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

OBJECTIVE: To compare inpatient hospital costs and complication rates within the 90-day global billing period among routes of hysterectomy. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Cesarean hysterectomy for placenta accreta spectrum: Surgeon specialty-specific assessment.

OBJECTIVE: To assess (i) clinical and pregnancy characteristics, (ii) patterns of surgical procedures, and (iii) surgical morbidity associated with cesarean hysterectomy for placenta accreta spectrum based on the specialty of the attending surgeon. METHODS: The Premier Healthcare Database was queried retrospectively to study patients with placenta accreta spectrum who underwent cesarean delivery and concurrent hysterectomy from 2016 to 2020. Surgical morbidity was assessed with propensity score inverse probability of treatment weighting based on surgeon specialty for hysterectomy: general obstetrician-gynecologists, maternal-fetal medicine specialists, and gynecologic oncologists. RESULTS: A total of 2240 cesarean hysterectomies were studies. The most common surgeon type was general obstetrician-gynecologist (n = 1534, 68.5%), followed by gynecologic oncologist (n = 532, 23.8%) and maternal-fetal medicine specialist (n = 174, 7.8%). Patients in the gynecologic oncologist group had the highest rate of placenta increta or percreta, followed by the maternal-fetal medicine specialist and general obstetrician-gynecologist groups (43.4%, 39.6%, and 30.6%, P < .001). In a propensity score-weighted model, measured surgical morbidity was similar across the three subspecialty groups, including hemorrhage / blood transfusion (59.4-63.7%), bladder injury (18.3-24.0%), ureteral injury (2.2-4.3%), shock (8.6-10.5%), and coagulopathy (3.3-7.4%) (all, P > .05). Among the cesarean hysterectomy performed by gynecologic oncologist, hemorrhage / transfusion rates remained substantial despite additional surgical procedures: tranexamic acid / ureteral stent (60.4%), tranexamic acid / endo-arterial procedure (76.2%), ureteral stent / endo-arterial procedure (51.6%), and all three procedures (55.4%). Tranexamic acid administration with ureteral stent placement was associated with decreased bladder injury (12.8% vs 23.8-32.2%, P < .001). CONCLUSION: These data suggest that patient characteristics and surgical procedures related to cesarean hysterectomy for placenta accreta spectrum differ based on surgeon specialty. Gynecologic oncologists appear to manage more severe forms of placenta accreta spectrum. Regardless of surgeon's specialty, surgical morbidity of cesarean hysterectomy for placenta accreta spectrum is significant.

Associations between race and ethnicity and perioperative outcomes among women undergoing hysterectomy for adenomyosis.

OBJECTIVE: To study racial and ethnic disparities among women undergoing hysterectomy performed for adenomyosis across the United States. DESIGN: A cohort study. SETTING: Data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2012-2020. PATIENTS: Patients with an adenomyosis diagnosis. INTERVENTION: Hysterectomy for adenomyosis. MAIN OUTCOME MEASURES: Patients were identified using the International Classification of Diseases 9th and 10th editions codes 617.0 and N80.0 (endometriosis of the uterus). Hysterectomies were classified on the basis of the Current Procedural Terminology codes. We compared baseline and surgical characteristics and 30-day postoperative complications across the different racial and ethnic groups. Postoperative complications were classified into minor and major complications according to the Clavien-Dindo classification system. RESULTS: A total of 12,599 women underwent hysterectomy for adenomyosis during the study period: 8,822 (70.0%) non-Hispanic White, 1,597 (12.7%) Hispanic, 1,378 (10.9%) non-Hispanic Black or African American, 614 (4.9%) Asian, 97 (0.8%) Native Hawaiian or Pacific Islander, and 91 (0.7%) American Indian or Alaska Native. Postoperative complications occurred in 8.8% of cases (n = 1,104), including major complications in 3.1% (n = 385). After adjusting for confounders, non-Hispanic Black race and ethnicity were independently associated with an increased risk of major complications (adjusted odds ratio 1.54, 95% confidence interval [CI] {1.16-2.04}). Laparotomy was performed in 13.7% (n = 1,725) of cases. Compared with non-Hispanic White race and ethnicity, the adjusted odd ratios for undergoing laparoscopy were 0.58 (95% CI 0.50-0.67) for Hispanic, 0.56 (95% CI 0.48-0.65) for non-Hispanic Black or African American, 0.33 (95% CI 0.27-0.40) for Asian, and 0.26 (95% CI 0.17-0.41) for Native Hawaiian or Pacific Islander race and ethnicity. CONCLUSION: Among women undergoing hysterectomy for postoperatively diagnosed adenomyosis, non-Hispanic Black or African American race and ethnicity were associated with an increased risk of major postoperative complications. Compared with non-Hispanic White race and ethnicity, Hispanic ethnicity, non-Hispanic Black or African American, Asian, Native Hawaiian, or Pacific Islander race and ethnicity were less likely to undergo minimally invasive surgery.

Long-Term and Short-Interval Assessment of Self-Reported Urinary and Sexual Functions after Nerve-Sparing Radical Hysterectomy: A Prospective Cohort Study.

The aim of this study was to determine the impact of nerve preservation confirmed by intraoperative electrical stimulation (IES) on subjective symptoms of urinary and sexual function in uterine cervical cancer patients who underwent radical hysterectomies. This study included 85 patients who underwent type C radical hysterectomy with IES. Pelvic splanchnic nerve preservation with IES after hysterectomy (nerve-stimulation positive group) was confirmed in 61 women and 24 women did not have nerve preservation (negative group). Urinary function was assessed with the Overactive Bladder Symptom Score (OABSS), International Prostate Symptom Score (IPSS), and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaires. Sexual function was surveyed using the Female Sexual Function Index (FSFI). Longitudinal changes in those scores according to response to nerve-stimulation were evaluated using a generalized estimating equation. IPSS quality of life (QOL) scores were significantly better in the nerve-stimulation positive group compared with the scores in the negative group until 12 months after surgery, whereas OABSS, IPSS total, IPSS voiding, and ICIQ-SF scores evaluating urinary symptoms were not significantly different between the two groups. FSFI scores were better in the nerve-stimulation positive group 36 months after surgery compared with the scores in the negative group. In this study, we assessed self-reported urinary and sexual symptoms after nerve-sparing radical hysterectomy (NSRH) with IES in the long term. We demonstrated that nerve-sparing significantly reduced distress associated with QOL until 1 year, improved urinary storage symptoms at 2 years, and sexual symptoms 3 years after surgery.

National validation of the Centers for Medicare & Medicaid Services strategy for identifying potential surgical-site infections following colon surgery and abdominal hysterectomy.

OBJECTIVE: National validation of claims-based surveillance for surgical-site infections (SSIs) following colon surgery and abdominal hysterectomy. DESIGN: Retrospective cohort study. SETTING: US hospitals selected for data validation by Centers for Medicare & Medicaid Services (CMS). PARTICIPANTS: The study included 550 hospitals performing colon surgery and 458 hospitals performing abdominal hysterectomy in federal fiscal year 2013. METHODS: We requested 1,200 medical records from hospitals selected for validation as part of the CMS Hospital Inpatient Quality Reporting program. For colon surgery, we sampled 60% with a billing code suggestive of SSI during their index admission and/or readmission within 30 days and 40% who were readmitted without one of these codes. For abdominal hysterectomy, we included all patients with an SSI code during their index admission, all patients readmitted within 30 days, and a sample of those with a prolonged surgical admission (length of stay > 7 days). We calculated sensitivity and positive predictive value for the different groups. RESULTS: We identified 142 colon-surgery SSIs (46 superficial SSIs and 96 deep and organ-space SSIs) and 127 abdominal-hysterectomy SSIs (58 superficial SSIs and 69 deep and organ-space SSIs). Extrapolating to the full CMS data validation cohort, we estimated an SSI rate of 8.3% for colon surgery and 3.0% for abdominal hysterectomy. Our colon-surgery surveillance codes identified 93% of SSIs, with 1 SSI identified for every 2.6 patients reviewed. Our abdominal-hysterectomy surveillance codes identified 73% of SSIs, with 1 SSI identified for every 1.6 patients reviewed. CONCLUSIONS: Using claims to target record review for SSI validation performed well in a national sample.

Prophylactic anticoagulation after minimally invasive hysterectomy for endometrial cancer: a cost-effectiveness analysis.

OBJECTIVE: To determine our institutional rate of venous thromboembolism (VTE) following minimally invasive surgery for endometrial cancer and to perform a cost-effectiveness analysis of extended prophylactic anticoagulation after minimally invasive staging surgery for endometrial cancer. METHODS: All patients with newly diagnosed endometrial cancer who underwent minimally invasive staging surgery from January 1, 2017 to December 31, 2020 were identified retrospectively, and clinicopathologic and outcome data were obtained through chart review. Event probabilities and utility decrements were obtained through published clinical data and literature review. A decision model was created to compare 28 days of no post-operative pharmacologic prophylaxis, prophylactic enoxaparin, and prophylactic apixaban. Outcomes included no complications, deep vein thrombosis (DVT), pulmonary embolism, clinically relevant non-major bleeding, and major bleeding. We assumed a willingness-to-pay threshold of $100 000 per quality-adjusted life year (QALY) gained. RESULTS: Three of 844 patients (0.36%) had a VTE following minimally invasive staging surgery for endometrial cancer. In this model, no pharmacologic prophylaxis was less costly and more effective than prophylactic apixaban and prophylactic enoxaparin over all parameters examined. When all patients were assigned prophylaxis, prophylactic apixaban was both less costly and more effective than prophylactic enoxaparin. If the risk of DVT was ≥4.8%, prophylactic apixaban was favored over no pharmacologic prophylaxis. On Monte Carlo probabilistic sensitivity analysis for the base case scenario, no pharmacologic prophylaxis was favored in 41.1% of iterations at a willingness-to-pay threshold of $100 000 per QALY. CONCLUSIONS: In this cost-effectiveness model, no extended pharmacologic anticoagulation was superior to extended prophylactic enoxaparin and apixaban in clinically early-stage endometrial cancer patients undergoing minimally invasive surgery. This model supports use of prophylactic apixaban for 7 days post-operatively in select patients when the risk of DVT is 4.8% or higher.

Surgical correction of the genital hiatus at the time of sacrocolpopexy - a 7-year Markov analysis: a cost-effectiveness analysis.

INTRODUCTION AND HYPOTHESIS: To perform a cost-effectiveness analysis of concurrent posterior repair performed at the time of laparoscopic hysterectomy with sacrocolpopexy over a 7-year time period. We hypothesize it is not cost-effective to perform a posterior colporrhaphy. METHODS: We used TreeAge Pro® to construct a decision model with Markov modeling to compare sacrocolpopexy with and without concurrent posterior repair (SCP and SCP+PR) over a time horizon of 7 years. Outcomes included probability and costs associated with prolapse recurrence, prolapse retreatment, and complications including rectal injury, rectovaginal hematoma requiring reoperation, and postoperative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) calculated as ∆ costs /∆ effectiveness and the willingness to pay (WTP) was set at $100,000/QALY. RESULTS: Our model showed that SCP was the dominant strategy, with lower costs (-$ 2681.06) and higher effectiveness (+0.10) compared to SCP+PR over the 7-year period. In two-way sensitivity analyses, we varied the probability of prolapse recurrence after both strategies. Our conclusions would only change if the probability of recurrence after SCP was at least 29.7% higher than after SCP+PR. When varying the probabilities of dyspareunia for both strategies, SCP+PR only became the dominant strategy if the probability of dyspareunia for SCP+PR was lower than the rate of SCP alone. CONCLUSIONS: In this 7-year Markov cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy. SCP+PR costs more with lower effectiveness than SCP alone, due to higher surgical cost of SCP+PR and higher probability of dyspareunia after SCP+PR.

Cost-effectiveness of Myomectomy versus Hysterectomy in Women with Uterine Fibroids.

STUDY OBJECTIVE: Increasing evidence suggests that hysterectomy to treat uterine fibroids (UFs), even with ovarian conservation (OC), is associated with a 33% increased risk of coronary artery disease (CAD). We sought to compare the cost-effectiveness of various treatment approaches for UFs to understand the trade-offs among development of CAD vs new fibroids. DESIGN: We developed a Markov model to include women with UFs who no longer desired pregnancy. The outcomes of interest were quality-adjusted life-years (QALYs) and total treatment costs. We conducted sensitivity analyses to test the effect of uncertain model inputs. SETTING: Health system perspective. PATIENTS: A hypothetical cohort of 10 000 40-year-old women. INTERVENTIONS: Myomectomy, hysterectomy with OC, and hysterectomy without OC. MEASUREMENTS AND MAIN RESULTS: Myomectomy was the best-value strategy, costing US$528 217 and providing 19.38 QALYs. Neither hysterectomy with OC nor hysterectomy without OC was found to be cost-effective, assuming a willingness-to-pay threshold of $100 000 per QALY gain as hysterectomy with OC provided more benefit than myomectomy at an average cost of $613 144 to gain one additional QALY. The sensitivity analyses showed that if the risk of new symptomatic UFs that required treatment after myomectomy was more than 13%, annually (base case, 3.6%), or the quality of life after myomectomy was less than 0.815 (base case, 0.834), then myomectomy would no longer be cost-effective, under a willingness-to-pay amount of US$100 000. CONCLUSION: Myomectomy is an optimal treatment of UFs compared with hysterectomy among women aged 40 years. The increased risk of CAD after hysterectomy and its associated costs and the effects on morbidity and quality of life made hysterectomy a costlier and less effective long-term strategy.

Application of transperineal ultrasound combined with shear wave elastography in pelvic floor function assessment after hysterectomy.

This study explored the application of transperineal ultrasound (TPUS) combined with shear wave elastography (SWE) in evaluating the pelvic structure function of women after total hysterectomy. Seventy healthy women and 76 women who underwent total hysterectomy were selected for ultrasound examination. They were divided into normal (nulliparous) group, (parous) group without hysterectomy, and (parous) group with hysterectomy. TPUS combined with SWE was used to evaluate the pelvic floor structure and function in the 3 groups of women. Posterior urethrovesical angle in resting and maximal Valsalva state, anteroposterior diameter of hiatus in the 3 states, the bladder neck descent, the urethral rotation angle, the Young modulus of left and right puborectalisis muscle in resting state, and the incidence of pelvic floor dysfunction diseases were all higher in the group with hysterectomy than in the group without hysterectomy (P < .05). Bladder neck-symphyseal distance and anorectal junction-symphyseal distance in the maximum Valsalva state, and the difference in Young modulus between the left and right PR before and after anus contraction were all lower in the group with hysterectomy than the group without hysterectomy (P < .05). The incidence of pelvic floor dysfunction in postmenopausal patients in the group with hysterectomy was higher than that in premenopausal patients (P < .05). Total hysterectomy had negative effects on female pelvic floor structure and function. TPUS combined with SWE can be used to evaluate pelvic floor function in multiple dimensions.

Hysterectomy with a general gynecologist vs gynecologic-oncologist in the setting of endometrial intraepithelial neoplasia: a cost-effectiveness analysis.

BACKGROUND: Standard treatment for patients with endometrial intraepithelial neoplasia (EIN) is a hysterectomy, which has a 43% risk of concomitant endometrial cancer on final pathology. General gynecologists and gynecologic-oncologists perform hysterectomies; however, patients who have a hysterectomy for EIN with a general gynecologist and are found to have cancer may require a second surgery by a gynecologic-oncologist to complete staging. There is ongoing discussion regarding whether patients with EIN should be provided the option to receive the initial hysterectomy with a gynecologic-oncologist. OBJECTIVE: This study aimed to better understand if patients with EIN should be initially referred to a gynecologic-oncologist for treatment. We examined the cost-effectiveness of hysterectomy by general gynecologists vs gynecologic-oncologists for patients with EIN. STUDY DESIGN: We created a decision-analytical model using TreeAge Pro software to compare outcomes between hysterectomies by general gynecologists and those by gynecologic-oncologists in patients with EIN. Our theoretical cohort contained 200,000 patients, an estimate of the number of individuals diagnosed with EIN each year in the United States. Outcomes included costs, quality-adjusted life years, primary lymph node dissection, secondary lymph node dissection, surgical site infection, and perioperative mortality. We assumed that surgical morbidity and mortality were the same under generalist and specialist care and applied costs of travel and lost work for those seeing a gynecologic-oncologist. We performed univariable sensitivity analyses and multivariable probabilistic sensitivity analysis to assess the model's robustness given the uncertainty of model inputs. RESULTS: In our theoretical cohort of 200,000 patients with EIN, hysterectomy with a gynecologic-oncologist was associated with a decrease of 10,811 second surgeries for lymph node dissection, 87 surgical site infections, and 9 perioperative mortalities. When hysterectomy was performed by a general gynecologist, 9 fewer patients had a lymph node dissection because of perioperative mortalities that occurred before lymph node dissection with a gynecologic-oncologist. Hysterectomy with a gynecologic-oncologist was the dominant, cost-effective strategy because it saved $116 million and increased quality-adjusted life years by 180. In our univariable analyses, hysterectomy with a gynecologic-oncologist was cost-saving and increased quality-adjusted life years over a wide range of probabilities and costs for lymph node dissection, surgical site infection, and perioperative mortality. However, hysterectomy with a gynecologic-oncologist was only a cost-effective and cost-saving strategy in just over 50% of multivariable simulations, demonstrating that there is significant uncertainty in the model's cost-effectiveness. CONCLUSION: In our model, hysterectomy with a gynecologic-oncologist for patients with EIN was associated with cost savings and increased quality-adjusted life years. Our study supports that patients undergoing hysterectomy for EIN at institutions using Mayo criteria to determine need for lymphadenectomy may benefit from surgery with a gynecologic-oncologist rather than a general gynecologist to reduce costs and adverse events associated with a second surgery.

Very Low Rates of Ureteral Injury in Laparoscopic Hysterectomy Performed by Fellowship-trained Minimally Invasive Gynecologic Surgeons.

STUDY OBJECTIVE: The objective of this case series is to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons. DESIGN: A retrospective chart review was performed, evaluating laparoscopic hysterectomy cases between 2009 and 2019 performed exclusively by fellowship-trained surgeons. SETTING: Division of Minimally Invasive Gynecologic Surgery (MIGS) at the Brigham and Women's Hospital and Brigham and Women's Faulkner Hospital, a Harvard Medical School teaching hospital in Boston. PATIENTS: All patients undergoing laparoscopic hysterectomy by one of 5 surgeons with fellowship training in MIGS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 5160 cases were handled by MIGS surgeons between 2009 and 2019 at our institution. Of these cases, 2345 were laparoscopic hysterectomy cases with available intraoperative and postoperative documentation. Most patients had undergone previous surgeries, and the most common indications for hysterectomy included uterine myomas, pelvic pain/endometriosis, and abnormal uterine bleeding. At the time of hysterectomy, 1 ureteral injury (0.04%) was noted. No additional delayed ureteral injuries were observed. Most patients were discharged home the same day (64.9%) and did not have any postoperative complications (63.9%) as designated by the Clavien-Dindo classification. CONCLUSION: Ureteral injury, although rare, is more prevalent in gynecologic surgery than in other surgical disciplines that have some focus on the pelvis. No study to date has evaluated the effect of surgical training and volume on rates of ureteral injuries. This study retrospectively examined ureteral injury rates for one group of high-volume fellowship-trained surgeons and found their rates to be lower than the national average. Proposals are presented for optimizing training and delivery of gynecologic surgical care to minimize complications.

Objective and Subjective Assessment of Bladder Function after Robot-assisted Laparoscopic Radical Hysterectomy for Early-stage Cervical Cancer.

STUDY OBJECTIVE: To examine whether objective bladder function after robot-assisted radical hysterectomy (RRH) for early-stage cervical cancer is correlated with subjective patient-reported outcomes and quality of life during the first year after RRH. DESIGN: Prospective observational study. SETTING: Karolinska University Hospital, Sweden. PATIENTS: Women with early-stage cervical cancer (International Federation of Gynecology and Obstetrics stage IA2-IB1) between July 2017 and May 2019 were assessed for eligibility. INTERVENTIONS: RRH. MEASUREMENTS AND MAIN RESULTS: Subjective bladder function was evaluated with the Female Lower Urinary Tract Symptoms and Urinary Incontinence Quality of Life modules of the International Consultation on Incontinence Questionnaire. Objective urinary function was characterized with urodynamic tests, and the nerves ablated at RRH were quantified by using immunohistochemical staining of biopsies from the resected paracervix, vesicouterine, and sacrouterine ligaments. Twenty-seven women were included for analysis at baseline, 2 weeks, 3 months, and 12 months after surgery. RRH caused hypotonia of the urinary bladder (p <.05). Patient-reported outcomes of voiding and filling dysfunction were most significant 2 weeks after surgery (p <.05) but for most of the women, bladder function recovered within 3 months. No correlations were found with either subjective or objective urinary function and the number of ablated nerves. CONCLUSION: For most women, objective and subjective urinary bladder dysfunction recovered within 3 months after RRH. The absence of correlation between functional outcomes and ablated autonomous nerves suggests that other underlying causes play a significant role. Early detection of bladder overextension after RRH is paramount, and the role of postoperative bladder catheterization needs further investigation.

Impact of Obesity on Clinical and Financial Outcomes of Minimally Invasive Hysterectomy for Benign Conditions.

OBJECTIVE: To evaluate the effect of obesity on clinical and financial outcomes of minimally invasive hysterectomy METHODS: This was a retrospective cohort study of 5 affiliated hospitals. We obtained demographic, operative, and financial characteristics to analyze the effects of obesity on outcomes, including operating room (OR) time, estimated blood loss (EBL), length of stay (LOS), adverse perioperative events, and hospital charges. Obesity was stratified by the following classes: no obesity (BMI <30 kg/m2), class I (BMI 30-34 kg/m2), class II (BMI 35-39 kg/m2), and class III (BMI >40 kg/m2). Descriptive statistics and multivariate logistic and linear regressions were performed. RESULTS: A total of 2483 women underwent benign, minimally invasive hysterectomy. Laparoscopic was the most common approach (79.8%), followed by robotic (12.2%), and vaginal (8.0%). Mean BMI was 30.13 ± 6.99 kg/m2, and total charges were US $13 928 ± $5954. Each additional minute in the OR increased costs by US $47.89 (P < 0.001). Compared with patients without obesity, OR time and EBL were significantly higher among patients with class I or II obesity and highest among patients with class III obesity (P < 0.001). Obesity did not affect LOS or occurrence of adverse perioperative events. Although obesity appeared to be a significant predictor of hysterectomy charges, after adjusting for covariates, charges for laparoscopic and robotic hysterectomy did not differ significantly by BMI. CONCLUSION: Obesity appears to have a significant effect on clinical outcomes of benign hysterectomy that is approach-dependent and most notable among patients with class III obesity. BMI was not, however, a predictor of financial outcomes.

Individualized Assessment of Risk of Complications after Benign Hysterectomy.

STUDY OBJECTIVES: The primary objective of this study is to identify patient characteristics associated with postoperative complications or readmissions after hysterectomy for a benign indication. DESIGN: Retrospective cohort. SETTING: The Surgical Gynecologic Scorecard Database includes performance metrics and patient outcomes for hysterectomies across 7 sites in Ontario, Canada. PARTICIPANTS: Individuals who underwent hysterectomy for benign gynecologic indication and were recorded in the Surgical Gynecologic Scorecard Database between July 2016 and June 2019 were included in this study. MEASUREMENTS AND MAIN RESULTS: Two outcomes of interest were considered: (1) complications grade II or greater on the Clavien-Dindo classification scale and (2) emergency room visits or hospital readmissions within 6 weeks after operation. Logistic models were generated to determine the associations between outcome of interest and potential predictors using a mixed-step AIC selection algorithm. A total of 2792 patients underwent hysterectomy for a benign indication during the study period, with a mean age of 52.6 ± 11.7 years and mean body mass index of 29.0 ± 0.7 kg/m2. The most common indications for surgery were abnormal uterine bleeding (33.3%) and myomas (33.6%). Previous cesarean delivery (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04-1.42), American Society of Anesthesiologists class ≥3 (aOR, 2.31; 95% CI, 1.42-3.99), preoperative anemia (aOR, 1.51; 95% CI, 1.12-2.02), and laparotomic approach (aOR, 1.73; 95% CI, 1.30-2.29) were associated with increased odds of complication. Perioperative complications (aOR, 2.95; 95% CI, 2.12-4.08), preoperative anemia (aOR, 1.43; 95% CI, 1.03-1.98), and vaginal (aOR, 1.94; 95% CI, 1.26-2.96) or laparotomic (aOR, 1.64; 95% CI, 1.10-2.43) approach were associated with increased odds of emergency room visit or readmission to hospital. CONCLUSION: This study identified several important risk factors for complications after hysterectomy. The utility of these data is important to help improve counseling for patients undergoing a hysterectomy and potentially optimize modifiable risk factors when identified preoperatively.

Clinical Utility and Cost of Postoperative Hemoglobin Level Testing Following Robotic-assisted Hysterectomy for Endometrial Cancer.

AIM: Our aim was to assess the clinical utility of postoperative hemoglobin testing following hysterectomy. PATIENTS AND METHODS: We carried out a retrospective cohort study of patients who underwent robotic surgery at an academic center during a 44-month study period. Data included demographics and perioperative outcomes. The mean postoperative decrease in hemoglobin level was evaluated using numerical and categorical variables. RESULTS: A total of 201 women were included. A total of 45 (22.4%) developed symptoms suggestive of hemodynamic compromise. When compared to asymptomatic patients, these patients were no different in operative time, estimated blood loss, pre- or post-operative hemoglobin levels, or the change in hemoglobin levels. Symptomatic patients did receive less fluid intraoperatively (1.2 vs. 1.5 l; p<0.0001). Perioperative outcomes were not associated with a greater postoperative decrease in hemoglobin (Hb). Postoperative anemia was associated with preoperative anemia (0% vs. 45%; p<0.0001). Patients with postoperative anemia were also more likely to be re-admitted within 30 days after surgery (7% vs. 23%; p=0.025). Of the three patients who received blood transfusions postoperatively, all three had preoperative Hb<9.5 g/dl, compared to 2.5% of those who were not transfused (p<0.0001). Using Institutional charges and Medicare reimbursement rates for blood hemoglobin testing, savings were estimated to be $3,629 and $1,236, respectively, during the study period. CONCLUSION: Postoperative Hb testing may be safely avoided unless starting Hb is less <10 g/dl. Clinical practice change can reduce healthcare costs without hindering patient care.

Assessment of risk and economic burden of surgical site infection (SSI) posthysterectomy using a U.S. longitudinal database.

BACKGROUND: Surgical site infection posthysterectomy has significant impact on patient morbidity, mortality, and health care costs. This study evaluates incidence, risk factors, and total payer costs of surgical site infection after hysterectomy in commercial, Medicare, and Medicaid populations using a nationwide claims database. METHODS: IBM MarketScan databases identified women having hysterectomy between 2014 and 2018. Deep-incisional/organ space (DI/OS) and superficial infections were identified over 6 months postoperatively with risk factors and direct infection-associated payments by insurance type over a 24-month postoperative period. RESULTS: Analysis identified 141,869 women; 7.8% Medicaid, 5.8% Medicare, and 3.9% commercially insured women developed deep-incisional/organ space surgical site infection, whereas 3.9% Medicaid, 3.2% Medicare, and 2.1% commercially insured women developed superficial infection within 6 months of index procedure. Deep-incisional/organ space risk factors were open approach (hazard ratio, 1.6; 95% confidence interval, 1.5-1.8) and payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.5]); superficial risk factors were payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.6]) and solid tumor without metastasis (hazard ratio, 1.4; 95% confidence interval, 1.3-1.6). Highest payments occurred with Medicare ($44,436, 95% confidence interval: $33,967-$56,422) followed by commercial ($27,140, 95% confidence interval: $25,990-$28,317) and Medicaid patients ($17,265, 95% confidence interval: $15,247-$19,426) for deep-incisional/organ space infection at 24-month posthysterectomy. CONCLUSIONS: Real-world cost of managing superficial, deep-incisional/organ space infection after hysterectomy was significantly higher than previously reported. Surgical approach, payer type, and comorbid risk factors contributed to increased risk of infection and economic burden. Medicaid patients experienced the highest risk of infection, followed by Medicare patients. The study suggests adoption of a robust evidence-based surgical care bundle to mitigate risk of surgical site infection and economic burden is warranted.

Risk Assessment Model for Complications in Minimally Invasive Hysterectomy: A Pilot Study.

Objective: To estimate the rate of intra-operative and postoperative complications, and to define the risk of 30-day major postoperative complications (Clavien-Dindo > 2) according to the presence of one of 10 different variables of minimally invasive (MI) hysterectomy; and then to create a risk assessment model easily applicable in clinical practice. Methods: A single center single arm retrolective study. Data of consecutive patients who have undergone MI hysterectomy for gynaecologic disorders between May 2018 and April 2021 were analyzed. Perioperative surgical outcomes, occurrence of intra- and postoperative complications, and readmissions within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major postoperative complications. Results: Over the study period, 445 patients were included in the study. The majority of patients developed a minor event, while major complications (grade III) were required in 14 patients. None of the patients showed a grade IV or V complication. Univariate analysis was performed on patients who had developed intra- or postoperative complications from those who did not experience complications. Body mass index (BMI) (p-value 0.045) and surgeon's experience (p-value 0.015) were found to be associated with a different surgery time. Regarding major postoperative complications, a statistically significant association was found for the variables: BMI (p-value 0.006), previous abdominal surgery (p-value 0.015), and surgeon's experience (p-value 0.035) in the univariate analysis. Also in the multivariate analysis, the risk of major postoperative complications was higher in these three different variables. BMI, previous surgery, and surgeon's experience were inserted in a reproducible risk assessment model in order to stratify the risk of major postoperative complications. Conclusions: We proposed a risk assessment model including factors not previously considered in the literature: the standardization of the surgical technique, the surgeon's experience, the best MI approach (laparoscopy or robot-assisted), and previous abdominal surgery are crucial tools to consider. Further prospective studies with a larger population sample are needed to validate these preliminary evaluations for patients undergoing MI hysterectomy.

Does obesity influence the preferred treatment approach for early-stage cervical cancer? A cost-effectiveness analysis.

OBJECTIVE: Abdominal radical hysterectomy in early-stage cervical cancer has higher rates of disease-free and overall survival compared with minimally invasive radical hysterectomy. Abdominal radical hysterectomy may be technically challenging at higher body mass index levels resulting in poorer surgical outcomes. This study sought to examine the influence of body mass index on outcomes and cost effectiveness between different treatments for early-stage cervical cancer. METHODS: A Markov decision-analytic model was designed using TreeAge Pro software to compare the outcomes and costs of primary chemoradiation versus surgery in women with early-stage cervical cancer. The study used a theoretical cohort of 6000 women who were treated with abdominal radical hysterectomy, minimally invasive radical hysterectomy, or primary chemoradiation therapy. We compared the results for three body mass index groups: less than 30 kg/m2, 30-39.9 kg/m2, and 40 kg/m2 or higher. Model inputs were derived from the literature. Outcomes included complications, recurrence, death, costs, and quality-adjusted life years. An incremental cost-effectiveness ratio of less than $100 000 per quality-adjusted life year was used as our willingness-to-pay threshold. Sensitivity analyses were performed broadly to determine the robustness of the results. RESULTS: Comparing abdominal radical hysterectomy with minimally invasive radical hysterectomy, abdominal radical hysterectomy was associated with 526 fewer recurrences and 382 fewer deaths compared with minimally invasive radical hysterectomy; however, abdominal radical hysterectomy resulted in more complications for each body mass index category. When the body mass index was 40 kg/m2 or higher, abdominal radical hysterectomy became the dominant strategy because it led to better outcomes with lower costs than minimally invasive radical hysterectomy. Comparing abdominal radical hysterectomy with primary chemoradiation therapy, recurrence rates were similar, with more deaths associated with surgery across each body mass index category. Chemoradiation therapy became cost effective when the body mass index was 40 kg/m2 or higher. CONCLUSION: When the body mass index is 40 kg/m2 or higher, abdominal radical hysterectomy is cost saving compared with minimally invasive radical hysterectomy and primary chemoradiation is cost effective compared with abdominal radical hysterectomy. Primary chemoradiation may be the optimal management strategy at higher body mass indexes.

Development of a Preoperative Clinical Risk Assessment Tool for Postoperative Complications After Hysterectomy.

STUDY OBJECTIVE: To develop a preoperative risk assessment tool that quantifies the risk of postoperative complications within 30 days of hysterectomy. DESIGN: Retrospective analysis. SETTING: Michigan Surgical Quality Collaborative hospitals. PATIENTS: Women who underwent hysterectomy for gynecologic indications. INTERVENTIONS: Development of a nomogram to create a clinical risk assessment tool. MEASUREMENTS AND MAIN RESULTS: Postoperative complications within 30 days were the primary outcome. Bivariate analysis was performed comparing women who had a complication and those who did not. The patient registry was randomly divided. A logistic regression model developed and validated from the Collaborative database was externally validated with hysterectomy cases from the National Surgical Quality Improvement Program, and a nomogram was developed to create a clinical risk assessment tool. Of the 41,147 included women, the overall postoperative complication rate was 3.98% (n = 1638). Preoperative factors associated with postoperative complications were sepsis (odds ratio [OR] 7.98; confidence interval [CI], 1.98-32.20), abdominal approach (OR 2.27; 95% CI, 1.70-3.05), dependent functional status (OR 2.20; 95% CI, 1.34-3.62), bleeding disorder (OR 2.10; 95% CI, 1.37-3.21), diabetes with HbA1c ≥9% (OR 1.93; 95% CI, 1.16-3.24), gynecologic cancer (OR 1.86; 95% CI, 1.49-2.31), blood transfusion (OR 1.84; 95% CI, 1.15-2.96), American Society of Anesthesiologists Physical Status Classification System class ≥3 (OR 1.46; 95% CI, 1.24-1.73), government insurance (OR 1.3; 95% CI, 1.40-1.90), and body mass index ≥40 (OR 1.25; 95% CI, 1.04-1.50). Model discrimination was consistent in the derivation, internal validation, and external validation cohorts (C-statistics 0.68, 0.69, 0.68, respectively). CONCLUSION: We validated a preoperative clinical risk assessment tool to predict postoperative complications within 30 days of hysterectomy. Modifiable risk factors identified were preoperative blood transfusion, poor glycemic control, and open abdominal surgery.

Ureteric injuries during hysterectomy-A Norwegian retrospective study of occurrence and claims for compensation over an 11-year period.

INTRODUCTION: Ureteric injury is a rare but serious, iatrogenic complication of hysterectomy. The risk depends on indication for surgery, predisposing risk factors, and peroperative conditions. Our aims were to evaluate and learn from compensation claims to The Norwegian System of Patient Injury Compensation (NPE) for ureteric injury occurring during hysterectomies to predict risk factors, time of identification, symptoms, and consequences, and to relate these cases to injuries registered in The Norwegian Patient Registry. MATERIAL AND METHODS: A retrospective study of ureteric injuries occurring during hysterectomies, reported to NPE and the Norwegian Patient Registry from 2009 through 2019. RESULTS: During the study period, 53 096 hysterectomies were registered in The Norwegian Patient Registry, of which ureteric injury was documented in 643 (1.2%). More ureteric injuries were registered in large hospital trusts than in small trusts (1.3% vs. 0.7%, p < 0.05). NPE received 69 claims due to ureteric injury occurring during hysterectomy, comprising 11% of all injuries in the study period. Compensation was approved for 15%. Women who claimed compensation were younger (48.1 ± 8.9 years vs. 55.1 ± 13.6 years, p < 0.01), more likely to have had a benign diagnosis (89.9% vs. 52.1%, p < 0.01), and more likely to have had the ureteric injury recognized after discharge (58.0% vs. 33.0%, p < 0.001) compared with non-complainants. Identification of the ureters during the hysterectomy was documented in 30% of the NPE patient files. Additional information for the NPE cases included the following. The most common symptoms of unidentified injury were pain (77%), fever (12%), urinary leakage (13%), and anuria (8%). Re-operation was necessary in 77% of the cases, and 10% of the women lost one kidney. Long-term consequences after repair, such as loss of a kidney or persistent pain, were seen in 17%. No women died because of the injury. CONCLUSIONS: The incidence of ureteric injury occurring during hysterectomy in Norway was 1.2%; 11% involved a claim for compensation, and 15% of these had their case approved. Most ureteric injuries were not recognized during the hysterectomy. Documentation of peroperative identification of the ureters during hysterectomy was often missing. Vigilance to pain as a postoperative symptom of peroperative unrecognized ureteric injury may result in earlier diagnosis and treatment.