Variables impacting prolonged post-anesthesia care unit length of stay in gynecologic cancer patients in the era of same day minimally invasive hysterectomy.

OBJECTIVES: Minimally invasive surgery for treatment of gynecologic malignancies is associated with decreased pain, fewer complications, earlier return to activity, lower cost, and shorter hospital stays. Patients are often discharged the day of surgery, but occasionally stay overnight due to prolonged post-anesthesia care unit (PACU) stays. The objective of this study was to identify risk factors for prolonged PACU length of stay (LOS). METHODS: This is a single institution retrospective review of patients who underwent minimally invasive hysterectomy for gynecologic cancer from 2019 to 2022 and had a hospital stay <24-h. The primary outcome was PACU LOS. Demographics, pre-operative diagnoses, and surgical characteristics were recorded. After Box-Cox transformation, linear regression was used to determine significant predictors of PACU LOS. RESULTS: For the 661 patients identified, median PACU LOS was 5.04 h (range 2.16-23.76 h). On univariate analysis, longer PACU LOS was associated with increased age (ρ = 0.106, p = 0.006), non-partnered status [mean difference (MD) = 0.019, p = 0.099], increased alcohol use (MD = 0.018, p = 0.102), increased Charlson Comorbidity Index (CCI) score (ρ = 0.065, p = 0.097), and ASA class ≥3 (MD = 0.033, p = 0.002). Using multivariate linear regression, increased age (R2 = 0.0011, p = 0.043), non-partnered status (R2 = 0.0389, p < 0.001), and ASA class ≥3 (R2 = 0.0250, p = 0.023) were associated with increased PACU LOS. CONCLUSIONS: Identifying patients at risk for prolonged PACU LOS, including patients who are older, non-partnered, and have an ASA class ≥3, may allow for interventions to improve patient experience, better utilize hospital resources, decrease PACU overcrowding, and limit postoperative admissions and complications. The relationship between non-partnered status and PACU LOS is the most novel relationship identified in this study.

Practice patterns and complications of hysterectomy for invasive cervical cancer after the Laparoscopic Approach to Cervical Cancer trial.

BACKGROUND: After the publication of the Laparoscopic Approach to Cervical Cancer trial, the standard surgical approach for early-stage cervical cancer is open radical hysterectomy. Only limited data were available regarding whether the change to open abdominal hysterectomy observed after the Laparoscopic Approach to Cervical Cancer trial led to an increase in postoperative complication rates as a consequence of the decrease in the use of the minimally invasive approach. OBJECTIVE: This study aimed to analyze whether there was a correlation between the publication of the Laparoscopic Approach to Cervical Cancer trial and an increase in the 30-day complications associated with surgical treatment of invasive cervical cancer. STUDY DESIGN: Data from the American College of Surgeons National Surgical Quality Improvement Program were used to compare the results in the pre-Laparoscopic Approach to Cervical Cancer period (January 2016 to December 2017) vs the results in the post-Laparoscopic Approach to Cervical Cancer period (January 2019 to December 2020). The rates of each surgical approach (open abdominal or minimally invasive) hysterectomy for invasive cervical cancer during the 2 periods were assessed. Subsequently, 30-day major complication, minor complication, unplanned hospital readmission, and intra- or postoperative transfusion rates before and after the publication of the Laparoscopic Approach to Cervical Cancer trial were compared. RESULTS: Overall, 3024 patients undergoing either open abdominal hysterectomy or minimally invasive hysterectomy for invasive cervical cancer were included in the study. Of the patients, 1515 (50.1%) were treated in the pre-Laparoscopic Approach to Cervical Cancer period, and 1509 (49.9%) were treated in the post-Laparoscopic Approach to Cervical Cancer period. The rate of minimally invasive approaches decreased significantly from 75.6% (1145/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 41.1% (620/1509) in the post-Laparoscopic Approach to Cervical Cancer period, whereas the rate of open abdominal approach increased from 24.4% (370/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 58.9% (889/1509) in the post-Laparoscopic Approach to Cervical Cancer period (P<.001). The overall 30-day major complications remained stable between the pre-Laparoscopic Approach to Cervical Cancer period (85/1515 [5.6%]) and the post-Laparoscopic Approach to Cervical Cancer period (74/1509 [4.9%]) (adjusted odds ratio, 0.85; 95% confidence interval, 0.61-1.17). The overall 30-day minor complications were similar in the pre-Laparoscopic Approach to Cervical Cancer period (103/1515 [6.8%]) vs the post-Laparoscopic Approach to Cervical Cancer period (120/1509 [8.0%]) (adjusted odds ratio, 1.17; 95% confidence interval, 0.89-1.55). The unplanned hospital readmission rate remained stable during the pre-Laparoscopic Approach to Cervical Cancer period (7.9% per 30 person-days) and during the post-Laparoscopic Approach to Cervical Cancer period (6.3% per 30 person-days) (adjusted hazard ratio, 0.78; 95% confidence interval, 0.58-1.04)]. The intra- and postoperative transfusion rates increased significantly from 3.8% (58/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 6.7% (101/1509) in the post-Laparoscopic Approach to Cervical Cancer period (adjusted odds ratio, 1.79; 95% confidence interval, 1.27-2.53). CONCLUSION: This study observed a significant shift in the surgical approach for invasive cervical cancer after the publication of the Laparoscopic Approach to Cervical Cancer trial, with a reduction in the minimally invasive abdominal approach and an increase in the open abdominal approach. The change in surgical approach was not associated with an increase in the rate of 30-day major or minor complications and unplanned hospital readmission, although it was associated with an increase in the transfusion rate.

Designing a core data set for benign hysterectomy registration system and its implementation in a referral teaching hospital in Northwest Iran.

BACKGROUND AND AIMS: Although minimally invasive hysterectomy offers advantages, abdominal hysterectomy remains the predominant surgical method. Creating a standardized dataset and establishing a hysterectomy registry system present opportunities for early interventions in reducing volume and selecting benign hysterectomy methods. This research aims to develop a dataset for designing benign hysterectomy registration system. METHODS: Between April and September 2020, a qualitative study was carried out to create a data set for enrolling patients who were candidate for hysterectomy. At this stage, the research team conducted an information needs assessment, relevant data element identification, registry software development, and field testing; Subsequently, a web-based application was designed. In June 2023the registry software was evaluated using data extracted from medical records of patients admitted at Al-Zahra Hospital in Tabriz, Iran. RESULTS: During two months, 40 patients with benign hysterectomy were successfully registered. The final dataset for the hysterectomy patient registry comprise 11 main groups, 27 subclasses, and a total of 91 Data elements. Mandatory data and essential reports were defined. Furthermore, a web-based registry system designed and evaluated based on data set and various scenarios. CONCLUSION: Creating a hysterectomy registration system is the initial stride toward identifying and registering hysterectomy candidate patients. this system capture information about the procedure techniques, and associated complications. In Iran, this registry can serve as a valuable resource for assessing the quality of care delivered and the distribution of clinical measures.

Effect of Preoperative Bilateral Ultrasound-Guided Quadratus Lumborum Nerve Block on Quality of Recovery After Minimally Invasive Hysterectomy in an Enhanced Recovery After Surgery (ERAS) Setting.

STUDY OBJECTIVE: To assess the effect of preoperative bilateral ultrasound-guided quadratus lumborum nerve block (QLB) on quality of recovery after minimally invasive hysterectomy, in an enhanced recovery after surgery setting. DESIGN: Randomized, controlled, double-blinded trial (Canadian Task Force level I). SETTING: University-affiliated tertiary medical center. PATIENTS: All women undergoing an elective robotic or laparoscopic hysterectomy. Women with chronic pain, chronic anticoagulation, and body mass index >50 kg/m2 were excluded. INTERVENTION: Patients were randomized with a 1:1 allocation, to one of the following 2 arms, and stratified based on robotic versus laparoscopic approach. 1. QLB: QLB (bupivacaine) + sham local trocar sites infiltration (normal saline) 2. Local infiltration: sham QLB (normal saline) + local infiltration (bupivacaine) MEASUREMENTS AND MAIN RESULTS: The primary outcome was defined as the quality of recovery score based on the validated questionnaire Quality of Recovery, completed 24 hours postoperatively. Secondary outcomes included dynamic pain scores, accumulated opioid consumption up to 24 hours, postoperative nausea and vomiting, surgical complications, length of hospital stay, time to first pain medication administration in the postanesthesia care unit, and adverse events. A total of 76 women were included in the study. Demographic characteristics were similar in both groups. Median age was 44 years (interquartile range 39-50), 47% of the participants were African American, and mean body mass index was 32.8 kg/m2 (standard deviation [SD] 8.1). The mean Quality of Recovery score was 179.1 (SD ± 10.3) in the QLB and 175.6 (SD ± 9.7) for the local anesthesia group (p = .072). All secondary outcomes were comparable between groups. CONCLUSIONS: QLBs do not significantly improve quality of recovery after elective robotic or laparoscopic hysterectomy compared with local anesthetic port site infiltration.

A National Database Study on Racial Disparities in Route of Hysterectomy with a Surrogate Control for Uterine Size: A Proposed Quality Metric for Benign Indications.

STUDY OBJECTIVE: To investigate the association between race and route of hysterectomy among patients undergoing hysterectomy for abnormal uterine bleeding (AUB) in the absence of uterine myoma disease and excluding malignancy. DESIGN: A cross-sectional cohort study utilizing the Healthcare Cost and Utilization Project Nationwide Inpatient Sample and National Ambulatory Surgical databases to compare abdominal to minimally invasive routes of hysterectomy. SETTING: Hospitals and hospital-affiliated ambulatory surgical centers participating in the Healthcare Cost and Utilization Project in 2019. PATIENTS: A total of 75 838 patients who had undergone hysterectomy for AUB, excluding uterine myoma and malignancy. INTERVENTIONS: n/a MEASUREMENTS AND MAIN RESULTS: Of the 75 838 hysterectomies performed for AUB in the absence of uterine myomas and malignancy, 10.1% were performed abdominally and 89.9% minimally invasively. After adjusting for confounders, Black patients were 38% more likely to undergo abdominal hysterectomy compared to White patients (OR 1.38, CI 1.12-1.70 p = .002). Black race, thus, is independently associated with open surgery. CONCLUSION: Despite excluding uterine myomas as a risk factor for an abdominal route of hysterectomy, Black race remained an independent predictor for abdominal versus minimally invasive hysterectomy, and Black patients were found to undergo a disproportionately higher rate of abdominal hysterectomy compared to White patients.

Risk of Bowel Obstruction After Hysterectomy for Benign Indication According to Surgical Method in Denmark, 1984-2013.

STUDY OBJECTIVE: To estimate the risk of bowel obstruction (BO) after hysterectomy for benign indications depending on the surgical method (abdominal, vaginal, or laparoscopic) and identify risk factors for adhesive BO. DESIGN: A national registry-based cohort. SETTING: Danish hospitals during the period 1984-2013. PATIENTS: Danish women who underwent hysterectomy for benign indications (N = 125 568). INTERVENTIONS: Abdominal hysterectomies were compared with vaginal hysterectomies, laparoscopic hysterectomies, and minimally invasive (vaginal and laparoscopic) hysterectomies. MEASUREMENTS AND MAIN RESULTS: The incidence of BO according to the surgical method was compared using Cox proportional hazard regression. The covariates included were the time period, age, concomitant operations, previous abdominal surgery or disease, and socioeconomic factors. In a subanalysis (n = 35 712 women) of the period 2004-2013, detailed information from the Danish Hysterectomy Database enabled the inclusion of patient-, surgery-, and complication-related covariates. The overall crude incidence of BO was 17.4 of 1000 hysterectomies (2196 incident cases). The 10-year cumulative incidence of BO differed among the surgical routes (abdominal, 1.7%; laparoscopic, 1.4%; and vaginal, 0.9%). In multiple-adjusted analyses, the risk of BO was higher after abdominal hysterectomy than after vaginal (hazard ratio 1.64 [95% confidence interval, 1.39-1.93]) and minimally invasive (vaginal or laparoscopic) hysterectomy (hazard ratio 1.54 [1.33-1.79]). Additional pre-existing risk factors for BO at the time of hysterectomy were increased age, low education, low income, smoking, high American Society of Anesthesiologists comorbidity score, history of infertility, abdominal infection, and previous abdominal surgery (apart from cesarean section), penetrating lesions in abdominal organs, or operative adhesiolysis. Perioperative risk factors at the time of hysterectomy included concomitant removal of the ovaries, adhesiolysis, blood transfusion, readmission, and overall presence of perioperative complications. CONCLUSION: Abdominal hysterectomy is associated with a 54% higher risk of BO than minimally invasive (laparoscopic or vaginal) hysterectomy.

Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Deconstructed: Expanding Minimally Invasive Gynecologic Surgeons' Toolbox.

Background: The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of vaginal hysterectomy declines. Methods: This review discusses nuances of the vNOTES technique applied to hysterectomy; describes vNOTES hysterectomy, step-by-step (including tips and tricks for low- and high-complexity cases for surgeons who may want to incorporate vNOTES hysterectomy into their surgical repertoires); and examines evidence and research trends in this field. Results: The descriptions in the text, figures, tables, and videos all contribute to giving readers a clear understanding of vNOTES, its advantages, limitations, and research potentials. Conclusions: vNOTES hysterectomy is a unique blend of vaginal, laparoscopic, and laparoendoscopic single-site surgery (LESS) techniques and is not a new procedure, but rather another tool to use in minimally invasive gynecologic surgery. (J GYNECOL SURG 40:78).

Safety and feasibility of same-day discharge following minimally invasive hysterectomy in the morbidly obese patient population.

OBJECTIVES: To determine whether morbid obesity should serve as an independent factor in the decision for same day discharge following minimally invasive hysterectomy. METHODS: Retrospective review was performed of patients with BMI ≥ 40 who underwent minimally invasive hysterectomy within a single comprehensive cancer center between January 2018 - August 2020. Demographics, perioperative factors, post-operative monitoring, complications, and readmissions were compared between patients who underwent same day discharge and overnight observation using Fisher's exact tests and Wilcoxon rank-sum tests. RESULTS: 374 patients with BMI ≥ 40 were included. Eighty-three (22.2%) patients underwent same day discharge, and 291 (77.8%) patients underwent overnight observation. Factors associated with increased likelihood of same day discharge included younger age (median age 53 vs 58; p = 0.001), lower BMI (median BMI 45 vs 47; p = 0.005), and fewer medical co-morbidities (Charlson Co-Morbidity Index 2 vs 3; p < 0.001). On multivariate regression analysis, frailty (OR 2.16 [1.14-4.11], p = 0.019) and surgical completion time after 12 PM (OR 3.67 [2.16-6.24], p < 0.001) were associated with increased risk of overnight observation. Few patients admitted for routine overnight observation required medical intervention (n = 14, 4.8%); most of these patients were frail (64.3%). The overall hospital readmission rate within 30 days of discharge was 3.2% (n = 12), with no patients discharged on the day of surgery being readmitted. CONCLUSIONS: Morbid obesity alone should not serve as a contraindication to same day discharge following minimally invasive hysterectomy. Admission for observation was associated with low rates of clinically meaningful intervention, and patients who underwent same day discharge were not at increased risk of adverse outcome.

Patient-reported symptoms after minimally invasive hysterectomy and association with postoperative complications.

OBJECTIVE: To describe patient-reported postoperative symptoms and to evaluate the use of digital symptom tracking and alerts to detect postoperative complications. METHODS: We retrospectively reviewed patients who underwent a minimally invasive hysterectomy and enrolled in our Recovery Tracker program from 4/5/17-12/31/21. The Recovery Tracker is an at-home virtual tool used to track patient-reported postoperative symptoms for 10 days. Predefined thresholds for "red" and "yellow" alerts are based on symptom severity and timing. Data on patient demographics, surgery, and postoperative course were collected to evaluate the association of alerts with complications and compare outcomes of patients who did/did not enroll in the program. RESULTS: Of 2362 eligible patients, 1694 (71.7%) enrolled in the Recovery Tracker program. Pain was the most severe symptom, followed by fatigue. Eighty-seven patients experienced 102 complications (5.1% complication rate) and 32 experienced 39 grade ≥ 2 complications (1.9% severe complication rate). Excluding complications that occurred prior to Recovery Tracker use, 1673 patients experienced 28 grade ≥ 2 complications. Of 345 patients (20.6%) who triggered a red alert, 13 (3.8%) had a grade ≥ 2 complication. Of 1328 patients (79.4%) with no red alerts, 15 (1.13%) had a grade ≥ 2 complication. Relative risk of a grade ≥ 2 complication if a red alert was triggered was 3.25 (95% CI: 1.6-6.9, P = .002). Rate of severe complications was significantly higher among patients who did not use the tool (3.3% vs 1.9%; P = .04). CONCLUSIONS: The Recovery Tracker tool may assist in early identification of postoperative symptoms after minimally invasive hysterectomy.

Laparoscopic administration of bupivacaine at the uterosacral ligaments during benign laparoscopic and robotic hysterectomy: a randomized controlled trial.

BACKGROUND: Postoperative pain continues to be an undermanaged part of the surgical experience. Multimodal analgesia has been adopted in response to the opioid epidemic, but opioid prescribing practices remain high after minimally invasive hysterectomy. Novel adjuvant opioid-sparing analgesia to optimize acute postoperative pain control is crucial in preventing chronic pain and minimizing opioid usage. OBJECTIVE: This study aimed to determine the effect of direct laparoscopic uterosacral bupivacaine administration on opioid usage and postoperative pain in patients undergoing benign minimally invasive (laparoscopic and robotic) hysterectomy. STUDY DESIGN: This was a single-blinded, triple-arm, randomized controlled trial at an academic medical center between March 15, 2021, and April 8, 2022. The inclusion criteria were patients aged >18 years undergoing benign laparoscopic or robotic hysterectomy. The exclusion criteria were non-English-speaking patients, patients with an allergy to bupivacaine or actively using opioid medications, patients undergoing transversus abdominis plane block, and patients undergoing supracervical hysterectomy or combination cases with other surgical services. Patients were randomized in a 1:1:1 fashion to the following uterosacral administration before colpotomy: no administration, 20 mL of normal saline, or 20 mL of 0.25% bupivacaine. All patients received incisional infiltration with 10 mL of 0.25% bupivacaine. The primary outcome was 24-hour oral morphine equivalent usage (postoperative day 0 and postoperative day 1). The secondary outcomes were total oral morphine equivalent usage in 7 days, last day of oral morphine equivalent usage, numeric pain scores from the universal pain assessment tool, and return of bowel function. Patients reported postoperative pain scores, total opioid consumption, and return of bowel function via Qualtrics surveys. Patient and surgical characteristics and primary and secondary outcomes were compared using chi-square analysis and 1-way analysis of variance. Multiple linear regression was used to identify predictors of opioid use in the first 24 hours after surgery and total opioid use in the 7 days after surgery. RESULTS: Of 518 hysterectomies screened, 410 (79%) were eligible, 215 (52%) agreed to participate, and 180 were ultimately included in the final analysis after accounting for dropout. Most hysterectomies (70%) were performed laparoscopically, and the remainder were performed robotically. Most hysterectomies (94%) were outpatient. Patients randomized to bupivacaine had higher rates of former and current tobacco use, and patients randomized to the no-administration group had higher rates of previous surgery. There was no difference in first 24-hour oral morphine equivalent use among the groups (P=.10). Moreover, there was no difference in numeric pain scores (although a trend toward significance in discharge pain scores in the bupivacaine group), total 7-day oral morphine equivalent use, day of last opioid use, or return of bowel function among the groups (P>.05 for all). The predictors of increased 24-hour opioid usage among all patients included only increased postanesthesia care unit oral morphine equivalent usage. The predictors of 7-day opioid usage among all patients included concurrent tobacco use and mood disorder, history of previous laparoscopy, estimated blood loss of >200 mL, and increased oral morphine equivalent usage in the postanesthesia care unit. CONCLUSION: Laparoscopic uterosacral administration of bupivacaine at the time of minimally invasive hysterectomy did not result in decreased opioid usage or change in numeric pain scores.

Less is more: clinical utility of postoperative laboratory testing following minimally invasive hysterectomy for endometrial cancer.

BACKGROUND: With the increasing rates of same-day discharge following minimally invasive surgery for endometrial cancer, the need for and value of routine postoperative testing is unclear. OBJECTIVE: This study aimed to determine whether routine postoperative laboratory testing following minimally invasive hysterectomy for endometrial cancer leads to clinically significant changes in postoperative care. STUDY DESIGN: This was a single-institution retrospective cohort study of patients undergoing minimally invasive hysterectomy for endometrial cancer by a gynecologic oncologist between June 2014 and June 2017. Patient demographics, preoperative comorbidities, operative and postoperative data, and pathologic findings were manually extracted from the patients' medical records. The financial burden of laboratory testing was computed using hospital-level cost data. RESULTS: Of the 649 women included in the analysis, most (91.4%) were White, with a mean age of 61 years, and mean body mass index of 38.0 kg/m2. The most common comorbidities were diabetes mellitus (31.9%, n=207), chronic pulmonary disease (7.9%, n=51), and congestive heart failure (3.2%, n=21). Median operative time was 151 minutes (range, 61-278), and median estimated blood loss was 100 mL (range, 10-1500). Most patients (68.6%, n=445) underwent lymphadenectomy. All patients had postoperative laboratory tests ordered: 100% complete blood count, 99.7% chemistry, 62.9% magnesium, 46.8% phosphate, 37.4% calcium, and 1.2% liver function tests. Twenty-six patients (4.0%) had a change in management owing to postoperative laboratory test results. Of these 26 women, 88% experienced a change in clinical status that would have otherwise prompted testing. Only 3 (0.5% of entire cohort) were asymptomatic: 1 received a blood transfusion for asymptomatic anemia, and the other 2, who did not carry a diagnosis of diabetes mellitus, had interventions for hyperglycemia. On univariable analysis, peripheral and cerebrovascular disease, diabetes mellitus with end-organ damage, and a Charlson Comorbidity Index of ≥3 were associated with increased odds of change in management; these were not significant on multivariable analysis. Routine postoperative laboratory evaluation in this cohort increased hospital costs by $292,000. CONCLUSION: Routine postoperative laboratory tests are unlikely to lead to significant changes in management for women undergoing minimally invasive hysterectomy for endometrial cancer, and may increase cost without providing a discernible clinical benefit. In the setting of strict postoperative guidelines, laboratory tests should be ordered when clinically indicated rather than as part of routine postoperative management for women undergoing minimally invasive hysterectomy for endometrial cancer.

Analysis of Sociodemographic Factors Affecting Ambulatory Surgical Center Discharge Patterns for Endometrial Cancer Hysterectomies.

STUDY OBJECTIVE: Investigate outcomes for patients undergoing minimally invasive hysterectomies (MIHs) performed for endometrial cancer at ambulatory surgery centers (ASCs). DESIGN: Our study aimed to explore the feasibility and discharge outcomes for MIHs for endometrial cancer in an ASC setting by using same-day discharge data. SETTING: The prevalence of MIH for endometrial cancer between 2016 and 2019 was estimated from the Nationwide Ambulatory Surgery Sample. PATIENTS: Patients who underwent MIHs for endometrial cancer at an ASC were included. INTERVENTIONS: N/A MEASUREMENTS MAIN RESULTS: Weighted estimates of prevalence and association between discharge status and sociodemographic factors were explored. Same-day discharge was defined as discharge on the day of surgery, and delayed discharge was defined as discharge after the day of surgery. An estimated 95 041 MIHs for endometrial cancer were performed at ASCs between 2016 and 2019. Notably, 91.9% (n = 87 372) resulted in same-day discharge, 1.2% (n = 1121) had delayed discharge, and 6.9% (n = 6548) had missing discharge information; 78.7% procedures (n = 68 812) were performed at public hospitals. The proportion of delayed discharges were lower in private, not-for profit ASCs (0.8%, p = .03) than public hospitals. Patients who had delayed discharges on average were older (69.7 vs 62.4 years, p <.001), more likely to have comorbid conditions including diabetes (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.25-1.75) and overweight or obese body mass indices (aOR 1.18, 95% CI 1.01-1.39), and more likely to have public insurance (aOR 1.78, 95% CI 1.40-2.25). CONCLUSION: MIHs for endometrial cancer are feasible in an ASC. Optimal candidates for receipt of MIHs for endometrial cancer at an ASC are patients who are younger and have less comorbidities, lower body mass index, and private insurance.

Hysterectomy Trends and Risk of Vaginal Cuff Dehiscence: An Update by Mode of Surgery.

STUDY OBJECTIVE: To analyze hysterectomy trends and vaginal cuff dehiscence (VCD) rates by mode of surgery at a tertiary care medical center and to describe characteristics of VCD cases. DESIGN: Observational retrospective cohort study. SETTING: Large academic hospital and affiliated community hospital. PATIENTS: 4722 patients who underwent hysterectomy at Columbia University Irving Medical Center between January 2010 and August 2021. INTERVENTIONS: Current Procedural Terminology and International Classification of Diseases codes identified hysterectomies and VCD cases. Hysterectomy trends and VCD rates were calculated by mode of surgery. Relative risks of VCD for each mode were compared with total abdominal hysterectomy (TAH). Clinical characteristics of VCDs were reviewed. MEASUREMENTS AND MAIN RESULTS: There were 4059 total hysterectomies. Laparoscopic hysterectomies, including total laparoscopic hysterectomies (TLHs), laparoscopic-assisted vaginal hysterectomies, and robot-assisted TLHs (RA-TLHs), increased from 41.9% in 2010 to 65.9% in 2021 (p <.001). RA-TLH increased from 5.7% in 2010 to 40.2% in 2021. Supracervical hysterectomies followed similar trends and were excluded from VCD analysis. There were 15 VCDs (overall rate 0.37%). VCD was highest after RA-TLH (0.66%), followed by TLH (0.32%) and TAH (0.27%), with no VCDs after laparoscopic-assisted vaginal hysterectomy or total vaginal hysterectomy. Compared with TAH, the relative risk for VCD after RA-TLH was 2.44 (95% confidence interval 0.66-9.00) and after TLH was 1.18 (95% confidence interval 0.24-5.83), which were not statistically significant. The mean time to dehiscence was 39 days (range 8-145 days). The most common trigger event was coitus (41%). CONCLUSION: VCD rates were low (<1%) for all modes of hysterectomy, and rates after robotic and laparoscopic hysterectomy were much lower than previously reported. Although VCD rates trended higher after robotic and laparoscopic hysterectomy compared with abdominal hysterectomy, the difference was not significant. It is difficult to determine whether this finding represents true lack of difference vs a lack of power to detect a significant difference given the rarity of VCD.

Relevance of Uterine Weight for Predicting Surgical Complications in Minimally Invasive Benign Hysterectomy.

STUDY OBJECTIVES: To describe the uterine weight threshold for increasing risk of complications after a laparoscopic hysterectomy using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. DESIGN: Cross-sectional analysis using the American College of Surgeons NSQIP database from 2016 to 2021. SETTING: American College of Surgeons NSQIP database. PATIENTS: Patients undergoing minimally invasive hysterectomy for benign indications (N = 64 289). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Uterine weight was entered in grams and 30-day complications were abstracted from patient charts. In the analytic sample, median uterine weight was 135 grams (interquartile range, 90-215) and 6% of patients (n = 4085) experienced complications. Uterine weight performed very poorly in predicting complications on bivariate analysis (area under the receiver operating characteristics curve, 0.53; 95% confidence interval, 0.53-0.54). On multivariable analysis, a uterine weight cutoff of 163 grams was associated with higher odds of complications (odds ratio, 1.11; 95% confidence interval, 1.03-1.19; p = .003), but this threshold achieved only a 43% sensitivity and 62% specificity for predicting complications. CONCLUSIONS: Uterine weight alone possessed negligible utility for predicting the risk of perioperative complications in minimally invasive hysterectomy.

Who will be readmitted? Evaluation of the laparoscopic hysterectomy readmission score in a gynecologic oncology population undergoing robotic-assisted hysterectomy.

OBJECTIVES: The laparoscopic hysterectomy readmission score (LHRS) was created to identify patients for whom same day discharge (SDD) after minimally invasive hysterectomy (MIH) may not be advisable and includes diabetes, chronic obstructive pulmonary disease, disseminated cancer, chronic steroid use, bleeding disorder, length of surgery, and any postoperative complication prior to discharge. We evaluated the performance of the score at predicting readmission in a gynecologic oncology population, and additionally sought to determine if any factors known prior to surgery could replace those that are not known until the time of surgery (operative time and postoperative complication). METHODS: This was a single-institution retrospective cohort study of women undergoing robotic hysterectomy by a gynecologic oncologist in 2018. Associations between pre-operative, operative and post-operative factors and 30-day readmission, SDD and postoperative complications were assessed using logistic regression. RESULTS: The 30-day readmission rate among the 423 women in the cohort was 4.5% and 1.9% in those undergoing SDD. Readmission rates by LHRS were: score 1 (4.9%), score 2 (7.8%), score 3 (13.6%), score 4 (16.7%). Patients with a LHRS of ≥3 had higher odds of readmission compared to those with a lower score (OR 4.20, p = 0.02). Infectious morbidity accounted for the majority of postoperative complications, emergency room visits and readmissions. We did not identify preoperative factors to replace the intra- and post-operative factors used in the score. CONCLUSIONS: The readmission rate following MIH is low, and a LHRS of ≥3 is associated with increased risk of readmission. Our findings support the applicability of the LHRS to a gynecologic oncology population; addressing risk factors for postoperative infection or closer follow up for patients with a LHRS ≥3 could reduce postoperative readmissions.

Predictors of same-day discharge following benign minimally invasive hysterectomy.

BACKGROUND: Same-day discharge following minimally invasive hysterectomy has been shown to be safe and feasible in select populations, but many nonclinical factors influencing same-day discharge remain unexplored. OBJECTIVE: To develop prediction models for same-day discharge following minimally invasive hysterectomy using both clinical and nonclinical attributes and to compare model concordance of individual attribute groups. STUDY DESIGN: We performed a retrospective study of patients who underwent elective minimally invasive hysterectomy for benign gynecologic indications at 69 hospitals in a statewide quality improvement collaborative between 2012 and 2019. Potential predictors of same-day discharge were determined a priori and placed into 1 of 7 attribute groupings: intraoperative, surgeon, hospital, surgical timing, patient clinical, patient socioeconomic, and patient geographic attributes. To account for clustering of same-day discharge practices among surgeons and within hospitals, hierarchical multivariable logistic regression models were fitted using predictors from each attribute group individually and all predictors in a composite model. Receiver operator characteristic curves were generated for each model. The Hanley-McNeil test was used for comparisons, 95% confidence intervals for the areas under the receiver operator characteristic curve were calculated, and a P value of <.05 was considered significant. RESULTS: Of the 23,513 patients in our study, 5062 (21.5%) had same-day discharge. The composite model had an area under the receiver operator characteristic curve of 0.770 (95% confidence interval, 0.763-0.777). Among models using factors from individual attribute groups, the model using intraoperative attributes had the highest concordance for same-day discharge (area under the receiver operator characteristic curve, 0.720; 95% confidence interval, 0.712-0.727). The models using surgeon and hospital attributes were the second and third most concordant, respectively (area under the receiver operator characteristic curve, 0.678; 95% confidence interval, 0.670-0.685; area under the receiver operator characteristic curve, 0.655; 95% confidence interval, 0.656-0.664). Models using surgical timing and patient clinical, socioeconomic, and geographic attributes had poor predictive ability (all areas under the receiver operator characteristic curve <0.6). CONCLUSION: Clinical and nonclinical attributes contributed to a composite prediction model with good discrimination in predicting same-day discharge following minimally invasive hysterectomy. Factors related to intraoperative, hospital, and surgeon attributes produced models with the strongest predictive ability. Focusing on these attributes may aid efforts to improve utilization of same-day discharge following minimally invasive hysterectomy.

Outcomes of vaginal and laparoscopic hysterectomy with concomitant pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Although vaginal hysterectomy(VH) is traditionally considered the safest route of hysterectomy, newer data suggest that laparoscopic hysterectomy (LH) might have lower risks of perioperative complications in contemporary practice. Using a large surgical database, we aimed to assess the hypothesis that there are no significant differences in rates of major and minor complications between LH and VH when performed with pelvic reconstructive surgery, controlling for the number and type of pelvic reconstructive procedures. METHODS: A total of 27,941 eligible LH and VH from the 2010-2018 National Surgical Quality Improvement Program database were identified. Concomitant pelvic reconstructive surgery was defined as either an apical suspension, enterocele repair, or colporrhaphy. Laparoscopy-assisted VH, gynecological malignancy, and concomitant nongynecological procedures were excluded. Complications within 30 days of surgery were grouped into major (Clavien-Dindo grade ≥3) or minor (grade 1-2) classifications. Bivariate analysis and inverse propensity-weighted logistic regression compared the outcomes of the VH and LH groups. Cochran-Armitage tests and multivariate regression assessed changes over time. RESULTS: The majority of hysterectomies (72%) were vaginal, although its utilization declined from 89% in 2010 to 64% in 2018 (p < 0.001). In multivariate analysis controlling for patient factors and the type and number of concomitant pelvic reconstructive procedures, LH was associated with a lower odds of major (adjusted odds ratio [aOR] 0.711, 95% confidence interval [CI]:0.639-0.791) and minor (aOR 0.659, 95% CI: 0.612-0.710) complications. CONCLUSIONS: Relative safety profiles should be considered among other patient factors when counseling women undergoing surgical prolapse repair. Our findings suggest that laparoscopic approaches can be safely utilized among older and sicker patients traditionally counseled toward a vaginal approach.

Variation in Vaginal Hysterectomy Rates in an Integrated Healthcare System.

STUDY OBJECTIVE: To describe trends in minimally invasive hysterectomy (MIH) and assess patient, surgical, and provider characteristics associated with differences in vaginal versus laparoscopic rates within an integrated healthcare system. DESIGN: A retrospective cohort study. SETTING: Kaiser Permanente Northern California from 2008 to 2018. PATIENTS: Patients who underwent MIH for benign conditions excluding uterine prolapse and incontinence surgeries. INTERVENTIONS: Hysterectomies. MEASUREMENTS AND MAIN RESULTS: A total of 27518 hysterectomies were performed for benign indications. Of these, the proportion of MIH increased from 29.1% (2008) to 96.7% (2018) (p <.001). The proportion of vaginal hysterectomies (VHs) of all hysterectomies did not change significantly over the study period (p = .07); however, the proportion of VH among MIH cases decreased from a high of 50.6% in 2008 to 13.2% in 2018 (p <.001). VH rates were lower in obese and morbidly obese patients (p <.001 and p = .02, respectively) and in women with uterine weights >250 g (p <.001). The differences persisted after controlling for patient demographic, clinical, and surgery characteristics. Low surgical volume was inversely associated with VH (adjusted relative risk, 7.19; 95% confidence interval, 6.62-7.81; p <.001). VH rates ranged from 11.5% to 27.8% across service areas (hospitals). Service area remained a significant predictor of VH after controlling for patient (including body mass index and uterine weight) and surgery-related characteristics. Postoperative hospital stay decreased from 33.8 ± 16.4 hours (2008) to 6.1 ± 12.2 (2018) for VH. Operative time was shorter for VH than laparoscopic hysterectomies (LHs) (1.7 vs 2.5 hours; p <.001). Overall operative/perioperative complications were low and not significantly different (VH vs LH). CONCLUSION: As the proportion of MIH increased, LH became the preferred route despite similar rates of postoperative stay and intraoperative complications and shorter operative time for VH compared with LH. Service area and provider volume were independent predictors of MIH route, suggesting that training and evidence-based guidelines for route selection may help preserve VH rates.

Decreasing utilization of minimally invasive hysterectomy for cervical cancer in the United States.

OBJECTIVE: To examine the influence of the first level I evidence (Laparoscopic Approach to Cervical Cancer [LACC] trial) on minimally invasive hysterectomy use and perioperative complications for cervical cancer surgery. METHODS: This was population-based retrospective observational study, querying National Inpatient Sample. Women with cervical cancer who underwent hysterectomy and lymphadenectomy from 10/2015-12/2018 were examined. A quasi-experimental analysis with interrupted-time series was performed to assess the influence of the LACC trial report on minimally invasive hysterectomy use and perioperative complication rates. RESULTS: 5120 women in the pre-LACC period and 1645 women in the post-LACC period were compared. Following the LACC trial report on 3/2018, the minimally invasive hysterectomy use dropped by 19.7 percent points in one month (55.2% in 3/2018 to 35.5% in 4/2018), followed by a continued decline of 8.0% (95% confidence interval 0.1-15.3) monthly. By 12/2018, minimally invasive hysterectomy was used in 17.9% of cases, which was 38.8 percent points lower than the expected rate per the pre-LACC period projection. In multivariable analysis, women in the post-LACC period were 63% less likely to undergo minimally invasive hysterectomy (adjusted-odds ratio 0.37, 95% confidence interval 0.33-0.42) but 23% more likely to have a perioperative complication (38.6% versus 29.1%, adjusted-odds ratio 1.23, 95% confidence interval 1.08-1.40) compared to those in the pre-LACC period. Women in the post-LACC group were more likely to have a longer hospital stay compared to those in the pre-LACC group (median, 3 versus 2 days, P < 0.001). CONCLUSION: Following the LACC trial results, U.S. surgeons rapidly shifted from minimally invasive to open hysterectomy for cervical cancer. Decreasing utilization of minimally invasive surgery was associated with an increase in perioperative complications and longer hospital admissions.

Trends in operative time and outcomes in minimally invasive hysterectomy from 2008 to 2018.

BACKGROUND: There is a national shift toward laparoscopic hysterectomy as the predominant form of minimally invasive hysterectomy. Previous research suggests that vaginal hysterectomy is associated with lower operative time and improved outcomes; however, this has not been validated in a modern cohort of women. OBJECTIVE: This analysis aims to evaluate whether total vaginal hysterectomy remains associated with lower operative times and fewer postoperative complications than total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, given recent shifts in clinical practice patterns and training experience. STUDY DESIGN: A secondary analysis of the National Surgical Quality Improvement Program database was performed. Three primary outcomes were defined for the analysis: operative time, rate of major complications, and rate of minor complications. Secondary outcomes included changes in route of surgery over time. Descriptive analyses were performed for all outcomes of interest. Operative time, rate of major complications, and rate of minor complications were compared for each of the 3 forms of minimally invasive hysterectomy: total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and total vaginal hysterectomy. Bivariate analyses were performed using analysis of variance, Kruskal-Wallis, Pearson chi-square, or Fisher exact tests where appropriate. Multivariable ordinary least squares and logistic regression were used to assess for overall differences in outcomes and trends over time, controlling for sociodemographic factors and medical comorbidities. Sensitivity analyses were performed using a propensity score-matched cohort created to balance groups across time. RESULTS: A total of 161,626 women met criteria for inclusion. Rates of total vaginal hysterectomy dropped from 51% to 13% between 2008 and 2018, whereas rates of total laparoscopic hysterectomy increased from 12% to 68% (P<.001). In multivariable analyses, total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy were associated with lower odds of major complications (adjusted odds ratio [95% confidence interval]: 0.813 [0.750-0.881] and 0.873 [0.797-0.957], respectively) and minor complications (adjusted odds ratio [95% confidence interval]: 0.723 [0.676-0.772] and 0.896 [0.832-0.964], respectively) than total vaginal hysterectomy. Temporal trends show an increase in total vaginal hysterectomy operative time and decreases in total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy operative times over the 11-year analysis period (P<.001), although total vaginal hysterectomy continues to have the shortest median operative time overall. No temporal trends were observed in rates of complications. CONCLUSION: This analysis highlights recent shifts in rates of minimally invasive hysterectomy. Alongside this change in practice pattern, this study also brings to light a resultant shift in the complication rates associated with each surgical approach, as laparoscopic hysterectomy has lower rates of complications than vaginal hysterectomy despite longer operative times.