A comparison of quality outcome measures in patients having a hysterectomy for benign disease: robotic vs. non-robotic approaches.

To measure procedure-related hospital readmissions within 30 days after discharge for patients who have a hysterectomy for benign disease. Secondary outcome quality measures evaluated were cost, estimated blood loss, length of stay and sum of costs associated with readmissions. Retrospective cohort study (Canadian Task Force classification II-2). Academic community hospital. Patients who underwent hysterectomy to treat benign disease from January 2008 to December 2012. Patients were grouped according to route of hysterectomy: robotic-assisted laparoscopic hysterectomy (robotic), laparoscopic hysterectomy (laparoscopic), abdominal hysterectomy (open via laparotomy), and vaginal hysterectomy (vaginal). Inclusion criteria were met by 2554 patients: 601 in the robotic group, 427 in the laparoscopic group, 1194 in the abdominal group, and 332 in the vaginal group. Readmission rates in the robotic cohort were significantly less (p<.05) than in non-robotic cohorts: Robotic (1%), laparoscopic (2.5%), open (3.5%), vaginal (2.4%). Estimated blood loss, length of stay, and sum of readmission costs were also significantly less in the robotic cohort (p<.05) compared with the other 3 cohorts. Patients who undergo robotic-assisted laparoscopic hysterectomy have a significantly lower chance of readmission <30 days after surgery compared with those who undergo laparoscopic, abdominal (open) hysterectomy, and vaginal approaches. Patients in the robotics cohort also experienced a shorter length of stay, less estimated blood loss, and a cost savings associated with readmissions when compared to non-robotic approaches. Prospective registries describing quality outcomes, total sum of costs including 30 days follow-up, as well as patient-related quality of life benefits are recommended to confirm these findings and determine which surgical route offers the highest patient and societal value.

Martino MA ，Berger EA ，McFetridge JT ，Shubella J ，Gosciniak G ，Wejkszner T ，Kainz GF ，Patriarco J ，Thomas MB ，Boulay R ... -  《-》

A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice.

Payne TN ，Dauterive FR 《Journal of Minimally Invasive Gynecology》

Predictors of 30-day readmission following hysterectomy for benign and malignant indications at a tertiary care academic medical center.

Hospital readmissions are costly, frequent, and increasingly under public scrutiny. With increased financial constraints on the medical environment, understanding the drivers of unscheduled readmissions following gynecologic surgery will become increasingly important to value-driven care. The current study was conducted to identify risk factors for 30-day readmission following hysterectomy for benign and malignant indications. A retrospective cohort study was conducted from 2008 through 2010 of all nongravid hysterectomies at a single tertiary care academic medical center. Clinical, perioperative, and physician characteristics were collected. Multivariable logistic regression models were used to identify predictors of 30-day readmission, stratified by malignant and benign indications for hysterectomy. Among 1649 women who underwent a hysterectomy (1009 for benign indications and 640 for malignancy), 6% were subsequently readmitted within 30 days (8.9% for malignancy vs 4.2% for benign; P < .0001). The mean time to readmission was 13 days (15 days for malignancy vs 10 days for benign; P = .004). The most common reasons for readmission were gastrointestinal (38%) and infectious (34%) etiologies, and 11.6% of readmitted patients experienced a perioperative complication. Among women undergoing hysterectomy for benign indications, a history of a laparotomy, including cesarean delivery (adjusted odds ratio [AOR], 2.12; 95% confidence interval [CI], 1.06-4.25; P = .03), as well as a perioperative complication (AOR, 2.41; 95% CI, 1.00-6.04; P = .05) were both associated with a >2-fold increased odds of readmission. Among women undergoing hysterectomy for malignancy, an American Society of Anesthesiologists Physical Status Classification of III or IV (AOR, 1.92; 95% CI, 1.05-3.50; P = .03), a longer length of initial hospitalization (3 days AOR, 7.83; 95% CI, 1.33-45.99; P = .02), and an estimated blood loss >500 mL (AOR, 3.29; 95% CI, 1.28-8.45; P = .01) were associated with a higher odds of readmission; however, women who underwent a laparoscopic hysterectomy (AOR, 0.32; 95% CI, 0.12-0.86; P = .02) and who were discharged on postoperative day 1 (AOR, 0.16; 95% CI, 0.03-0.82; P = .02) were at a decreased risk of readmission. Physician and operative characteristics were not significant predictors of readmission. This study found that malignancy, perioperative complications, and prior open abdominal surgery, including cesarean delivery, are significant risk factors for consequent 30-day readmission following index hysterectomy. It may be possible to identify patients at highest risk for readmission at the time of hysterectomy, which can assist in developing interventions to reduce such events.

Lee MS ，Venkatesh KK ，Growdon WB ，Ecker JL ，York-Best CM ... -  《-》

A Comparison of Outcomes Between Robotic-Assisted, Single-Site Laparoscopy Versus Laparoendoscopic Single Site for Benign Hysterectomy.

To compare the perioperative outcomes, including estimated blood loss, conversion to open laparotomy, length of stay, and total operative time of hysterectomies using robotic-assisted, single-site laparoscopy with laparoendoscopic single site (LESS) for benign indications. A retrospective cohort study (Canadian Task Force classification Level II-2. Multicenter (private hospitals). Gynecologic patients who underwent a hysterectomy for benign indications via robotic-assisted, single-site laparoscopy (n = 50) versus LESS (n = 50). Observational study. Continuous outcomes were analyzed using multiple linear regression, whereas the dichotomous outcome of conversion was analyzed using a multiple log-binomial regression model. Linear and log-binomial regression coefficients were adjusted for the ages of the patients and other clinical factors. A total of 100 consecutive patient records were available for analysis: 50 for robotic-assisted, single-site laparoscopy and 50 for LESS. Univariate analyses revealed that both groups were similar in mean age (robotic, 46.0 years; LESS, 45.4 years; p = .75), but not mean body mass index (robotic, 25.9 kg/m(2); LESS, 28.8 kg/m(2); p = .02). There was no difference in the unadjusted (crude) risk of conversion to a multiport procedure between the robotic and laparoscopic groups (p = .37). There were only 2 major complications (cystotomy and vaginal dehiscence) in the LESS arm and 1 vaginal dehiscence in the robotic-assisted, single-site arm. After adjusting for 7 potential confounders, no relationship was detected between the type of approach (robotic vs laparoscopic) and the outcome of a major complication (exact odds ratio, 0.55; exact p = 1.0). A multivariate linear regression analysis that compared the 2 groups (robotic-assisted single site vs LESS) revealed no differences in estimated blood loss. On average, the robotic-assisted, single-site group had a length of stay that was 8.12 hours shorter than the LESS group (p = .003) after adjusting for patient characteristics. Total operative time was an average of 24.9 min longer in the robotic-assisted, single-site group (p = .002) after adjustment. A plot of total operative time in minutes by chronological case number and procedural approach was analyzed to estimate a learning curve. This plot showed a steeper learning curve with the robotic-assisted, single-site approach. This preliminary observational study found that the robotic-assisted, single-site group had a statistically significant decrease in length of hospital stay, but also experienced an increase in total operative time. There were no conversions to open laparotomies.

Lopez S ，Mulla ZD ，Hernandez L ，Garza DM ，Payne TN ，Farnam RW ... -  《-》

Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications.

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. We sought to compare clinical outcomes and estimated cost of robotic-assisted vs other routes of minimally invasive hysterectomy for benign indications. 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. 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 $3269 per case, or 24% lower cost, compared to robotic-assisted hysterectomy ($10,160 vs $13,429). 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.

Swenson CW ，Kamdar NS ，Harris JA ，Uppal S ，Campbell DA Jr ，Morgan DM ... -  《-》