Inpatient Hospital Costs and Route of Hysterectomy for Management of Benign Uterine Disease in the 90-Day Global Billing Period.

To compare inpatient hospital costs and complication rates within the 90-day global billing period among routes of hysterectomy. The Premier Healthcare Database was used to identify patients who underwent hysterectomy between 2000 and 2020. Current Procedural Terminology codes were used to group patients based on route of hysterectomy. Comorbidities and complications were identified using International Classification of Diseases codes. Fixed, variable, and total costs for inpatient care were compared. Fixed costs consist of costs that are set for the case, such as operating room time or surgeon costs. Variable costs include disposable and reusable items that are billed additionally. Total costs equal fixed and variable costs combined. Data were analyzed using analysis of variance, t test, and χ 2 test, as appropriate. Factors independently associated with increased total costs were assessed using linear mixed effects models. Multivariate logistic regression was performed to evaluate associations between the route of surgery and complication rates. A cohort of 400,977 patients were identified and grouped by route of hysterectomy. Vaginal hysterectomy demonstrated the lowest inpatient total cost ($6,524.00 [interquartile range $4,831.60, $8,785.70]), and robotic-assisted laparoscopic hysterectomy had the highest total cost ($9,386.80 [interquartile range $6,912.40, $12,506.90]). These differences persisted with fixed and variable costs. High-volume laparoscopic and robotic surgeons (more than 50 cases per year) had a decrease in the cost difference when compared with costs of vaginal hysterectomy. Abdominal hysterectomy had a higher rate of complications relative to vaginal hysterectomy (adjusted odds ratio [aOR] 1.52, 95% CI, 1.39-1.67), whereas laparoscopic (aOR 0.85, 95% CI, 0.80-0.89) and robotic-assisted (aOR 0.92, 95% CI, 0.84-1.00) hysterectomy had lower rates of complications compared with vaginal hysterectomy. Robotic-assisted hysterectomy is associated with higher surgical costs compared with other approaches, even when accounting for surgeon volume. Complication rates are low for minimally invasive surgery, and it is unlikely that the robotic-assisted approach provides an appreciable improvement in perioperative outcomes.

Bauer HH ，Sahmoud A ，Rhodes SP ，Sheyn D ... -  《-》

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 ... -  《-》

The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for the large uterus.

There are currently sparse data on the relationship between surgeon- and patient-related factors and perioperative morbidity in the setting of elective hysterectomy for the larger uterus. We sought to evaluate the impact of surgeon case volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for uteri >250 g. This is a retrospective cohort study of all women who underwent total vaginal, total laparoscopic, laparoscopic-assisted vaginal, or robotic-assisted total laparoscopic hysterectomy from January 2014 through July 2016. Hysterectomy was performed for: fibroids, pelvic pain, abnormal uterine bleeding, or prolapse. Patients were identified by Current Procedural Terminology codes and the systemwide electronic medical record was queried for demographic and perioperative data. Perioperative adverse events were defined a priori and classified using the Clavien-Dindo scale. Surgeon case volume was defined as the mean number of minimally invasive hysterectomy cases performed per month by each surgeon during the study period. In all, 763 patients met inclusion criteria: 416 (54.5%) total laparoscopic hysterectomy, 196 (25.7%) robotic-assisted total laparoscopic hysterectomy, 90 (11.8%) total vaginal hysterectomy, and 61 (8%) laparoscopic-assisted vaginal hysterectomy. Mean (±SD) age was 47.3 ± 6.1 years, and body mass index was 31.1 ± 7.4 kg/m2. In all, 66 surgeons performed minimally invasive hysterectomy for uteri >250 g during the study period, and the median rate of minimally invasive hysterectomy cases for large uteri per month was 3.4 (0.4-3.7) cases/month. The median (IQR) uterine weight was 409 (308-606.5) g. The rate of postoperative adverse events Dindo grade >2 was 17.8% (95% confidence interval, 15.2-20.7). The overall rate of intraoperative adverse events was 4.2% (95% confidence interval, 2.9-5.9). The rate of conversion to laparotomy was 5.5% (95% confidence interval, 4.0-7.4). There was no significant difference in adverse event rates between the routes of minimally invasive hysterectomy cases (25.6% vs 17.5% vs 18.0% vs 14.8% for total laparoscopic hysterectomy, robotic-assisted laparoscopic hysterectomy, total vaginal hysterectomy, and laparoscopic-assisted vaginal hysterectomy, respectively, P = .2). In a logistic regression model controlling for age, body mass index, uterine weight, operating time, and history of laparotomy, higher monthly minimally invasive hysterectomy volume was significantly associated with the likelihood that a patient would experience a postoperative adverse event (adjusted odds ratio, 1.1 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.0-1.3). When controlling for the same variables, a higher incidence of intraoperative complications was significantly associated with monthly minimally invasive hysterectomy case volume (adjusted odds ratio, 1.5 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.20-2.08). Increasing age was associated with a lower incidence of complications (adjusted odds ratio, 0.9 for each additional year; 95% confidence interval, 0.8-0.9). Higher monthly minimally invasive hysterectomy volume was associated with a lower rate of conversion from a minimally invasive approach to laparotomy (adjusted odds ratio, 0.4 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 0.2-0.5). The overall rate of serious adverse events associated with minimally invasive hysterectomy for uteri >250 g was low. Higher monthly minimally invasive hysterectomy case volume was associated with a higher rate of intraoperative and postoperative adverse events but was associated with a lower rate of conversion to laparotomy.

Bretschneider CE ，Frazzini Padilla P ，Das D ，Jelovsek JE ，Unger CA ... -  《-》

Cost evaluation, quality of life and pelvic organ function of three approaches to hysterectomy for benign uterine conditions: study protocol for a randomized controlled trial.

Ekanayake C ，Pathmeswaran A ，Kularatna S ，Herath R ，Wijesinghe P ... -  《Trials》

Laparoscopic and Robotic-Assisted Hysterectomy for Uterine Leiomyomas: A Comparison of Complications and Costs.

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. 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. 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 $33 928.00 compared with $23 753.00 for laparoscopic hysterectomy. 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.

Ngan TYT ，Zakhari A ，Czuzoj-Shulman N ，Tulandi T ，Abenhaim HA ... -  《-》