Long-Term Costs of Minimally Invasive Sacral Colpopexy Compared to Native Tissue Vaginal Repair With Concomitant Hysterectomy.

STUDY OBJECTIVE: To determine the long-term costs of hysterectomy with minimally invasive sacrocolpopexy (MISCP) versus uterosacral ligament suspension (USLS) for primary uterovaginal prolapse repair. DESIGN: A hospital-based decision analysis model was built using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Those with prolapse were modeled to undergo either vaginal hysterectomy with USLS or minimally invasive total hysterectomy with sacrocolpopexy (MISCP). We modeled the chance of complications of the index procedure, prolapse recurrence with the option for surgical retreatment, complications of the salvage procedure, and possible second prolapse recurrence. The primary outcome was cost of the surgical strategy. The proportion of patients living with prolapse after treatment was the secondary outcome. SETTING: Tertiary center for urogynecology. PATIENTS: Female patients undergoing surgical repair by the same team for primary uterovaginal prolapse. INTERVENTIONS: Comparison analysis of estimated long-term costs was performed. MEASUREMENTS AND MAIN RESULTS: Our primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19 935 and that undergoing USLS as the primary index procedure cost $15 457, a difference of $4478. Furthermore, 21.1% of women in the USLS group will be living with recurrent prolapse compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize recurrence risk would cost $30 054 per case of prolapse prevented. Additionally, a surgeon would have to perform 6.7 cases by MISCP instead of USLS in order to prevent 1 patient from having recurrent prolapse. CONCLUSION: The higher initial costs of MISCP compared to USLS persist in the long term after factoring in recurrence and complication rates, though more patients who undergo USLS live with prolapse recurrence.

The impact of verbal goal setting on operating room turnover time: a randomized trial.

INTRODUCTION AND HYPOTHESIS: Operating room turnover times are highly variable, with longer times having a significant negative impact on hospital costs, surgeon volume, and satisfaction. The primary aim of this randomized trial was to examine the impact of a verbalized time goal on the likelihood of meeting institutional goals. METHODS: This is a prospective, single-blind, randomized study conducted across four operative sites: inpatient main campus and three outpatient centers. Sequential cases for the same surgeon in the same room were randomized to receive a verbal prompt versus usual care, in which no goal setting was verbalized. Multivariate and univariate statistical analyses were performed. RESULTS: From July through October 2022, five attending surgeons randomized 88 cases (44 verbal prompt, 44 usual care). Of these, 30 were at the main inpatient hospital. The case mixture included 36% vaginal, 27% endoscopy, 8% open, 10% robotic, and others. Average turnover time was 51.7 and 35.3 min for inpatient and outpatient cases respectively. Overall, only 39.8% of cases hit the institutional turnover time goal. Verbal prompting did not significantly increase the likelihood of achieving the institutional goal (38.4% vs 43.4% p = 0.352) except for in minor surgery (64.0 vs 39.0%, p = 0.0477). A verbal prompt reduced turnover time in major surgery (59.7 vs 47.8 min, p = 0.0445). CONCLUSION: Our academic center achieved goal turnover times in only 39.8% of cases. Although verbal prompting did not significantly improve the likelihood of meeting institutional goals in the group as a whole, some subgroups were significantly improved.

Financial analysis of minimally invasive sacrocolpopexy compared with native tissue vaginal repair with concomitant hysterectomy.

INTRODUCTION: Minimally invasive sacrocolpopexy (MISCP) is increasingly used for uterovaginal prolapse, but comparative cost data of MISCP versus native tissue vaginal repair (NTR) are lacking. The objective was to determine the cost difference, from a hospital perspective, between MISCP and NTR performed with hysterectomy for uterovaginal prolapse. METHODS: This was a retrospective cohort study at a tertiary care center of women who underwent NTR or MISCP with concomitant hysterectomy in 2021. Hospital charges, direct and indirect costs, and operating margin (revenue minus costs) were obtained from Strata Jazz and compared using SPSS. RESULTS: A total of 82 women were included, 33 MISCP (25 robotic, 8 laparoscopic) versus 49 NTR. Demographic and surgical data were similar, except that MISCP had younger age (50.5 vs 61.1 years, p<0.01). Same-day discharge and estimated blood loss were similar, but operative time was longer for MISCP (204 vs 161 min, p<0.01). MISCP total costs were higher (US$17,422 vs US$13,001, p<0.01). MISCP had higher direct costs (US$12,354 vs US$9,305, p<0.01) and indirect costs (US$5,068 vs US$3,696, p<0.01). Consumable supply costs were higher with MISCP (US$4,429 vs US$2,089, p<0.01), but the cost of operating room time and staff was similar (US$7,926 vs US$7,216, p=0.07). Controlling for same-day discharge, anti-incontinence procedures and smoking, total costs were higher for MISCP (adjusted beta = US$4,262, p<0.01). Mean charges (US$102,060 vs US$97,185, p=0.379), revenue (US$22,214 vs US$22,491, p=0.929), and operating margin (US$8,719 vs US$3,966, p=0.134) were not statistically different. CONCLUSION: Minimally invasive sacrocolpopexy had higher costs than NTR; however, charges, reimbursement, and operating margins were not statistically significantly different between the groups.

An assessment of urethral radiation exposure in the treatment of endometrial and rectal cancers.

INTRODUCTION AND HYPOTHESIS: Female survivors of endometrial and rectal cancers have increased risk of urinary incontinence. Survivors with prior radiation therapy are counseled against mesh incontinence surgery. We hypothesize that urethral radiation dose varies based on modality which may influence surgical risks. We aimed to demonstrate urethral radiation dose differences between vaginal brachytherapy (VBT) and external beam radiation therapy (EBRT). METHODS: This is a retrospective cohort study of women exposed to VBT for endometrial cancer and EBRT for rectal cancer. The urethra was contoured on CT imaging to calculate radiation doses in centigray (cGy). The primary outcome was the percent of treatment radiation dose estimated to be received by the urethra based on the volume dose to 0.2 cc of urethra. Secondary outcomes were point doses to the bladder neck, mid-urethra, and total mean urethral dose. Descriptive statistics described demographic characteristics. Bivariate analyses compared urethral radiation dose based on radiation modality. RESULTS: Between 2014-2017, 32 women treated were included: 18 with VBT and 14 with EBRT. Mean ± SD urethral volume doses were lower in VBT (1266 cGy ± 533, 42.2% of prescribed treatment dose) compared to EBRT (5051 cGy ± 192, 100.2% of prescribed treatment dose), p < 0.0001. VBT also had significantly lower mean total urethral dose and point doses to bladder neck and mid- urethra compared to EBRT (p < 0.0001). CONCLUSIONS: The female urethra is exposed to significantly less radiation in VBT compared to EBRT. These data highlight that modality of pelvic radiation should be considered in treatment counseling on urinary incontinence in women.

Safety and economics of an enhanced recovery after surgery protocol in pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: We hypothesized that an enhanced recovery after surgery (ERAS) protocol for patients undergoing female pelvic reconstructive surgery would conserve hospital resources without compromising patient safety. METHODS: In June 2020, an ERAS protocol designed to promote same-day discharge was initiated that included pre-operative hydration, a urinary anesthetic, non-narcotic analgesia, perineal ice, a bowel regimen, enrollment of the family to assist with care, and communication regarding planned same-day discharge. We compared demographic, operative, hospital stay, complications, and cost data in patients undergoing pelvic organ prolapse or incontinence surgery over 4 sequential months pre (PRE; N = 82) and post (POST; N = 91) ERAS implementation using univariate statistics. RESULTS: There were no differences in demographics, operative details, or complications (p > 0.05). There were no significant differences in overall revenues or expenses (p > 0.05), but bed unit cost was significantly lower in the POST group ($210 vs $533, p < 0.0001). There was a trend toward an increased operating margin in POST patients ($4,554 vs $2,151, p = 0.1163). Significantly more POST surgeries were performed in an ambulatory setting (73.6% vs 48.8%, p = 0.0008) and resulted in same-day discharge (80.2% vs 50.0%, p = 0.0003). There were no differences in the rates of emergency room or unexpected clinic visits (p > 0.05). Prescribed post-operative opiate dose was significantly reduced in POST patients (p < 0.0001). CONCLUSIONS: In patients undergoing female pelvic reconstructive surgery, an ERAS protocol facilitated transfer of procedures to an ambulatory surgical site and permitted same-day discharge without increasing complications, clinic visits, or emergency room visits. It also reduced bed unit cost and may improve operating margins.

Establishing Validity for a Vaginal Hysterectomy Simulation Model for Surgical Skills Assessment.

OBJECTIVE: To use the Messick validity framework for a simulation-based assessment of vaginal hysterectomy skills. METHODS: Video recordings of physicians at different levels of training and experience performing vaginal hysterectomy on a high-fidelity vaginal surgery model were objectively assessed using a modified 10-item Vaginal Surgical Skills Index, a one-item global scale of overall performance, and a pass-fail criterion. Participants included obstetrics and gynecology trainees and faculty from five institutions. Video recordings were independently assessed by expert surgeons blinded to the identities of the study participants. RESULTS: Fifty surgeons (11 faculty, 39 trainees) were assessed. Experience level correlated strongly with both the modified Vaginal Surgical Skills Index and global scale score, with more experienced participants receiving higher scores (Pearson r=0.81, P<.001; Pearson r=0.74, P<.001). Likewise, surgical experience was also moderately correlated with the modified Vaginal Surgical Skills Index and global scale score (Pearson r=0.55, P<.001; Pearson r=0.58, P<.001). The internal consistency of the modified Vaginal Surgical Skills Index was excellent (Cronbach's alpha=0.97). Interrater reliability of the modified Vaginal Surgical Skills Index and global scale score, as measured by the intraclass correlation coefficient, was moderate to good (0.49-0.95; 0.50-0.87). Using the receiver operating characteristic curve and the pass-fail criterion, a modified Vaginal Surgical Skills Index cutoff score of 27 was found to most accurately (area under the curve 0.951, 95% CI 0.917-0.983) differentiate competent from noncompetent surgeons. CONCLUSION: We demonstrated validity evidence for using a high-fidelity vaginal surgery model with the modified Vaginal Surgical Skills Index or global scale score to assess vaginal hysterectomy skills.

Impact of robotic operative efficiency on profitability.

OBJECTIVE: We sought to determine the impact of robotic operative efficiency on profitability and assess the impact of secondary variables. STUDY DESIGN: Financial data were collected for all robotic cases performed for fiscal years 2010 (FY10) and 2011 (FY11) at University of North Carolina at Chapel Hill, and included 9 surgical subspecialties. Profitability was defined as a positive operating income. RESULTS: From July 2009 through June 2011, 1295 robotic cases were performed. Robotic surgery was profitable in both fiscal years, with an operating income of $386,735 in FY10 and $822,996 in FY11. In FY10, urogynecology and pediatric surgery were the only nonprofitable subspecialties. In FY11, all subspecialties were profitable. Profitability was associated with case time, payor mix, and procedure type (all P < .05). Urogynecology case time decreased from 220-179 minutes (P = .012) and pediatric surgery from 418-258 minutes (P = .019). CONCLUSION: Robotic operative efficiency has a large impact on overall profitability regardless of surgical specialty.

The contraceptive needs of incarcerated women.

OBJECTIVES: We assessed the contraceptive needs of women incarcerated in jails in the southeastern United States to determine feasible and effective birth control interventions based on the needs of this population. METHODS: Participants were recruited from local jails around a medium-sized metro area. Participants completed a survey of demographics, sexual health, contraceptive use, and preferred method of contraception. RESULTS: The survey was completed by 188 women in jail. Participants reported high rates of sexually transmitted diseases (STDs) (50.5%), inconsistent use of birth control (36.5%), and use of unreliable and user-dependent methods of birth control. The majority did not desire to become pregnant in the future (61.5%) but intended to have sex after release from jail (76.9%). Women who were able to bear children were more likely to report intentions to use birth control or STD protection after release (77.9%). Additionally, significant racial differences were found. Specifically, nonwhites were more likely to be single and have more STDs and less use of a variety of birth control methods than whites. CONCLUSIONS: Women in this sample were at high risk for unplanned pregnancies. Therefore, a primary contraceptive need for this population appeared to be education about longer lasting, user-independent forms of contraception. Many of these women would be ideal candidates for such forms of contraception, especially if it was provided prior to release.