The Impact of Exclusively Virtual Preoperative Evaluation on Complications of Gynecologic Surgery.

To evaluate the impact of virtual versus in-person preoperative evaluation on perioperative complication rates in a minimally invasive gynecologic surgery (MIGS) practice. Retrospective cohort study. Quaternary care academic hospital in the United States. Patients who underwent surgery with a MIGS surgeon between January 2016 and May 2023. Patients underwent either in-person or virtual preoperative visits (defined as the initial consultation and any subsequent follow-up or preoperative counseling visits). Those who had both an in-person and virtual preoperative visit were excluded. Complication rates among the virtual and in-person cohorts were compared, and logistic regression was performed to adjust for potential confounders. The analysis included 2,947 patients, 1196 (40.6%) with exclusively virtual preoperative visits and 1751 (59.4%) with exclusively in-person visits. Following the implementation of telemedicine in 3/2020, 80.6% of patients had all their preoperative visits conducted virtually via videoconference. Surgical approach included conventional laparoscopy (78.8%), robotic-assisted laparoscopy (3.8%), laparotomy (2.1%), and other gynecologic procedures without abdominal entry (15.3%). The most common procedures were endometriosis excision (43.1%), myomectomy (34.0%), and hysterectomy (24.8%). Composite perioperative complication rates were similar between cohorts (5.9% virtual vs 6.3% in-person, adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.58-1.17). There were no significant differences for major complications (2.3% virtual vs 1.2% in-person, aOR 1.52, 95% CI 0.85-2.74) or minor complications (5.7% virtual vs 6.1% in-person, aOR 0.83, 95% CI 0.59-1.19). Conversion to laparotomy was rare in both groups (0.1% virtual vs 0.2% in-person). Implementation of virtual preoperative visits within a MIGS practice did not impact composite surgical complication rates. For subspecialized gynecologic surgeons, a virtual preoperative evaluation may offer a safe alternative to the traditional in-person visit.

Schneyer RJ ，Meyer R ，Hamilton KM ，Truong MD ，Wright KN ，Siedhoff MT ... -  《-》

The Impact of Minimally Invasive Gynecologic Surgery Subspecialty Training on Outcomes of Myomectomy: A Retrospective Cohort Study.

To compare surgical outcomes among patients undergoing minimally invasive myomectomy (MIM) or abdominal myomectomy (AM) with MIGS subspecialists versus general obstetrician/gynecologists (OB/GYNs), and to characterize the complexity of myomectomies by surgeon type. Retrospective cohort study. Quaternary care institution. Patients who underwent MIM (laparoscopic or robotic) or AM with a fellowship-trained MIGS subspecialist or general OB/GYN from March 15, 2015 to March 14, 2020. Myomectomy. Of 609 myomectomies, 460 (75.5%) were MIM, 404 (87.8%) of which were performed by MIGS subspecialists. The remaining 149 (24.5%) cases were AM, 36 (24.1%) of which were performed by MIGS subspecialists. Compared to general OB/GYNs, MIGS subspecialists excised a greater number of fibroids for both MIM (median 3.0 [range 1.0-30.0] vs 2.0 [1.0-9.0], p <.001) and AM (21.0 [10.0-60.0] vs 6.0 [1.0-42.0], p <.001), and had a greater proportion of uteri >20 weeks size for AM (22.2% vs 3.5%, p = .003). Composite perioperative complication rates were significantly higher for general OB/GYNs than for MIGS subspecialists (29.0% vs 11.8%, adjusted odds ratio [aOR] 2.70, 95% confidence interval [CI] 1.48-4.92). In a subgroup analysis of MIM only, general OB/GYNs had higher rates of composite perioperative complications (28.6% vs 9.9%, aOR 4.51, 95% CI 2.27-8.97), excessive blood loss and/or transfusion (10.7% vs 3.0%, unadjusted odds ratio [OR] 3.92, 95% CI 1.41-10.91), surgery time ≥ 90th percentile (25.0% vs 8.9%, aOR 5.05, 95% CI 2.39-10.64), and conversions to laparotomy (10.7% vs 0.2%, unadjusted OR 48.36, 95% CI 5.71-409.93). For AM only, there were no significant differences in perioperative complication rates between groups. Fellowship-trained MIGS subspecialists had improved surgical outcomes for MIM compared to general OB/GYNs, with fewer conversions to laparotomy, reduced surgery time, and less blood loss, while outcomes for AM were similar by surgeon type. MIGS subspecialists excised a greater number of fibroids regardless of surgical approach, highlighting a level of comfort in complex benign gynecology beyond endoscopic surgery at our institution.

Schneyer RJ ，Meyer R ，Barker ML ，Hamilton KM ，Siedhoff MT ，Truong MD ，Wright KN ... -  《-》

The impact of minimally invasive gynecologic surgery subspecialty training on outcomes of benign laparoscopic hysterectomy- a retrospective cohort study.

Meyer R ，Schneyer R ，Hamilton K ，Levin G ，Truong MD ，Siedhoff MT ，Wright KN ... -  《-》

Geographic and racial disparities in the quality of surgical care among patients with nonmetastatic uterine cancer.

Although the rates of minimally invasive surgery and sentinel lymph node biopsy have increased considerably over time in the surgical management of early-stage uterine cancer, practice varies significantly in the United States, and there are disparities among low-volume centers and patients of Black race. A significant number of counties in the United States are without a gynecologic oncologist, and almost half of the counties with the highest gynecologic cancer rates lack a local gynecologic oncologist. This study aimed to evaluate the relationships of distance traveled and proximity to gynecologic oncologists with the receipt of and racial disparities in the quality of surgical care among patients who underwent a hysterectomy for nonmetastatic uterine cancer. Patients who underwent a hysterectomy for nonmetastatic uterine cancer in Kentucky, Maryland, Florida, and North Carolina were identified in the 2012 to 2018 State Inpatient Database and the State Ambulatory Surgery Services Database files. County-to-county distances were used as the distances traveled to the nearest gynecologic oncologist. Factors associated with the receipt of minimally invasive surgery and lymph node dissection were analyzed using multivariable logistic regression models, as was the assessment of the interaction between travel for surgery and patient race. Among 21,837 cases, 45.5% lived in a county without a gynecologic oncologist; overall, 55.5% traveled to another county for surgery, including 88% of those who lacked a local gynecologic oncologist. Patients who lacked access to a local gynecologic oncologist in their county who did not travel for surgery were more likely to receive open surgery and no lymph node dissection, and those in counties without access in any surrounding county were affected even more. Among patients in counties without a gynecologic oncologist, those who traveled for surgery had a similar likelihood of undergoing minimally invasive surgery (71%) but had a greater likelihood of undergoing lymph node dissection (64.7% vs 57.2%) than nontravelers. Among those in counties without a gynecologic oncologist, a longer distance traveled was associated with receipt of a lymph node assessment. When compared with non-Black patients, Black patients were less likely to undergo minimally invasive surgery (57.0% vs 74.1%). In adjusted regression models that controlled for a diagnosis of fibroids, Black race was an independent risk factor for the receipt of open surgery. There was a significant interaction between Black race and travel for surgery, and Black patients who lived in counties without a gynecologic oncologist who did not travel faced an incrementally lower likelihood of receiving minimally invasive surgery (odds ratio, 0.57 when compared with non-Black patients who traveled for surgery; odds ratio, 0.60 as interaction term; P<.001 for both). Similar disparities in surgical quality by race were noted for Black patients who lived in counties with a gynecologic oncologist who traveled out of county for surgery. Patients, particularly those of Black race, who lacked local access to gynecologic oncologist specialty care benefitted from traveling to specialty centers to ensure access to high-quality surgery for nonmetastatic uterine cancer. Further work is needed to ensure equitable and universal access to high-quality care through patient travel or specialist outreach.

Anastasio MK ，Spees L ，Ackroyd SA ，Shih YT ，Kim B ，Moss HA ，Albright BB ... -  《-》

Approach to radical hysterectomy for cervical cancer after the Laparoscopic Approach to Cervical Cancer trial and associated complications: a National Surgical Quality Improvement Program study.

The Laparoscopic Approach to Cervical Cancer study results revolutionized our understanding of the best surgical management for this disease. After its publication, the guidelines state that the standard and recommended approach for radical hysterectomy is an open abdominal approach. Nevertheless, the effect of the Laparoscopic Approach to Cervical Cancer trial on real-world changes in the surgical approach to radical hysterectomy remains elusive. This study aimed to investigate the trends and routes of radical hysterectomy and to evaluate postoperative complication rates before and after the Laparoscopic Approach to Cervical Cancer trial (2018). The National Surgical Quality Improvement Program registry was used to examine radical hysterectomy for cervical cancer performed between 2012 and 2022. This study excluded vaginal radical hysterectomies and simple hysterectomies. The primary outcome measures were the trends in the route of surgery (minimally invasive surgery vs laparotomy) and surgical complication rates, stratified by periods before and after the publication of the Laparoscopic Approach to Cervical Cancer trial in 2018 (2012-2017 vs 2019-2022). The secondary outcome measure was major complications associated specifically with the different routes of surgery. Of the 3611 patients included, 2080 (57.6%) underwent laparotomy, and 1531 (42.4%) underwent minimally invasive radical hysterectomy. There was a significant increase in the minimally invasive surgery approach from 2012 to 2017 (45.6% in minimally invasive surgery in 2012 to 75.3% in minimally invasive surgery in 2017; P<.01) and a significant decrease in minimally invasive surgery from 2018 to 2022 (50.4% in minimally invasive surgery in 2018 to 11.4% in minimally invasive surgery in 2022; P<.001). The rate of minor complications was lower in the period before the Laparoscopic Approach to Cervical Cancer trial than after the trial (317 [16.9%] vs 288 [21.3%], respectively; P=.002). The major complication rates were similar before and after the Laparoscopic Approach to Cervical Cancer trial (139 [7.4%] vs 78 [5.8%], respectively; P=.26). The rates of blood transfusions and superficial surgical site infections were lower in the period before the Laparoscopic Approach to Cervical Cancer trial than in the period after the trial (137 [7.3%] vs 133 [9.8%] [P=.012] and 20 [1.1%] vs 53 [3.9%] [P<.001], respectively). In a comparison of minimally invasive surgery vs laparotomy radical hysterectomy during the entire study period, patients in the minimally invasive surgery group had lower rates of minor complications than in those in the laparotomy group (190 [12.4%] vs 472 [22.7%], respectively; P<.001), and the rates of major complications were similar in both groups (100 [6.5%] in the minimally invasive surgery group vs 139 [6.7%] in the laparotomy group; P=.89). In a specific complications analysis, the rates of blood transfusion and superficial surgical site infections were lower in the minimally invasive surgery group than in the laparotomy group (2.4% vs 12.7% and 0.6% vs 3.4%, respectively; P<.001; for both comparisons), and the rate of deep incisional surgical site infections was lower in the minimally invasive surgery group than in the laparotomy group (0.2% vs 0.7%, respectively; P=.048). In the multiple logistic regression analysis, the route of radical hysterectomy was not independently associated with the occurrence of major complications (adjusted odds ratio, 1.02; 95% confidence interval, 0.63-1.65). Although the proportion of minimally invasive radical hysterectomies decreased abruptly after the Laparoscopic Approach to Cervical Cancer trial, there was no change in the rate of major postoperative complications. In addition, the hysterectomy route was not associated with major postoperative complications.

Levin G ，Ramirez PT ，Wright JD ，Slomovitz BM ，Hamilton KM ，Schneyer RJ ，Barnajian M ，Nasseri Y ，Siedhoff MT ，Wright KN ，Meyer R ... -  《-》