Cross sectional survey of Ob/Gyn residents' graduated experience with robotic surgery.

STUDY OBJECTIVE: Ob/Gyn resident experience with robotic gynecologic surgery has been evaluated at time of graduation, but no specific surgical procedures were identified to differentiate the experiences of residents at each level. This study proposes to determine which factors are correlated with more hands-on robotic surgery experience and resident satisfaction. DESIGN: An IRB-approved, 15-question survey was distributed electronically. 98 responses were received for a rate of 44%. Linear regression and ANOVA statistical analysis were performed. SETTING: Current residents at eight Ob/gyn residency programs in the US were surveyed. PATIENTS: N/A INTERVENTIONS: Survey administration MEASUREMENT AND MAIN RESULTS: The majority of respondents were satisfied (48%) or had neutral feelings (20%) with regard to their robotic surgery experience. All respondents reported experience with uterine manipulation or bedside assisting by PGY2. Earliest experience performing hysterectomy was most common in PGY2 or PGY3. Seventy-six percent of PGY3 or PGY4 residents report operating on the console for some or all major robotic surgeries, with 69% having participated in greater than 20 robotic surgery cases during residency. Only exposure to MIGS faculty is significantly associated with high robotic surgery experience (p=.022). Overall satisfaction with robotic surgery experience increased significantly with higher level of participation (p<.0001), particularly operating at the console during some or most of the surgery; longitudinal experiences with hysterectomy, myomectomy, and salpingectomy/oophorectomy (p<.05); but not with solely bedside assisting or vaginal cuff closure. Factors limiting robotic console experience included case time constraints, lack of first assists, case complexity, and attending comfort. CONCLUSIONS: Ob/Gyn resident satisfaction with training is significantly related to level and duration of robotic surgery participation. MIGS faculty contribute to more resident experience, and limiting factors include time constraints, case complexity and lack of first assists. These results can provide a framework for structuring resident training in robotic surgery.

Feasibility and Perioperative Outcomes of Minimally Invasive Higher Order Myomectomy.

STUDY OBJECTIVE: To investigate perioperative outcomes of minimally invasive higher order myomectomy as defined by removal of 10 or more fibroids. DESIGN: A retrospective cohort study between January 2018 and December 2022. SETTING: A tertiary academic medical center. PATIENTS: Women who underwent minimally invasive myomectomy via laparoscopic or robotic approach. INTERVENTIONS: Surgical intervention in the form of minimally invasive myomectomy. MEASUREMENTS AND MAIN RESULTS: A total of 735 women met inclusion criteria of whom 578 had fewer than 10 fibroids removed, and 157 patients had 10 or more removed (average number of fibroids removed 3.8 vs 14.7, p <.001; specimen's weight 317.4 g vs 371.0 g, p = .07). Body mass index was similar in both groups (p = .66) and patients with higher order myomectomy were more likely to have a history of myomectomy (12.0% vs 26.8%, p <.001). The average estimated blood loss (EBL) was 246 mL vs 470 mL in each group (p <.001). There were no significant differences in packed red blood cell transfusion (1.0% vs 0.6%, p = .65), conversion to laparotomy (0.5% vs 0.6%, p = .86), or complications including visceral injury, wound complication, venous thromboembolism, ileus, or readmission (5.9% vs 4.5%, p = .49). The hospital length of stay was similar in both groups (0.5 days vs 0.5 days, p = .63). On linear regression analysis, after adjusting for specimen's weight, operative time, and history of myomectomy, EBL remained significantly higher in patients with 10 or more fibroids removed (p = .02). CONCLUSION: EBL is increased in higher order myomectomy; however, blood transfusions, conversion to laparotomy, complication rates, and length of hospital stay did not differ compared with patients with fewer than 10 fibroids removed, highlighting the feasibility of minimally invasive higher order myomectomy.

Abdominal hysterectomy and high frailty score are associated with complications among older patients.

OBJECTIVE: To evaluate effects of frailty and hysterectomy route on 30-day postoperative morbidity for older hysterectomy patients. METHODS: Participants included patients in the American College of Surgeons' National Surgical Quality Improvement Program database aged 60 years or older and undergoing simple hysterectomy from 2014 to 2018. The Five-Factor Modified Frailty Index approximated frailty: women with scores of 3 or more, indicating more severe comorbidities, were considered frail. Logistic regression multivariable models with and without an interaction term were used to study the independent and interactive effects of frailty and route on postoperative complications. RESULTS: Of 19 888 hysterectomies, 4356 (21.9%) were abdominal, 13 382 (67%) were laparoscopic, and 2150 (10.8%) were vaginal, with 251 (1.3%) frail patients. Frailty (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.32-2.70, P = 0.001) and abdominal versus laparoscopic hysterectomy (OR 2.14, 95% CI 1.88-2.45, P < 0.001) increased complication odds. Assessing interaction, complication odds for abdominal versus laparoscopic hysterectomy were higher for frail patients (OR 4.12, 95% CI 1.96-8.67, P < 0.001) versus non-frail patients (OR 2.10, 95% CI 1.84-2.40). CONCLUSION: Frail older patients have increased risk for hysterectomy complications, especially with abdominal hysterectomy versus laparoscopic hysterectomy. A frailty index can be a useful preoperative tool to guide counseling and route choice.

Volume-outcome relationships for kidney cancer may be driven by disparities and patient risk.

PURPOSE: Provider and hospital factors influence healthcare quality, but data are lacking to assess their impact on renal cancer surgery. We aimed to assess factors related to surgeon and hospital volume and study their impact on 30-day outcomes after radical nephrectomy. MATERIALS AND METHODS: Renal surgery data were abstracted from Maryland's Health Service Cost Review Commission from 2000 to 2018. Patients ≤18 years old, without a diagnosis of renal cancer, and concurrently receiving another major surgery were excluded. Volume categories were derived from the mean annual cases distribution. Multivariable logistic and linear regression models assessed the association of volume on length of stay, intensive care days, cost, 30-day mortality, readmission, and complications. RESULTS: 7,950 surgeries, completed by 573 surgeons at 48 hospitals, were included. Demographic, surgical, and admission characteristics differed between groups. Radical nephrectomies performed by low volume surgeons demonstrated increased post-operative complication frequency, mortality frequency, length of stay, and days spent in intensive care relative to other groups. However, after logistic regression adjusting for clinical risk and socioeconomic factors, only increased length of stay and ICU days remained associated with lower surgeon volume. Similarly, after adjusted logistic regression, hospital volume was not associated with the studied outcomes. CONCLUSIONS: Surgeons and hospitals differ in regards to patient demographic and clinical factors. Barriers exist regarding access to high-volume care, and thus some volume-outcome trends may be driven predominantly by disparities and case mix.

Comparison of Perioperative and Pathologic Outcomes Between Single-port and Standard Robot-assisted Radical Prostatectomy: An Analysis of a High-volume Center and the Pooled World Experience.

OBJECTIVE: To perform an early comparative study of outcomes between single-port and robot-assisted laparoscopic radical prostatectomy (SP-RALRP) and standard RALRP at our institution and pooled analysis of series to date. PATIENTS AND METHODS: Patients with organ-confined prostate cancer undergoing SP-RALRP at a high-volume institution were identified retrospectively along with reported SP-RALRP series to date. Data were compared to a contemporary prospective cohort of men undergoing standard RALRP. Patient demographics, perioperative and postoperative data, and complications categorized by the Clavien-Dindo system were compared for the institutional and pooled SP-RALRP cohorts to standard RALRP. RESULTS: A total of 208 SP-RALRP cases were identified (26 from our institution) and compared to 376 standard RALRP cases. In the institutional analysis, there was no difference in operative time, length of stay, overall complications (15.4% vs 17.3%, P= 1.0), major (Clavien ≥III) complications (3.8% vs 3.7%, P = .6), inpatient opioid use, or patient-reported pain scores; median estimated blood loss (100 mL vs 150 mL, P = .02) and number of lymph nodes removed (5.5 vs 9, P = .002) were lower for SP-RALRP. In the pooled analysis, 208 patients receiving SP-RALRP had similar estimated blood loss and complication rates but fewer lymph nodes removed (P = .02) and marginally longer operating time (+16 minutes, P = .01) compared to standard RALRP. The difference in rate of positive surgical margins was not statistically significant (31.3% vs 24.5%, P = .08). CONCLUSION: Based on an early experience with SP-RALRP at a high-volume center and a pooled analysis of SP series to date, perioperative and pathologic outcomes appear nearly equivalent compared to standard RALRP.