterine Artery Embolization and classical Abdominal Hysterectomy by region, race, payor, complications, length of stay, and referral source. Study Design: The 2004 -2008 National Hospital Discharge data sets for Hysterecstomy and Uterine Artery Embolization were trimmed and categorized. Crosstabs determined cost distributions by region, place/location, age, race, income, education, length of stay, and payor.
Multinomial Logistic Regression analyses determined correlates for all stratified factors. Results: Relationships between race, payor, length of stay, region, income, and care cost showed different regional patterns. All regions were less likely than the West to be more expensive. African Americans were more likely to pay below 30,000.00. For hysterectomy, minor complications were more likely to cost below 4,223.52). Conclusion: With significant disparity between regions, especially at low cost levels, and race, further research needs to determine cost correlates background/context for affordability, material hardship, multi-sectorial policy, workforce development, and other social determinants. A clear epidemiological picture of uterine fibroids, through appropriately vigilant surveillance, is needed.
... Hysterectomy and bilateral oophorectomy are very important parts of female-to-male gender affirmation surgery, in both the esthetic and psychological respect [10]. Although laparoscopic, robotic-assisted, and vaginal hysterectomy have similar outcomes in females with benign gynecological disease, the vaginal route is currently associated with greater benefits, such as shorter operative times, lower infection rates, vaginal dehiscence, and conversion to laparotomy, as well as lower costs [11][12][13][14]. ...
Introduction
The optimal route for hysterectomy with bilateral salpingo-oophorectomy in female-to-male gender affirmation surgery is still under debate, due to the quite limited and inconsistent published data. The aim of this study is to present and compare the results of vaginal and laparoscopic hysterectomy as part of gender affirmation surgery in female-to-male transsexuals.
Materials and Methods
Between 2012 and 2017, 124 female-to-male transsexuals, aged 18–43 years (mean age: 28.5), underwent hysterectomy with bilateral salpingo-oophorectomy, followed by colpocleisis and gender affirmation surgery. Transvaginal and laparoscopic hysterectomy were performed in 92 and 32 patients, respectively. Standard outcome measures (types and rates of complications, operative time, blood loss, and postoperative hospital stay) were used to compare the two groups of patients.
Results
The mean follow-up was 41 months (ranged from 6 to 65 months). The duration of transvaginal approach was significantly shorter (51 minutes compared to 76 minutes, p < 0.001). The total complication rates (less than 3%), reoperation rates (0%), blood loss, and postoperative hospital stays (4.3 days compared to 4.5 days) showed no statistical difference.
Conclusions
Both approaches are safe, with minimal complications. However, we prefer transvaginal hysterectomy due to its shorter operative time, cost-effectiveness, and simpler continuation with one-stage female-to-male gender affirmation surgery.
The decision to add hysterectomy to planned adnexectomy is often nuanced and likely increases the complexity of the planned procedure; however, these risks are not well characterized in practice. We conducted a comprehensive search in the PubMed database for English‐language articles from 1997 to 2022, identifying studies reporting complication rates for open and minimally invasive surgery (MIS) hysterectomy and adnexal surgeries. We calculated medians and first and third quartiles for each complication and used a Mann–Whitney U test to calculate differences between complications for minimally invasive hysterectomy and adnexal case data. We identified 135 appropriate studies for inclusion. There were higher prevalences of blood loss requiring transfusion (1.70% versus 0.13%, P = 0.01) and urinary tract injury (0.80% versus 0.20%, P = 0.001) in MIS hysterectomy cases compared with MIS adnexal surgery, respectively. MIS hysterectomy cases were similar to MIS adnexal surgery cases in the risk of surgical site infection (1.20% versus 1.49%, P = 0.74), bowel injury (0.50% versus 0.35%, P = 0.45), vascular injury (0.20% versus 0.9%, P = 0.82), and conversion to laparotomy (1.95% versus 3.84%, P = 0.49). There were not enough data on open adnexal surgery complications to make a meaningful comparison between complications of open hysterectomy and adnexal‐only cases. Patients should be counseled that the addition of hysterectomy to planned MIS adnexal surgery likely increases the risk of blood loss requiring transfusion and urinary tract injury. The increased comorbidity associated with adding hysterectomy to planned open adnexal removal is less clear.
In 2010, the estimated annual cost of uterine fibroids in the United States ranged from 5.9 to 34.4 billion USD. In the past decade, more uterine-sparing and fertility preserving interventions have become available to treat symptomatic fibroids. This comparative cost-analysis aims to evaluate change in societal costs of uterine fibroids in the US between 2010 and 2022 given changing fibroid and obstetric management, population growth, and inflation. A systematic review was conducted to update uterine fibroid, treatment, and obstetric complication prevalence, direct costs of medical and surgical interventions, indirect productivity costs, and obstetric costs attributable to fibroids in 2022. A comparative cost-analysis with paired t-tests was performed using baseline data published in 2010. Percent (%) changes between 2010 and 2022 were reported. NIH research funding for fibroids and other common diseases was compared. All costs were converted to 2023 USD. The number of US women with uterine fibroids increased by 10.6% from 2010 to 2022. Over this period, the economic burden of uterine fibroids increased up to 41.4 billion USD compared to 34.4 billion USD in 2010. Overall costs increased to 42.2 billion USD after incorporating new costs associated with MRgFUS and infertility. Direct costs of medical management decreased while costs of surgical interventions increased as a result of evolving treatment-seeking behavior. Lost work costs continue to account for the largest proportion of the economic burden for fibroids. Cesarean section delivery remains the largest contributor (average 80.0%) to indirect obstetrical costs. Despite the rise in the number of individuals affected by uterine fibroids and its sizable annual cost to society, uterine fibroids research continues to be underfunded.
Objective: The objective of this study was to compare the oncologic outcomes between those who underwent robotic surgery or conventional laparoscopic surgery for endometrial cancer.
Method: We performed a retrospective review of patients from a single institution who underwent either laparoscopic or robotic surgery for the treatment of endometrial cancer between January 2010 and December 2020. Tumor characteristics, recurrence rate, disease-free survival, and overall survival were compared according to surgical approach.
Results: Among the 268 patients included in this study, 95 underwent robotic surgery (35.4%) and 173 underwent laparoscopic surgery (64.6%). The median follow-up durations were 51 and 59 months for the robotic surgery and laparoscopic surgery groups, respectively (p = 0.085). The recurrence rate did not differ significantly between the two groups. (p = 0.371). Disease-free survival (p = 0.721) and overall survival (p = 0.453) were similar between the two groups. In both univariate and multivariate analyses, the type of surgery was not related to disease-free survival. The median total cost per admission was significantly higher for RS than for LS (12,123 vs. 6,884 USD, p < 0.0001).
Conclusion: With consistently greater costs and similar survival outcomes, robotic systems have few advantages compared with laparoscopy.
Starting from the first robotic hysterectomy, currently, this method is widely accepted all over the world as an alternative to open or laparoscopic surgery due to the technical advantages it offers. We are currently using the DaVinci Xi platform, whose components, instruments, and accessories are described. This chapter aims to present all surgical steps of a robotically assisted hysterectomy, starting with patient positioning, uterine manipulator insertion, port insertion, pneumoperitoneum performing, and the operative technique of the total robotic hysterectomy: connective vascular disconnection, colpotomy, uterus retrieval, and colporrhaphy. A special mention belongs to radical robotic hysterectomy with sentinel node detection and pelvic lymphadenectomy. The chapter ends with a brief description of the perioperative complications.
The potential benefits and limitations of benign hysterectomy surgical approaches are still debated. We aimed at evaluating any differences with a systematic review and meta-analysis. PubMed, MEDLINE, and EMBASE databases were last searched on 6/2/2021 to identify English randomized controlled trials (RCTs), prospective cohort and retrospective independent database studies published between Jan 1, 2010 and Dec 31, 2020 reporting perioperative outcomes following robotic hysterectomy versus laparoscopic, open, or vaginal approach (PROSPERO #CRD42022352718). Twenty-four articles were included that reported on 110,306 robotic, 262,715 laparoscopic, 189,237 vaginal, and 554,407 open patients. The robotic approach was associated with a shorter hospital stay (p < 0.00001), less blood loss (p = 0.009), and fewer complications (OR: 0.42 [0.27, 0.66], p = 0.0001) when compared to the open approach. The main benefit compared to the laparoscopic and vaginal approaches was a shorter hospital (R/L WMD: – 0.144 [– 0.21, – 0.08], p < 0.0001; R/V WMD: – 0.39 [– 0.70, – 0.08], p = 0.01). Other benefits seen were sensitive to the inclusion of database studies. Study type differences in outcomes, a lack of RCTs for robotic vs. open comparisons, learning curve issues, and limited robotic vs. vaginal publications are limitations. While the robotic approach was mainly comparable to the laparoscopic approach, this meta-analysis confirms the classic benefits of minimally invasive surgery when comparing robotic hysterectomy to open surgery. We also reported the advantages of robotic surgery over vaginal surgery in a patient population with a higher incidence of large uterus and prior surgery.
Obtaining medical consent preoperatively is one of the key steps in preparing for surgery, and is an important step in informed decision making with the patient. According to good medical practice guidelines, doctors are required to have the knowledge and skills to treat patients as well as inform them, respect their wishes, and establish trust between themselves and their patients. Valid consent includes elements of competence, disclosure, understanding, and voluntariness. Documentation of these elements is also very important. The International Federation of Gynecology and Obstetrics (FIGO) Education Communication and Advocacy Consortium (ECAC) has realized that the quality of consent varies considerably across the world and has developed simple guidelines regarding consent and procedure‐specific checklists for the most common obstetric and gynecological procedures.
Objective
Systematic evaluation of the efficacy and safety of robotic-assisted laparoscopic myomectomy (RALM) versus laparoscopic myomectomy (LM).
Methods
PubMed, Embase, The Cochrane Library, and Web of Science database were searched by computer to seek relevant literature in order to compare the efficacy and safety of RALM with that of LM from the establishment of the databases to January 2023, and Review Manager 5.4 software was utilized to perform a meta-analysis on the literature.
Results
A total of 15 retrospective clinical controlled studies were included. There exists a total of 45,702 patients, among 11,618 patients in the RALM group and the remaining 34,084 patients in the LM group. Meta-analysis results revealed that RALM was associated with lesser intraoperative bleeding (MD = − 32.03, 95%CI − 57.24 to − 6.83, P = 0.01), lower incidence of blood transfusions (OR = 0.86, 95%CI 0.77 to 0.97, P = 0.01), shorter postoperative hospital stay (MD = − 0.11, 95%CI − 0.21 to − 0.01, P = 0.03), fewer transitions to open stomach (OR = 0.82, 95%CI 0.73 to 0.92, P = 0.0006), and lower incidence of postoperative complications (OR = 0.58, 95%CI 0.40 to 0.86, P = 0.006) than LM, whereas LM is more advantageous in terms of operative time (MD = 38.61, 95%CI 19.36 to 57.86, P < 0.0001). There was no statistical difference between the two surgical methods in terms of maximum myoma diameter (MD = 0.26, 95%CI − 0.17 to 0.70, P = 0.24).
Conclusion
In the aspects of intraoperative bleeding, lower incidence of blood transfusions, postoperative hospital stay, transit open stomach rate, and postoperative complications, RALM has a unique advantage than that of LM, while LM has advantages over RALM in terms of operative time.
Study Objective
: Transvaginal extraction is feasible method to remove surgical specimen. In this study, we aim to report our experience with in-bag transvaginal specimen retrieval after laparoscopic myomectomy over the last 15 years.
Design
: Single-center retrospective analysis.
Setting
: Academic hospital.
Patients
: Women who underwent laparoscopic myomectomy from January 2005 to April 2021.
Intervention
: Posterior colpotomy and in-bag transvaginal extraction of the surgical specimen.
Measurements and Main Results
: We collected and analyzed data about patients’ characteristics, main indication for surgery, intra- and post-operative (within 30 days) complications.
Results
: A total of 692 women underwent transvaginal specimen retrieval after laparoscopic myomectomy (mean largest myoma diameter: 6.64 ± 2.21 cm; mean specimen weight: 177 ± 140 grams; mean operative time: 84.1 ± 37.1 minutes; mean blood loss: 195 ± 191 ml). Within 30-days, we reported the following colpotomy-related complications: 4 (0.6%) cases of vaginal bleeding, which resolved spontaneously in 3 cases (one case required readmission with new colporrhaphy under general anesthesia); 2 (0.3%) cases of vaginal pain, with no underlying cause identified on physical examination and pelvic ultrasound. Specimen weight was positively correlated with longer operative time, intraoperative blood loss and length of hospital stay.
Conclusion
: Posterior colpotomy and in-bag transvaginal extraction can be considered a feasible option for retrieval of surgical specimens after laparoscopic myomectomy.
Introduction:
To date, there is no robust evidence suggesting whether transvaginal (TVSR) or port-site specimen retrieval (PSSR) after laparoscopic myomectomy (LM) may lead to better surgical outcomes. Considering this element, we aimed to compare surgical outcomes of TVSR versus PSSR after LM.
Methods:
A search (PROSPERO ID: CRD42020176490) of international databases, from 1980 to 2020, in English language, was conducted. We selected studies that included women who underwent LM with TVSR compared with PSSR.
Results:
We did not find significant differences for operative time (MD=-8.90 [95% CI -30.00, 12.20]; I2=87%), myoma retrieval time (MD=-1.85 [95% CI -13.55, 9.85]; I2=98%), blood loss (MD=-27.62 [95% CI -178.68, 124.43]; I2=91%), intra-operative complication rate (OR 0.51, 95% CI 0.01-23.09; I2=69%) and hospital stay (MD=-0.14 [95% CI -0.43; 0.15]; I2=64%); we found a significant lower post-operative rescue analgesics utilization in the TVSR group compared with the PSSR group (OR 0.31, 95% CI 0.16-0.61, I2=0).
Conclusion:
TVSR and PSSR after LM showed comparable results for operative time and surgery-related complications. However, the need of post-operative rescue analgesics was lower in women who underwent TVSR.
Purpose: The present study aimed to compare surgical outcomes and cost analysis of robotic-assisted surgery (RAS) and conventional laparoscopic surgery (CLS) hysterectomy procedures.
Materials and Methods: The patients who underwent total robotic hysterectomy or total conventional laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy due to benign gynecological disorders such as uterine fibroid, abnormal uterine bleeding, endometrial hyperplasia, adenomyosis, persistent ovarian cysts, chronic pelvic pain were retrospectively evaluated.
Results: A total of 80 women underwent RAS or CLS hysterectomy during the study period. The mean total operative time was 187 ±10 min. in RAS and 133 ±24 min. in CLS groups, respectively. The mean total cost of the RAS hysterectomy group was 17.710 TL, and CLS hysterectomy group was 7000 TL.
Conclusion: Both CLS and RAS hysterectomies for benign gynecological indications are safe surgical procedures with negligible complication rates. RAS is a more expensive procedure compared to CLS.
Introduction:
The study aims to analyze differences between robot-assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon and hospital volume.
Material and methods:
All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo-oophorectomy from January 1, 2015 to December 31, 2017 (n = 12 386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses.
Results:
TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios [aOR] 2.8, 95% CI 1.3-5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2-2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2-25.4), a higher blood loss (200-500 mL aOR 3.5, 95% CI 2.7-4.7; > 500 mL aOR 7.6, 95% CI 4.0-14.6) and a longer operative time (1-2 h aOR 16.7 95% CI 10.2-27.5; >2 h aOR 47.6, 95% CI 27.9-81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4-0.9).
Conclusions:
RATLH led to better perioperative outcome and higher patient satisfaction 1 year after surgery. These outcome differences were slightly more pronounced in very low-volume surgeons but persisted across all surgeon volume groups.
OBJECTIVE:
We performed a systematic review of the literature and meta-analysis of the infectious complications of hysterectomy, comparing robotic-assisted hysterectomy to conventional laparoscopic-assisted hysterectomy.
METHODS:
We searched PubMed, CINAHL, CDSR, and EMBASE through July 2018 for studies evaluating robotic-assisted hysterectomy, laparoscopic-assisted hysterectomy, and infectious complications. We employed random-effect models to obtain pooled OR estimates. Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic. Pooled ORs were calculated separately based on the reason for hysterectomy (eg, benign uterine diseases, endometrial cancer, and cervical cancer).
RESULTS:
Fifty studies were included in the final review for the meta-analysis with 176 016 patients undergoing hysterectomy. There was no statistically significant difference in the number of infectious complication events between robotic-assisted hysterectomy and laparoscopic-assisted hysterectomy (pooled OR 0.97; 95 % CI 0.74 to 1.28). When we performed a stratified analysis, similar results were found with no statistically significant difference in infectious complications comparing robotic-assisted hysterectomy to laparoscopic-assisted hysterectomy among patients with benign uterine disease (pooled OR 1.10; 95 % CI 0.70 to 1.73), endometrial cancer (pooled OR 0.97; 95 % CI 0.55 to 1.73), or cervical cancer (pooled OR 1.09; 95 % CI 0.60 to 1.97).
CONCLUSION:
In our meta-analysis the rate of infectious complications associated with robotic-assisted hysterectomy was no different than that associated with conventional laparoscopic-assisted hysterectomy.
Objective. To evaluate operative and perioperative outcomes in patients undergoing total laparoscopic hysterectomy according to their body mass index. Method. A retrospective study was performed for patients undergoing total laparoscopic hysterectomy at a tertiary care center for a period of 4 years. Patients were divided into two groups: obese (BMI > 30 Kg/m2) and nonobese (BMI < 30 Kg/m2). Duration of surgery, intraoperative blood loss, successful laparoscopic completion, and intraoperative complications were compared in two groups. Result. A total of 253 patients underwent total laparoscopic hysterectomy from January 2010 to December 2013. Out of them, 105 women (41.5%) had a BMI of more than 30 kg/m2. Overall, the mean blood loss was 85.79 ± 54.17 mL; the operative time was 54.17 ± 19.83 min. The surgery was completed laparoscopically in 244 (96.4%) women while laparotomy was done in 4 cases and vaginal suturing and closure of vault were done in 5 cases. Risk of vaginal assistance was higher in obese patients whereas out of the 4 conversions to laparotomy 3 had BMI < 30 kg/m2. The operative time was increased as the BMI of patient increased. Conclusions. Total laparoscopic hysterectomy is a safe and effective procedure for obese patients and can be performed with an efficacy similar to that in nonobese patients.
Background:
Cervical cancer continues to be a global burden for women, with >500,000 cases and 275,000 deaths reported annually. Resources-rich countries have seen a dramatic reduction in the prevalence of invasive cervical cancer due to widely accessed radical hysterectomy (RH). We aimed to compare initial surgical outcomes and complication rates of conventional laparoscopic RH (LRH) and robotic RH (RRH) for treating cervical cancer through a systematic meta-analysis.
Methods:
PubMed, EMBASE, and the Cochrane Library databases were systematically searched for all relevant studies. Data were abstracted independently. A meta-analysis was performed to compare intra- and post-operative outcomes for the two techniques.
Results:
A total of 12 clinical trials were identified. Meta-analysis showed that although LRH and RRH were similar in terms of operating time, the length of hospital stay, and a number of pelvic lymph nodes resected, RRH presented less blood loss and overwhelming advantage against LRH with the respect of complications.
Conclusion:
RRH may be a reliable technique for treating early cervical cancer. Available evidence suggests that it is better than LRH for postoperative recovery, while the two techniques involve similar surgical outcomes and share the same limits in clinical practice.
Context
A nonlaparotomic route is recommended for hysterectomy for benign indications.
Objective
1) Predict the difficulty of hysterectomy to treat benign disease as measured by operative time and risk of laparotomy, 2) confirm the safety and quality of increasing our minimally invasive hysterectomy (MIH) rate, and 3) determine whether the assistant’s experience affected the likelihood of an MIH being performed in equally difficult hysterectomies.
Design
All hysterectomies for benign disease performed at the Kaiser Permanente Fontana Medical Center in Fontana, CA, in 2012 were reviewed for length of surgery, length of stay, complications, and readmissions. A three-tiered category system was developed from four preoperative parameters (body mass index, number of vaginal deliveries, clinical uterine size, and history of major abdominal surgery) to anticipate length and difficulty of surgery.
Main Outcome Measures
Rates of MIH, complications, and readmissions as well as length of surgery and length of stay for similarly difficult hysterectomies. These outcomes were compared with surgeons’ and assistants’ experience.
Results
Of 576 hysterectomies performed for benign disease, 89% were MIH with a 3% complication rate and 4% readmission rate. An increase in the hysterectomy category was statistically significantly associated with longer surgery times and a higher percentage of laparotomy. With the most experienced assistants, the MIH rate was 98%.
Conclusions
Using 4 preoperative parameters, the average operating time for hysterectomy for benign disease can be predicted. A higher hysterectomy category predicts a more difficult surgery. Our center has increased its MIH rate to 89% while maintaining safety.
FDA approved Da Vinci Surgical System in 2005 for gynecological surgery. It has been rapidly adopted and it has already assumed an important position at various centers where this is available. It comprises of three components: A surgeon's console, a patient-side cart with four robotic arms and a high-definition three-dimensional (3D) vision system. In this review we have discussed various robotic-assisted laparoscopic benign gynecological procedures like myomectomy, hysterectomy, endometriosis, tubal anastomosis and sacrocolpopexy. A PubMed search was done and relevant published studies were reviewed. Surgeries that can have future applications are also mentioned. At present most studies do not give significant advantage over conventional laparoscopic surgery in benign gynecological disease. However robotics do give an edge in more complex surgeries. The conversion rate to open surgery is lesser with robotic assistance when compared to laparoscopy. For myomectomy surgery, Endo wrist movement of robotic instrument allows better and precise suturing than conventional straight stick laparoscopy. The robotic platform is a logical step forward to laparoscopy and if cost considerations are addressed may become popular among gynecological surgeons world over.
Currently, benefits of robotic surgery in patients with benign gynecological conditions remain unclear. In this study, we compared the surgical outcome of robotic and laparoscopic total hysterectomies and evaluated the feasibility of robotic surgery in cases with pelvic adhesions or large uterus.
A total of 216 patients receiving total hysterectomy via robotic or laparoscopic approach were included in this study. Of all 216 patients, 88 underwent robotic total hysterectomy and 128 underwent laparoscopic total hysterectomy. All cases were grouped by surgical type, adhesion score, and uterine weight to evaluate the interaction or individual effect to the surgical outcomes. The perioperative parameters, including operation time, blood loss, postoperative pain score, time to full diet resumption, length of hospital stay, conversion rate, and surgery-related complications were compared between the groups.
Operation time and blood loss were affected by both surgical type and adhesion score. For cases with severe adhesions (adhesion score greater than 4), robotic surgery was associated with a shortened operation time (113.9 ± 38.4 min versus 164.3 ± 81.4 min, P = 0.007) and reduced blood loss (187.5 ± 148.7 mL versus 385.7 ± 482.6, P=0.044) compared with laparoscopy. Moreover, robotic group showed a lower postoperative pain score than laparoscopic group, as the effect was found to be independent of adhesion score or uterine weight. The grade-II complication rate was also found to be lower in the robotic group.
Comparing to laparoscopic approach, robotic surgery is a feasible and potential alternative for performing total hysterectomy with severe adhesions.
Background and Objectives:
The goal of this study is to obtain updated surveillance statistics for hysterectomy procedures in the United States and identify factors associated with undergoing a minimally invasive approach to hysterectomy.
Methods:
A cross-sectional analysis of the 2009 United States Nationwide Inpatient Sample was performed. Subjects included all women aged 18 years or older who underwent hysterectomy of any type. Logistic regression and multivariate analyses were performed to assess the proportion of hysterectomies performed by various routes, as well as factors associated with undergoing minimally invasive surgery (laparoscopic, vaginal, or robotic).
Results:
A total of 479 814 hysterectomies were performed in the United States in 2009, 86.6% of which were performed for benign indications. Among the hysterectomies performed for benign indications, 56% were completed abdominally, 20.4% were performed laparoscopically, 18.8% were performed vaginally, and 4.5% were performed with robotic assistance. Factors associated with decreased odds of a minimally invasive hysterectomy included the following: minority race (P < .0001), fibroids (P < .0001), concomitant adnexal surgery (P < .0001), self-pay (P = .01) or Medicaid as insurer (P < .0001), and increased severity of illness (P < .0001). Factors associated with increased odds of a minimally invasive hysterectomy included the following: age >50 years (P < .0001), prolapse or menstrual disorder (P < .0001), median household income of 62 999 (P = .007) or ≥38 161).
Conclusion:
The US hysterectomy incidence in 2009 decreased from prior years' reports, with an increasing frequency of laparoscopic and robotic approaches. Racial and socioeconomic factors influenced hysterectomy mode.
The purpose was to compare robotic assisted total laparoscopic hysterectomy (TRH), laparoscopic assisted hysterectomy (TLH) and total abdominal hysterectomy (TAH) with surgical staging +/- lymphadenectomy for the management of uterine cancer.
Institutional review board approval was obtained and patient characteristics, pathologic data, and data related to the surgical procedure were collected from chart review. Data were analyzed with SAS statistical software.
A total of 102 TRHs were compared to 115 TLHs and 79 TAHs. There were more grade I and endometrial intraepithelial (EIN) lesions in the preoperative pathology of TLHs (P < 0.01). Pelvic lymphadenectomy was performed in 71 (70%) TRH, 46 (58%) TAH, and 28 (24%) TLH cases (P < 0.01). Mean surgical time was 203, 133 and 132 minutes for TRHs, TLHs, and TAHs (P < 0.05). Estimated blood loss was 69, 86, and 215 ml for TRH, TLH, and TAH (P < 0.05). Blood transfusions were 19% in TAHs versus 3% and 2% in TLHs and TRHs (P < 0.01). There were fewer wound infections (2% vs. 10%) in TRHs versus TAHs (P < 0.01). Length of stay was shorter for the TRH and TLH groups (P < 0.05).
Despite longer surgical times, benefits of minimally invasive technology included shortened length of stay, decreased wound infections, transfusions, and blood loss. In our population, procedure selection for TLH versus TRH may have been influenced by lower preoperative grade, with reservation of robotic technology for cases anticipated to be more complex, and therefore justifying increased technology costs and operating times.
Robotic-assisted surgery has evolved over the past 2 decades with constantly improving technology that assists surgeons in multiple subspecialty disciplines. The surgical requirements of lithotomy and steep Trendelenburg positions, along with the creation of a pneumoperitoneum and lack of direct access to the patient all present management challenges in gynecologic surgery. Patient positioning requirements can have significant physiologic effects and can result in many complications.
This review focuses on the anesthetic and surgical implications of robot-assisted technology in gynecologic surgery.
Good communication among team members and knowledge of the nuances of robotic surgery have the potential to improve patient outcomes, increase efficiency, and reduce complications.
(Abstracted from Am J Obstet Gynecol 2016;215(5):650.e1–650.e8)
The popularization of robotic-assisted laparoscopic hysterectomy (RH) over the past decade has provided an alternative approach to performing minimally invasive hysterectomy.
Background:
Despite a lack of evidence showing improved clinical outcomes with robotic-assisted hysterectomy over other minimally invasive routes for benign indications, this route has increased in popularity over the last decade.
Objective:
We sought to compare clinical outcomes and estimated cost of robotic-assisted vs other routes of minimally invasive hysterectomy for benign indications.
Study design:
A statewide database was used to analyze utilization and outcomes of minimally invasive hysterectomy performed for benign indications from Jan. 1, 2013, through July 1, 2014. A 1-to-1 propensity score-match analysis was performed between women who had a hysterectomy with robotic assistance vs other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmissions, and reoperations were compared. Cost estimates of hysterectomy routes, surgical site infection, and postoperative blood transfusion were derived from published data.
Results:
In all, 8313 hysterectomy cases were identified: 4527 performed using robotic assistance and 3786 performed using other minimally invasive routes. A total of 1338 women from each group were successfully matched using propensity score matching. Robotic-assisted hysterectomies had lower estimated blood loss (94.2 ± 124.3 vs 175.3 ± 198.9 mL, P < .001), longer surgical time (2.3 ± 1.0 vs 2.0 ± 1.0 hours, P < .001), larger specimen weights (178.9 ± 186.3 vs 160.5 ± 190 g, P = .007), and shorter length of stay (14.1% [189] vs 21.9% [293] ≥2 days, P < .001). Overall, the rate of any postoperative complication was lower with the robotic-assisted route (3.5% [47] vs 5.6% [75], P = .01) and driven by lower rates of superficial surgical site infection (0.07% [1] vs 0.7% [9], P = .01) and blood transfusion (0.8% [11] vs 1.9% [25], P = .02). Major postoperative complications, intraoperative bowel and bladder injury, readmissions, and reoperations were similar between groups. Using hospital cost estimates of hysterectomy routes and considering the incremental costs associated with surgical site infections and blood transfusions, nonrobotic minimally invasive routes had an average net savings of 10,160 vs $13,429).
Conclusion:
Robotic-assisted laparoscopy does not decrease major morbidity following hysterectomy for benign indications when compared to other minimally invasive routes. While superficial surgical site infection and blood transfusion rates were statistically lower in the robotic-assisted group, in the absence of substantial reductions in clinically and financially burdensome complications, it will be challenging to find a scenario in which robotic-assisted hysterectomy is clinically superior and cost-effective.
Objective:
The operating room (OR) is a major driver of hospital costs; therefore, operative time is an expensive resource. The training of surgical residents must include time spent in the OR, but that experience comes with a cost to the surgeon and hospital. The objective of this article is to determine the effect of surgical resident involvement in the OR on operative time and subsequent hospital labor costs.
Design:
The Kruskal-Wallis statistical test is used to determine whether or not there is a difference in operative times between 2 groups of cases (with residents and without residents). This difference leads to an increased cost in associated hospital labor costs for the group with the longer operative time.
Setting:
Cases were performed at Greenville Memorial Hospital. Greenville Memorial Hospital is part of the larger healthcare system, Greenville Health System, located in Greenville, SC and is a level 1 trauma center with up to 33 staffed ORs.
Participants:
A total of 84,997 cases were performed at the partnering hospital between January 1st, 2011 and July 31st, 2015. Cases were only chosen for analysis if there was only one CPT code associated with the case and there were more than 5 observations for each group being studied. This article presents a comprehensive retrospective analysis of 29,134 cases covering 246 procedures.
Results:
The analysis shows that 45 procedures took significantly longer with a resident present in the room. The average increase in operative time was 4.8 minutes and the cost per minute of extra operative time was determined to be 2,257,433, or $492,889 per year.
Conclusions:
Knowing the affect on operative time and OR costs allows managers to make smart decisions when considering alternative educational and training techniques. In addition, knowing the connection between residents in the room and surgical duration could help provide better estimates of surgical time in the future and increase the predictability of procedure duration.
Increasingly, robotic surgery is being used for total hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection for uterine cancer. The purpose of this study is to compare the costs and complications among women undergoing robotic and laparoscopic hysterectomy for uterine cancer STUDY DESIGN: We carried out a cohort study using the Nationwide Inpatient Sample (NIS) database between 2008 and 2012 on all women diagnosed with uterine cancer, classifying women as either laparoscopically or robotically treated, excluding laparotomies or vaginal approaches. Logistic regression analyses were used to evaluate the adjusted effect of surgical approach on complication rates.
There were 10,347 women who underwent hysterectomies for uterine cancer either laparoscopically (39%) or robotically (61%). The rate of robotic surgery consistently increased over the five-year period. Women undergoing robotic surgery had more comorbid conditions (diabetes, hypertension, cardiovascular disease, renal disease, obesity or morbid obesity, and pulmonary disease). In adjusted analyses, women undergoing robotic surgery were more likely to have a lymph node dissection (73.01% vs. 66.04%, p< 0.0001) and an admission lasting less than 3 days (86.01% vs. 82.5% p< 0.0001) compared to those undergoing laparoscopic surgery. The composite endpoint of any complication was similar between both cohorts (20.56% robotic vs. 21.00% laparoscopy). In overall and subset analyses, robotic surgery was more costly, with median charges of 31,476.00 in those undergoing laparoscopic surgery (p< 0.0001).
Despite the considerably greater burden of comorbidities in those undergoing robotic surgery compared to laparoscopy, the former have shorter hospital admissions, a greater rate of lymph node dissection, and similar post-operative morbidity and mortality, albeit at greater total cost.
Copyright © 2015 Elsevier Inc. All rights reserved.
The relationship between operative time and perioperative morbidity has not been fully characterized in gynecology. We aimed to determine the impact of operative time on 30-day perioperative complications following laparoscopic and robotic hysterectomy.
Patients undergoing laparoscopic and robotic hysterectomy for benign disease from 2006 to 2011 within the National Surgical Quality Improvement Program (NSQIP) database were identified by CPT code. Operative times were stratified into 60-minute intervals and complication rates analyzed. Primary outcomes included 30-day overall, medical, and surgical complications. Bivariate analyses utilizing Chi-squared, Fisher's exact, and one-way ANOVA tests were performed to compare clinical and procedural characteristics associated with longer operative time and complications. Multivariable logistic regression analyses were then performed to determine the independent association between operative time and perioperative complications.
Canadian Task Force classification II-2 (Evidence obtained from well-designed cohort or case-control studies preferably from more than one center or research group).
American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).
Patients who underwent laparoscopic or robotic hysterectomy for benign disease from 2006 to 2011 at any institution participating in NSQIP.
None, retrospective database study.
Of the 7,630 laparoscopic and robotic hysterectomies identified, 399 patients (5.2%) experienced complications, most commonly urinary tract infection (UTI; 2.1%), superficial surgical site infection (SSI; 1.0%), and blood transfusion (1.0%). Return to the operating room (OR) was required in 97 patients (1.3%) and there were 4 deaths, for a mortality rate of 0.05%. Complications increased steadily with longer operative time. Operative time ≥240 minutes was associated with increased overall complications (13.8% versus 4.6%, p<.001), surgical complications (5.4% versus 1.5%, p<.001), medical complications (10.4% versus 3.2%, p<.001), return to the OR (2.7% versus 1.2%, p=.002), deep venous thrombosis (DVT; 0.5% versus 0.06%, p=.011), pulmonary embolism (PE; 0.7% versus 0.1%, p=.012), and blood transfusion (3.4% versus 0.8%, p<.001). These associations remained statistically significant after multivariable regression analysis. Based on continuous regression modeling, each additional hour of operative time would be expected to increase odds of overall complications (OR 1.4, 95% CI 1.28 to 1.54, p<.001), medical complications (OR 1.42, 95% CI 1.28 to 1.57, p<.001), surgical complications (OR 1.32, 95% CI 1.17 to 1.49, p<.001), VTE (OR 1.47, 95% CI 1.12 to 1.92, p=.005), UTI (OR 1.20, 95% CI 1.05 to 1.36, p=.006), blood transfusion (OR 1.42, 95% CI 1.18 to 1.71, p<.001), and return to the OR (OR 1.25, 95% CI 1.08 to 1.45, p=.003).
We demonstrated a direct, independent association between operative time and 30-day complications after laparoscopic and robotic hysterectomy. Future research should aim to further delineate risk factors for prolonged operative time and morbidity in laparoscopic hysterectomy in order to allow surgeons to maximize preoperative planning and optimize patient selection for minimally invasive hysterectomy.
Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.
The authors assessed the risk of uterine leiomyomata in relation to reproductive factors and hormonal contraception in a prospective cohort study of US Black women. From March 1997 through March 2001, the authors followed 22,895 premenopausal women with intact uteri and no prior self-reported diagnosis of uterine leiomyomata. The authors used age- and time-stratified Cox regression models to estimate incidence rate ratios for self-reported uterine leiomyomata, confirmed by ultrasound or hysterectomy, in association with selected reproductive and hormonal factors. During 76,711 person-years of follow-up, 2,279 new cases of ultrasound- or hysterectomy-confirmed uterine leiomyomata were self-reported. After adjustment for age, body mass index, smoking, alcohol intake, and other reproductive covariates, the risk of ultrasound- or hysterectomy-confirmed leiomyomata was inversely associated with age at menarche, parity, and age at first birth and positively associated with years since last birth. Overweight or obesity appeared to attenuate the inverse association between parity and uterine leiomyomata. Current use of progestin-only injectables was inversely associated with risk. No consistent patterns were observed for other forms of hormonal contraception. Reproductive history is an important determinant of leiomyomata risk in premenopausal US Black women. Progestin-only injectables may reduce risk.
Objectives:
The aim of this guideline is to provide clinicians with an understanding of the pathophysiology, prevalence, and clinical significance of myomata and the best evidence available on treatment modalities.
Options:
The areas of clinical practice considered in formulating this guideline were assessment, medical treatments, conservative treatments of myolysis, selective uterine artery occlusion, and surgical alternatives including myomectomy and hysterectomy. The risk-to-benefit ratio must be examined individually by the woman and her health care provider.
Outcomes:
Implementation of this guideline should optimize the decision-making process of women and their health care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options, and reviewed the risks and anticipated benefits.
Evidence:
Published literature was retrieved through searches of PubMed, CINAHL, and Cochrane Systematic Reviews in February 2013, using appropriate controlled vocabulary (uterine fibroids, myoma, leiomyoma, myomectomy, myolysis, heavy menstrual bleeding, and menorrhagia) and key words (myoma, leiomyoma, fibroid, myomectomy, uterine artery embolization, hysterectomy, heavy menstrual bleeding, menorrhagia). The reference lists of articles identified were also searched for other relevant publications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to January 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies.
Benefits, harms, and costs:
The majority of fibroids are asymptomatic and require no intervention or further investigations. For symptomatic fibroids such as those causing menstrual abnormalities (e.g. heavy, irregular, and prolonged uterine bleeding), iron defficiency anemia, or bulk symptoms (e.g., pelvic pressure/pain, obstructive symptoms), hysterectomy is a definitive solution. However, it is not the preferred solution for women who wish to preserve fertility and/or their uterus. The selected treatment should be directed towards an improvement in symptomatology and quality of life. The cost of the therapy to the health care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat investigative or treatment modalities.
Values:
The quality of evidence in this document was rated using the criteria described in the Report of the Caadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Uterine fibroids are common, appearing in 70% of women by age 50; the 20% to 50% that are symptomatic have considerable social and economic impact in Canada. (II-3) 2. The presence of uterine fibroids can lead to a variety of clinical challenges. (III) 3. Concern about possible complications related to fibroids in pregnancy is not an indication for myomectomy except in women who have had a previous pregnancy with complications related to these fibroids. (III) 4. Women who have fibroids detected in pregnancy may require additional maternal and fetal surveillance. (II-2) 5. Effective medical treatments for women with abnormal uterine bleeding associated with uterine fibroids include the levonorgestrel intrauterine system, (I) gonadotropin-releasing hormone analogues, (I) selective progesterone receptor modulators, (I) oral contraceptives, (II-2) progestins, (II-2) and danazol. (II-2) 6. Effective medical treatments for women with bulk symptoms associated with fibroids include selective progesterone receptor modulators and gonadotropin-releasing hormone analogues. (I) 7. Hysterectomy is the most effective treatment for symptomatic uterine fibroids. (III) 8. Myomectomy is an option for women who wish to preserve their uterus or enhance fertility, but carries the potential for further intervention. (II-2) 9. Of the conservative interventional treatments currently available, uterine artery embolization has the longest track record and has been shown to be effective in properly selected patients. (II-3) 10. Newer focused energy delivery methods are promising but lack long-term data. (III) Recommendations 1. Women with asymptomatic fibroids should be reassured that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated. (III-D) 2. Treatment of women with uterine leiomyomas must be individualized based on symptomatology, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, the availability of therapy, and the experience of the therapist. (III-B) 3. In women who do not wish to preserve fertility and/or their uterus and who have been counselled regarding the alternatives and risks, hysterectomy by the least invasive approach possible may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. (II-2A) 4. Hysteroscopic myomectomy should be considered first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. (II-3A) 5. Surgical planning for myomectomy should be based on mapping the location, size, and number of fibroids with the help of appropriate imaging. (III-A) 6. When morcellation is necessary to remove the specimen, the patient should be informed about possible risks and complications, including the fact that in rare cases fibroid(s) may contain unexpected malignancy and that laparoscopic power morcellation may spread the cancer, potentially worsening their prognosis. (III-B) 7. Anemia should be corrected prior to proceeding with elective surgery. (II-2A) Selective progesterone receptor modulators and gonadotropin-releasing hormone analogues are effective at correcting anemia and should be considered preoperatively in anemic patients. (I-A) 8. Use of vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduce blood loss at myomectomy and should be considered. (I-A) 9. Uterine artery occlusion by embolization or surgical methods may be offered to selected women with symptomatic uterine fibroids who wish to preserve their uterus. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, including the likelihood that fecundity and pregnancy may be impacted. (II-3A) 10. In women who present with acute uterine bleeding associated with uterine fibroids, conservative management with estrogens, selective progesterone receptor modulators, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention may be considered, but hysterectomy may become necessary in some cases. In centres where available, intervention by uterine artery embolization may be considered. (III-B).
Study objective:
To investigate the hospital cost and short-term clinical outcome of traditional minimally invasive hysterectomy vs robot-assisted hysterectomy in women primarily not considered candidates for vaginal surgery.
Design:
Randomized controlled trial (Canadian Task Force classification I).
Setting:
University Hospital in Sweden.
Patients:
One hundred twenty-two women with uterine size ≤ 16 gestational weeks scheduled to undergo minimally invasive hysterectomy because of benign disease.
Interventions:
Robot-assisted hysterectomy or traditional vaginal or laparoscopic minimally invasive hysterectomy.
Measurements and main results:
All women underwent surgery as randomized. There were no demographic differences between the 2 groups. Vaginal hysterectomy was possible in 41% in the traditional minimally invasive group, at a mean hospital cost of 7059 for traditional laparoscopic hysterectomy. This was reflected in a mean hospital cost of 1607 when including investments and cost of maintenance. A per-protocol subanalysis comparing laparoscopy and robotics demonstrated similar hospital cost when the robot was a preexisting investment (7016). Robotic-assisted hysterectomy was associated with less blood loss and fewer postoperative complications.
Conclusion:
A similar hospital cost can be attained for laparoscopy and robotics when the robot is a preexisting investment. From the perspective of hospital costs, robotic-assisted hysterectomy is not advantageous for treating benign conditions when a vaginal approach is feasible in a high proportion of patients.
Hysterectomy is one of the most commonly performed procedures in the United States. It is a unique procedure with multiple routes of access and multiple operative techniques. While focus has shifted towards minimally invasive techniques, the vaginal hysterectomy should be ranked first in this category, as it represents an original natural orifice surgery. Vaginal hysterectomy offers the least invasive approach to hysterectomy, with the lowest associated risks and costs. Despite these benefits, vaginal hysterectomy has experienced a decline in the last two decades. This decline is likely due to both the prevalence of fibroid uterus as a major indication for hysterectomy, and the decline of vaginal surgical skills among gynecologic surgeon due to more recent focus on laparoscopic proficiency. While vaginal hysterectomy is not risk-free, and is not the best option for all diagnoses, it should be given first-line consideration when planning to perform a benign hysterectomy. The purpose of this review is to understand the origins and evolution of the vaginal hysterectomy, the evidence-based benefits of this route of surgery, and best practice methods to ensure that patients receive safe and effective surgical treatment.
To estimate the necessity of routine patient positioning in steep Trendelenburg in robotic-assisted gynecologic surgery performed for benign indications.
Descriptive study (Canadian Task Force classification II-2).
University-affiliated community hospital.
Twenty women undergoing robotic-assisted gynecologic surgery for benign indications.
Robotic-assisted total hysterectomy, supracervical hysterectomy, myomectomy, and sacrocolpopexy.
Demographic data and perioperative variables were recorded including age, body mass index, procedure type, console time, perioperative complications, estimated blood loss, hospital length of stay, and degree of Trendelenburg position. The degree of Trendelenburg position was measured at the end of each procedure using an electronic level. The surgeons were blinded to the degree of Trendelenburg used. All procedures were performed successfully without conversion to laparotomy. All patients were discharged to home within 24 hours. No perioperative complications were noted. The mean (SD; 95% CI) Trendelenburg position used in this cohort was 16.4 (4.1; 14.4-18.3) degrees. Patient body mass index was 28.5 (5.3; 26.1-31.1). Median console time was 87.5 (27-112) minutes.
Robotic-assisted benign gynecologic surgery can be effectively performed without use of the steep Trendelenburg position. The practice of routine adherence to steep Trendelenburg positioning in benign gynecologic robotic surgery should be questioned.
Robotic surgery is the latest innovation in the field of minimally invasive surgery. In the case of robotic surgery, instead of directly moving the instruments the surgeon uses a robotic system to control the instruments for surgical procedures. Robotic surgical systems have been used in various gynaecological surgeries for benign disease, such as hysterectomy (removal of the uterus), myomectomy (removal of uterine leiomyomas) and tubal reanastomosis (the reuniting of a divided tube). The mounting evidence demonstrates the feasibility and safety of robotic surgery in benign gynaecological disease. Robotic surgery is advertised as having promising advantages including more precise vision and procedures, improved ergonomics and shorter length of hospital stay. However, the main disadvantages of the robotic surgical system should not be overlooked, including the high cost of disposable instruments and retraining for both surgeons and nurses.
To assess the effectiveness and safety of robot-assisted surgery in the treatment of benign gynaecological disease.
We searched the Cochrane Menstrual Disorders and Subfertility Group's Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2011), MEDLINE and EMBASE up to November 2011 and citation lists of relevant publications.
All randomised controlled trials (RCTs) comparing robotic surgery for benign gynaecological disease to laparoscopic or open surgical procedures. RCTs comparing different types of robotic assistants were also included. We contacted study authors for unpublished information, but failed in obtaining a response.
Two review authors independently screened studies for inclusion. The domains assessed for risk of bias were allocation concealment, blinding, incomplete outcome data and selective outcome reporting. Odds ratios (OR) were used for reporting dichotomous data with 95% confidence intervals (CI), whilst mean differences (MD) were determined for continuous data. Statistical heterogeneity was assessed using the I(2) statistic. We contacted the primary authors for missing data but failed in obtaining a response.
Two trials involving 158 participants were included. Since one included trial was published in conference proceedings, limited usable data were available for further analysis. The only analysis in this trial showed comparable rates of conversions to open surgery between the robotic group and the laparoscopic group (OR 1.41, 95% CI 0.22 to 9.01; P = 0.72). One RCT showed longer operation time (MD 66.00, 95% CI 40.93 to 91.07; P < 0.00001), higher cost (MD 1936.00, 95% CI 445.69 to 3426.31; P = 0.01) in the robotic group compared with the laparoscopic group. Also, both studies reported that robotic and laparoscopic surgery seemed comparable regarding intraoperative outcome, complications, length of hospital stay and quality of life.
Currently, the limited evidence showed that robotic surgery did not benefit women with benign gynaecological disease in effectiveness or in safety. Further well-designed RCTs with complete reported data are required to confirm or refute this conclusion.
The impact of intraoperative erythrocyte transfusion on outcomes of anemic patients undergoing noncardiac surgery has not been well characterized. The objective of this study was to examine the association between blood transfusion and mortality and morbidity in patients with severe anemia (hematocrit less than 30%) who are exposed to one or two units of erythrocytes intraoperatively.
This was a retrospective analysis of the association of blood transfusion and 30-day mortality and 30-day morbidity in 10,100 patients undergoing general, vascular, or orthopedic surgery. We estimated separate multivariate logistic regression models for 30-day mortality and for 30-day complications.
Intraoperative blood transfusion was associated with an increased risk of death (odds ratio [OR], 1.29; 95% CI, 1.03-1.62). Patients receiving an intraoperative transfusion were more likely to have pulmonary, septic, wound, or thromboembolic complications, compared with patients not receiving an intraoperative transfusion. Compared with patients who were not transfused, patients receiving one or two units of erythrocytes were more likely to have pulmonary complications (OR, 1.76; 95% CI, 1.48-2.09), sepsis (OR, 1.43; 95% CI, 1.21-1.68), thromboembolic complications (OR, 1.77; 95% CI, 1.32-2.38), and wound complications (OR, 1.87; 95% CI, 1.47-2.37).
Intraoperative blood transfusion is associated with a higher risk of mortality and morbidity in surgical patients with severe anemia. It is unknown whether this association is due to the adverse effects of blood transfusion or is, instead, the result of increased blood loss in the patients receiving blood.
To quantify the incidence of uterine leiomyoma confirmed by hysterectomy, ultrasound, or pelvic examination according to age and race among premenopausal women.
From September 1989 through May 1993, 95,061 premenopausal nurses age 25-44 with intact uteri and no history of uterine leiomyoma were followed to determine incidence rates of uterine leiomyoma. The self-reported diagnosis was confirmed in 93% of the medical records obtained for a sample of cases. Using pooled logistic regression, we estimated relative risks (RRs) of uterine leiomyoma according to race and examined whether adjustment for other potential risk factors could explain the variation in the race-specific rates.
During 327,065 woman-years, 4181 new cases of uterine leiomyoma were reported. The incidence rates increased with age, and the age-standardized rates of ultrasound- or hysterectomy-confirmed diagnoses per 1000 woman-years were 8.9 among white women and 30.6 among black women. After further adjustment for marital status, body mass index, age at first birth, years since last birth, history of infertility, age at first oral contraceptive use, and current alcohol consumption, the rates among black women were significantly greater for diagnoses confirmed by ultrasound or hysterectomy (RR 3.25; 95% confidence interval [CI] 2.71, 3.88) and by hysterectomy (RR 1.82; 95% CI 1.17, 2.82) compared with rates among white women. We observed similar RRs when the cohort was restricted to participants who reported undergoing a screening physical examination within the 2 years before baseline.
A higher prevalence of known risk factors did not explain the excess rate of uterine leiomyoma among premenopausal black women.
Uterine leiomyomas (fibroids, myomas) are the most common tumors occurring in the genital tract of women over 30 years of age. These benign uterine smooth-muscle tumors are estimated to be clinically significant in at least 25% of the American female population during their reproductive years. Furthermore, when thorough pathologic examination of hysterectomy specimens has been performed in patients with or without clinical history of myomatous uteri, the incidence of fibroids is 77%, suggesting that these tumors are far more prevalent than estimated by clinical cases. In spite of their high prevalence, little is known concerning the etiology or the molecular basis of their development and growth. It is well known that leiomyoma growth is regulated by ovarian steroid hormones, yet the exact molecular pathway(s) involved in tumor growth and the role of genetic susceptibility/predisposition and the environment are unclear. This article is an overview of some of the topics addressed at the conference on Women's Health and the Environment: The Next Century--Advances in Uterine Leiomyoma Research. A summary of research needs and recommendations for future research directions based on conference discussions are also presented.
To follow up in prospective fashion patients with coronary artery anastomoses completed endoscopically with robotic assistance. The robotic system was evaluated for safety and its effectiveness in completing microsurgical coronary anastomoses.
Recently there has been an interest in using robotics and computers to enhance the surgeon's ability to perform endoscopic cardiac surgery. This interest has stemmed from the rapid advancement of technology and the desire to make cardiac surgery less invasive. Using traditional endoscopic instruments, it has not been possible to perform coronary surgery.
Nineteen patients underwent robotically assisted endoscopic coronary artery bypass grafting of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD). Two robotic instruments and one endoscopic camera were placed through three 5-mm ports. A robotic system was used to construct the LITA-LAD anastomosis. All other required grafts were completed by conventional techniques.
Seventeen LITA-LAD grafts (89%) had adequate intraoperative flow. The mean LITA-LAD graft flow was 38.5 +/- 5 mL/min. At 8 weeks, LITA-LAD grafts were assessed by angiography and showed 100% patency with thrombolysis in myocardial infarction (TIMI) I flow. At a mean follow-up of 17 +/- 4.2 months, all patients were NYHA class I and there were no adverse cardiac events.
The results from the first prospective clinical trial of robotically assisted endoscopic coronary bypass surgery in the United States showed favorable short-term outcomes with no adverse events. Robotic assistance is an enabling technology allowing the performance of endoscopic coronary anastomoses.
Uterine leiomyoma, or fibroid tumors, are the leading indication for hysterectomy in the United States, but the proportion of women in whom fibroid tumors develop is not known. This study screened for fibroid tumors, independently of clinical symptoms, to estimate the age-specific proportion of black and white women in whom fibroid tumors develop.
Randomly selected members of an urban health plan who were 35 to 49 years old participated (n = 1364 women). Medical records and self-report were used to assess fibroid status for those women who were no longer menstruating (most of whom had had hysterectomies). Premenopausal women were screened by ultrasonography. We estimated the age-specific cumulative incidence of fibroid tumors for black and white women.
Thirty-five percent of premenopausal women had a previous diagnosis of fibroid tumors. Fifty-one percent of the premenopausal women who had no previous diagnosis had ultrasound evidence of fibroid tumors. The estimated cumulative incidence of tumors by age 50 was >80% for black women and nearly 70% for white women. The difference between the age-specific cumulative incidence curves for black and white women was highly significant (odds ratio, 2.9; 95% CI, 2.5-3.4; P <.001).
The results of this study suggest that most black and white women in the United States develop uterine fibroid tumors before menopause and that uterine fibroid tumors develop in black women at earlier ages than in white women.
To review the history, development, and current applications of robotics in surgery.
Surgical robotics is a new technology that holds significant promise. Robotic surgery is often heralded as the new revolution, and it is one of the most talked about subjects in surgery today. Up to this point in time, however, the drive to develop and obtain robotic devices has been largely driven by the market. There is no doubt that they will become an important tool in the surgical armamentarium, but the extent of their use is still evolving.
A review of the literature was undertaken using Medline. Articles describing the history and development of surgical robots were identified as were articles reporting data on applications.
Several centers are currently using surgical robots and publishing data. Most of these early studies report that robotic surgery is feasible. There is, however, a paucity of data regarding costs and benefits of robotics versus conventional techniques.
Robotic surgery is still in its infancy and its niche has not yet been well defined. Its current practical uses are mostly confined to smaller surgical procedures.
To identify the preoperative factors affecting the risk of conversion to laparotomy during total laparoscopic hysterectomy (TLH) indicated for benign conditions (surgery performed in cases of genital prolapse and/or urinary stress incontinence was excluded).
Retrospective comparative study (Canadian Task Force classification II-2).
University tertiary referral center for gynecologic endoscopic surgery.
Four hundred sixteen consecutive patients who underwent TLH during the first 5 years of our experience performing TLH.
Total laparoscopic hysterectomy.
The rate of conversion to laparotomy was 7% (29 patients). Factors that were found to be independently related to the risk of conversion to laparotomy are the following: body mass index (adjusted OR 1.09; 95% CI 1.01-1.18); uterine width on transvaginal ultrasonography (US) between 8 and 10 cm (adjusted OR 4.01; 95% CI 1.54-10.45); uterine width on US greater than 10 cm (adjusted OR 9.17; 95% CI 2.74-30.63); lateral myoma measuring greater than 5 cm on US (adjusted OR 3.57; 95% CI 0.97-13.17); history of adhesion-causing abdominopelvic surgery (adjusted OR 2.92; 95% CI 1.23-6.94).
Transvaginal US evaluation is essential before performing TLH. Awareness of the risk factors for conversion to laparotomy is essential for proper patient information and better selection of patients.
To determine if an enlarged uterus is associated with an increased rate of intraoperative and postoperative complications and prolonged hospital length of stay (LOS) after benign total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH).
Women who underwent TAH or TLH were stratified, according to uterine weight, into 3 groups: group 1, uterine weight < 200 g; group 2, 201-500 g; and group 3, > 500 g. Indications included uterine leiomyomas, chronic pelvic pain, prolapsed uterus, endometriosis and adenomyosis, dysfunctional uterine bleeding; all had benign final pathology. Statistical analysis compared risks of intraoperative and postoperative morbidity and prolonged hospital stay.
Prolonged hospital stay risk increased for uterine weight > 500 g (p < or = 0.001). There was a significant association between postoperative complications and uterine size (p < or = 0.001). Mean estimated blood loss (EBL) also increased with uterine weight > 500 g (p < or = 0.001). TLH was associated with fewer postoperative complications, shorter LOS and reduced EBL (p < or = 0.001).
Average LOS and risk of blood loss, blood transfusion and other postoperative complications after hysterectomy for benign disease increased with increasing uterine weight. TLH is an excellent alternative for enlarged uteri; it was strongly associated with decreased morbidity, shorter LOS, and reduced EBL and blood transfusion rate in all uterine weight groups when adjusted for other variables.
Socioeconomic status and race are important determinants of health care access in the United States. The purpose of our study was to evaluate whether these factors influence use of laparoscopic hysterectomy for management of benign gynecologic diseases.
Retrospective cohort study (Canadian Task Force classification II-3).
Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 1998 to 2002.
All records of women with primary discharge diagnosis of uterine leiomyomas or menorrhagia who underwent hysterectomy (laparoscopy or abdominal) were included in the study.
Race (Caucasian, African-American, Hispanic, or other), median household income (<25000, 25000-34999, 35000-45000), and insurance status (private, Medicare, Medicaid, or other) were evaluated as determinants of laparoscopic surgical intervention. Unconditional logistic regression was used to estimate likelihood of laparoscopic approach to hysterectomy.
Of 341487 records for hysterectomy, 295857 were performed by abdominal and 45630 by laparoscopic approach. In adjusted analyses, African-Americans, Hispanics, and other ethnicities were less likely to undergo laparoscopic hysterectomy; adjusted OR (95% CI): 0.44 (0.42-0.45), 0.58 (0.55-0.61), and 0.68 (0.64-0.72), respectively, as compared with Caucasians. As compared with women with median income of less than 25000 to 35000 to 45000 and above, 1.14 (1.06-1.22). As compared with women with Medicaid, laparoscopic approach was more likely to be performed on women with private insurance: 1.45 (1.42-1.62).
In the United States, median household income, insurance status, and race appear to be important independent determinants of access to laparoscopic hysterectomy for benign diseases.
To compare gynecologic practice and perioperative outcomes of patients undergoing total laparoscopic hysterectomy and robotic hysterectomy before and after implementation of a robotics program.
A retrospective chart review of the last 200 consecutive hysterectomy cases completed before and after implementation of a robotics program (Canadian Task Force classification III).
Community hospital.
All patients requiring hysterectomy for benign indications between November 2004 and January 2007.
Patients were candidates for total laparoscopic, abdominal, or vaginal hysterectomy before February 2006 and were candidates for total laparoscopic, total abdominal, total vaginal, or robotic-assisted laparoscopic hysterectomy after February 2006. Perioperative characteristics and trends were studied.
In all, 100 patients intended to be treated by laparoscopic hysterectomy before the implementation of a robotics program were compared with 100 patients treated by robotic hysterectomy after robot implementation. Overall the robotic cohort experienced longer operative times by an average of 27 minutes. The prerobotic cohort, however, when compared with the last 25 robotic cases had longer operative times (92.4 minutes [29.2], 95% CI 46.0-225.0 vs 78.7 minutes [29.5], 95% CI 66.0-91.2, p = .03). The mean blood loss in the prerobotic cohort was twice that of the robotic cohort (113 mL [85.9], 95% CI 95.9-130.1 vs 61.1 mL [60.9], 95% CI 48.9-73.2, p <.0001) and the mean length of hospital stay was half a day longer in the prerobotic cohort than in the robotic cohort (1.6 days [1.4], 95% CI 1.3-1.9 vs 1.1 days [0.7], 95% CI 1.0-1.3, p <.007). The incidence of adverse events was the same in both groups. The total number of exploratory laparotomies in the prerobotic cohort was significantly greater than in the robotic group (11% vs 0%). The rate of intraoperative conversions to total abdominal hysterectomy from laparoscopy was approximately 2-fold higher in the prerobotic cohort as compared with the robotic cohort (9% vs 4%).
A higher likelihood of exploratory laparotomy for hysterectomy in the prerobotic cohort versus the robotic cohort and a higher likelihood of intraoperative conversion to laparotomy with the prerobotic cohort than with the robotic cohort existed. Reduced operative time, reduced blood loss, and shortened length of stay may be achieved in patients who are treated robotically versus a nonrobotic approach. Robotics may facilitate the minimally invasive treatment of patients while potentially reducing the rate of abdominal hysterectomies.
ACOG Committee Opinion No. 444: choosing the route of hysterectomy for benign disease
The effects of body mass on lung volumes, respiratory mechanics, and gas exchange during general anesthesia
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