The impact of fellowship surgical training on operative time and patient morbidity during robotics-assisted sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Abdominal sacrocolpopexy is commonly performed for the surgical correction of pelvic organ prolapse (POP) in the USA. Over the last decade, fellowship programs have increased the number of these procedures performed robotically. Currently, there is a paucity of literature exploring the impact of fellowship training on outcomes of robotic-assisted sacrocolpopexy (RASC). We sought to explore the impact of an expert surgeon operating alone versus with a fellow on operative time and perioperative morbidity associated with RASC. METHODS: This is an analysis of a retrospectively collected cohort of all RASCs performed to treat POP from June 2010 to August 2015 by a single attending surgeon. Outcomes were compared by expert surgeon alone and with a fellow. RESULTS: We identified 208 RASCs, of which 124 (59.6%) were performed by an expert surgeon alone and 84 (40.4%) with a fellow. Eight fellows were included, with a median of 7 cases (interquartile range 5-13.5). Cases with fellows were 31.1 min longer than an expert surgeon alone (155.6 vs 124.5 min, p < 0.001), a 25% increase. Increased operative time for fellows remained significant on multivariate regression (34.2 min, p < 0.001) after adjusting for case order postmenopausal status, hysterectomy, mid-urethral sling, and bowel injury. Years in fellowship did not have an impact on operative time (p = 0.80). Complications were seen in 34 women (16.4%). On univariate regression, fellows did not have an impact on complications (OR 1.49, 95% CI [0.65-3.43]), which was unchanged on multivariate regression (OR 0.628, 95% CI [0.26-1.54]). Prolapse recurrence was seen in 19 women (9.5%). Fellows had no impact on prolapse recurrence (OR 0.478, 95% CI [0.17-1.38]), which was unchanged on multivariate regression (OR 0.266, 95% CI [0.17-1.49]). CONCLUSION: When an expert surgeon operated together with a fellow, operative time increased by 34 min without increasing prolapse recurrence or complications.

Host response to synthetic mesh in women with mesh complications.

BACKGROUND: Despite good anatomic and functional outcomes, urogynecologic polypropylene meshes that are used to treat pelvic organ prolapse and stress urinary incontinence are associated with significant complications, most commonly mesh exposure and pain. Few studies have been performed that specifically focus on the host response to urogynecologic meshes. The macrophage has long been known to be the key cell type that mediates the foreign body response. Conceptually, macrophages that respond to a foreign body can be dichotomized broadly into M1 proinflammatory and M2 proremodeling subtypes. A prolonged M1 response is thought to result in chronic inflammation and the formation of foreign body giant cells with potential for ongoing tissue damage and destruction. Although a limited M2 predominant response is favorable for tissue integration and ingrowth, excessive M2 activity can lead to accelerated fibrillar matrix deposition and result in fibrosis and encapsulation of the mesh. OBJECTIVE: The purpose of this study was to define and compare the macrophage response in patients who undergo mesh excision surgery for the indication of pain vs a mesh exposure. STUDY DESIGN: Patients who were scheduled to undergo a surgical excision of mesh for pain or exposure at Magee-Womens Hospital were offered enrollment. Twenty-seven mesh-vagina complexes that were removed for the primary complaint of a mesh exposure (n = 15) vs pain in the absence of an exposure (n = 12) were compared with 30 full-thickness vaginal biopsy specimens from women who underwent benign gynecologic surgery without mesh. Macrophage M1 proinflammatory vs M2 proremodeling phenotypes were examined via immunofluorescent labeling for cell surface markers CD86 (M1) vs CD206 (M2) and M1 vs M2 cytokines via enzyme-linked immunosorbent assay. The amount of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) proteolytic enzymes were quantified by zymography and substrate degradation assays, as an indication of tissue matrix degradation. Statistics were performed with the use of 1-way analysis of variance with appropriate post hoc tests, t-tests, and Fisher's Exact test. RESULTS: Twenty-seven mesh-vaginal tissue complexes were excised from 27 different women with mesh complications: 15 incontinence mid urethral slings and 12 prolapse meshes. On histologic examination, macrophages surrounded each mesh fiber in both groups, with predominance of the M1 subtype. M1 and M2 cytokines/chemokines, MMP-9 (pro- and active), and MMP-2 (active) were increased significantly in mesh-vagina explants, as compared with vagina without mesh. Mesh explants that were removed for exposure had 88.4% higher pro-MMP-9 (P = .035) than those removed for pain. A positive correlation was observed between the profibrotic cytokine interleukin-10 and the percentage of M2 cells (r = 0.697; P = .037) in the pain group. CONCLUSION: In women with complications, mesh induces a proinflammatory response that persists years after implantation. The increase in MMP-9 in mesh explants that were removed for exposure indicates degradation; the positive association between interleukin-10 and M2 macrophages in mesh explants that are removed for pain is consistent with fibrosis.

Impact of Age on Perioperative Complications After Obliterative Vaginal Surgery.

IMPORTANCE: Obliterative vaginal surgery is often reserved for older patients with prolapse, but the effect of age as an independent risk factor for perioperative complications in this cohort is poorly understood. OBJECTIVE: The aim of this study was to assess the association between age and perioperative complications in women undergoing obliterative vaginal surgery. STUDY DESIGN: This was a retrospective cohort study that included 371 patients undergoing colpocleisis between 2010 and 2013 at a single academic medical center. Seventy demographic and clinical variables, including complications within 12 weeks of surgery, were analyzed. The χ2 and Fisher exact tests were used for categorical variables. Student t and Mann-Whitney U tests were used for continuous variables. Univariate logistic regression was performed to identify predictors of perioperative complications, and candidate variables with P < 0.2 were used in multivariate logistic regression. RESULTS: The mean patient age was 75.4 ± 6.4 years (range, 59-94 years). One hundred ten (29.7%) patients experienced at least 1 complication, the most common of which was urinary tract infection (n = 47, 12.7%). In the final multivariable model, only age (odds ratio, 1.05 per year; 95% confidence interval, 1.01-1.08) remained a significant predictor of perioperative complications. A cut point of age ≥70.5 years maximized sensitivity and specificity for predicting complications. CONCLUSIONS: Among women undergoing obliterative vaginal surgery, age is a predictor of perioperative complications. Each increasing year of age increases the complication likelihood by 1.05-fold, such that an 85-year-old woman is 1.05^20 or 2.65 times more likely than a 65-year-old woman to have a complication. A cut point of ≥70.5 years best predicted complications. Despite this association, severe perioperative complications following obliterative surgery are rare.

The Impact of a Dedicated Robotic Team on Robotic-Assisted Sacrocolpopexy Outcomes.

BACKGROUND: Robotic-assisted sacrocolpopexy has been criticized for high cost. A strategy to increase operating room efficiency and decrease cost is implementation of a dedicated robotic team. Our objective was to determine if a dedicated robotic team decreases operative time. STUDY DESIGN: This institutional review board-approved retrospective cohort study included all robotic-assisted sacrocolpopexy performed from June 2010 to August 2015 by a single surgeon at 2 institutions in 1 health system. One hospital had a dedicated robotic team, whereas the other did not. To assess baseline differences, χ and t tests were used. Multivariable linear regression identified factors impacting operative time. RESULTS: Eighty-eight robotic-assisted sacrocolpopexy cases met inclusion criteria. Subjects were primarily white (92.8%) and postmenopausal (85.5%) with stage III prolapse (71.1%). Mean age was 60.6 ± 9.0 years, and BMI was 28.5 ± 5.1 kg/m. Seventeen cases (19.3%) had a dedicated team. In the 71 cases without a dedicated team, there were 16 different surgical technologist and no advanced practice providers. Groups had similar baseline characteristics (all P > 0.05).Mean operative time for the dedicated team was significantly less (131.8 vs 160.2 minutes, P < 0.001), a 17.7% time reduction. The decrease persisted on multivariable regression (ß = -25.98 minutes, P < 0.001) after adjusting for case order on the day (ß = -8.6 minutes, P = 0.002) and prior to hysterectomy (ß = -36.1 minutes, P < 0.001). Operative complications and prolapse recurrence were low overall and not different between the dedicated and nondedicated teams (0% vs 2.9%, P = 0.50; 0% vs 7.5%, P = 0.29). CONCLUSIONS: A dedicated robotic team during robotic-assisted sacrocolpopexy significantly decreased operative time by 26 minutes, a 17.7% reduction at our institution.

The Impact of Individual Surgeon Volume on Hysterectomy Costs.

BACKGROUND AND OBJECTIVE: Hysterectomy is one of the most common surgical procedures women will undergo in their lifetime. Several factors affect surgical outcomes. It has been suggested that high-volume surgeons favorably affect outcomes and hospital cost. The objective is to determine the impact of individual surgeon volume on total hospital costs for hysterectomy. METHODS: This is a retrospective cohort of women undergoing hysterectomy for benign indications from 2011 to 2013 at 10 hospitals within the University of Pittsburgh Medical Center System. Cases that included concomitant procedures were excluded. Costs by surgeon volume were analyzed by tertile group and with linear regression. RESULTS: We studied 5,961 hysterectomies performed by 257 surgeons: 41.5% laparoscopic, 27.9% abdominal, 18.3% vaginal, and 12.3% robotic. Surgeons performed 1-542 cases (median = 4, IQR = 1-24). Surgeons were separated into equal tertiles by case volume: low (1-2 cases; median total cost, $4,349.02; 95% confidence interval [CI] [$3,903.54-$4,845.34]), medium (3-15 cases; median total cost, $2,807.90; 95% CI [$2,693.71-$2,926.93]) and high (>15 cases, median total cost $2,935.12, 95% CI [$2,916.31-$2,981.91]). ANOVA analysis showed a significant decrease (P < .001) in cost from low-to-medium- and low-to-high-volume surgeons. Linear regression showed a significant linear relationship (P < .001), with a $1.15 cost reduction per case with each additional hysterectomy. Thus, if a surgeon performed 100 cases, costs were $115 less per case (100 × $1.15), for a total savings of $11,500.00 (100 × $115). CONCLUSION: Overall, in our models, costs decreased as surgeon volume increased. Low-volume surgeons had significantly higher costs than both medium- and high-volume surgeons.

Intraovarian oxidized cellulose (Surgicel) mimicking acute ovarian pathology after recent pelvic surgery.

Oxidized regenerated cellulose (Ethicon Surgicel) is often used during surgery to achieve hemostasis. The appearance of Surgicel on postoperative computed tomography (CT) may be mistaken for abscess. Meanwhile, the literature regarding its ultrasound appearance remains scant. We report the CT and sonographic appearances of Surgicel in the right ovary of a 21-year-old woman presenting to the emergency department with pelvic pain 7 days after ovarian cystectomy. The patient was discharged home with only supportive measures, and follow-up ultrasound obtained 26 days later demonstrated resolution of the sonographic abnormality. This case stresses the importance of familiarity with common imaging appearances of topical hemostatic agents and the need to correlate radiologic findings with the patient's clinical condition and prior operative reports to identify patients suitable for conservative management.

Cost analysis when open surgeons perform minimally invasive hysterectomy.

BACKGROUND AND OBJECTIVE: The costs to perform a hysterectomy are widely variable. Our objective was to determine hysterectomy costs by route and whether traditionally open surgeons lower costs when performing laparoscopy versus robotics. METHODS: Hysterectomy costs including subcategories were collected from 2011 to 2013. Costs were skewed, so 2 statistical transformations were performed. Costs were compared by surgeon classification (open, laparoscopic, or robotic) and surgery route. RESULTS: A total of 4,871 hysterectomies were performed: 34.2% open, 50.7% laparoscopic, and 15.1% robotic. Laparoscopic hysterectomy had the lowest total costs (P < .001). By cost subcategory, laparoscopic hysterectomy was lower than robotic hysterectomy in 6 and higher in 1. When performing robotic hysterectomy, open and robotic surgeon costs were similar. With laparoscopic hysterectomy, open surgeons had higher costs than laparoscopic surgeons for 1 of 2 statistical transformations (P = .007). Open surgeons had lower costs performing laparoscopic hysterectomy than robotic hysterectomy with robotic maintenance and depreciation included (P < .001) but similar costs if these variables were excluded. CONCLUSION: Although laparoscopic hysterectomy had lowest costs overall, robotics may be no more costly than laparoscopic hysterectomy when performed by surgeons who predominantly perform open hysterectomy.