Trends in Route of Hysterectomy after the Implementation of a Comprehensive Robotic Training Program.

OBJECTIVE: To evaluate trends in surgical approach for hysterectomy following the introduction and implementation of a comprehensive robotic surgery program. METHODS: A retrospective review of all hysterectomies done at two institutions, a community hospital and a suburban, tertiary-care teaching hospital, in the same health system over a five-year period, January 2010 through December 2014. A robotic surgery training program was implemented during the first year of the study and trends in route of hysterectomy were evaluated in the subsequent years. RESULTS: A total of 5175 patients undergoing hysterectomy, for both benign and malignant indications, were included in the study. There was a significant decrease in the percent of cases performed through an abdominal approach at both the community and teaching hospitals (19.3% decline at each institution). There was an inversely related significant increase in the percent of robotic procedures at both the community and teaching hospitals (44.5% and 17%, respectively). A decrease in number of cases performed vaginally over this period was only noted in the community hospital site (25.2% decrease), and there was a slightly higher rate of vaginal hysterectomies at the teaching hospital over this study period (21.9% in 2010, 24.1% in 2014). CONCLUSION: The decrease in number of abdominal and laparoscopic hysterectomies and increase in number of robotic hysterectomies that was seen are consistent with national trends. The initiation of a robotic training program did not prevent the proliferation of use of the robot but did aim to ensure proficiency on the robot prior to gaining privileges for patient use. This type of comprehensive training and monitoring program could be applied to future technologic advances to ensure a standard level of surgical proficiency. Trends in route of hysterectomy are clearly multifactorial and involve patient, provider, and location-specific factors that are likely to continue to change.

Risk factors for trachelectomy following supracervical hysterectomy.

INTRODUCTION: We identified risk factors for trachelectomy after supracervical hysterectomy (SCH) due to persistence of symptoms. MATERIAL AND METHODS: A retrospective case-control study in a university-affiliated hospital. Seventeen women who underwent a trachelectomy following SCH for nonmalignant indications between June 2002 and October 2014 were compared with 68 randomly selected women (controls) who underwent a SCH within the same time period. Demographics and clinical characteristics were compared between the study and control groups. Univariate analysis identified potential risk factors for trachelectomy following SCH. Univariate logistic regression models predicted which patients would have a trachelectomy following SCH. RESULTS: The occurrence of trachelectomy following SCH during the study period was 0.9% (17/1892). The study group was younger than the control group (mean age 38 ± 6 years vs. 44 ± 5 years; p < 0.001). Patients who had a history of endometriosis [odds ratio (OR) 6.23, 95% CI 1.11-40.5, p = 0.038] had increased risk for trachelectomy. Pathology diagnosed endometriosis only among women in the study group. Preoperative diagnosis of abnormal uterine bleeding (OR 0.22, 95% CI 0.06-0.075, p = 0.016), anemia (OR 0.12, 95% CI 0.01-0.53; p = 0.003), and fibroid uterus (OR 0.24, 95% CI 0.07-0.82, p = 0.024) reduced the risk for future trachelectomy. CONCLUSION: Young age and endometriosis are significant risk factors for trachelectomy following SCH.

Robotic Trachelectomy After Supracervical Hysterectomy for Benign Gynecologic Disease.

BACKGROUND AND OBJECTIVES: A renewed interest in the supra cervical approach to hysterectomy has created a cohort of patients with a retained cervix at risk of persistent symptoms requiring a subsequent trachelectomy. The objective of this study was to evaluate the efficacy of robotic trachelectomy after a previous supracervical hysterectomy. METHODS: This is a retrospective chart review of women who had robotic trachelectomy after supracervical hysterectomy for benign gynecologic disease from January 2009 through October 2014. RESULTS: Eleven patients underwent robotic trachelectomy for benign conditions during the observed period. Prior supracervical hysterectomy had been performed for pelvic pain (8/11, 73%), abnormal uterine bleeding (7/11, 64%), and dysmenorrhea (5/11, 45%). In 10 of 11 patients, the symptoms leading to robotic trachelectomy were the same as those leading to supracervical hysterectomy. The time from hysterectomy to recurrence of symptoms ranged from 0.5 to 26 months (median, 6), whereas the time interval from previous surgery to robotic trachelectomy ranged from 1 to 57 months (median, 26). Mean age and body mass index at robotic trachelectomy were 42 ± 5.4 years and 32 ± 6.1 kg/m(2). Mean length of surgery was 218 ± 88 minutes (range, 100-405). There was 1 major postoperative complication involving bladder perforation and subsequent vesicovaginal fistula (VVF). Endometriosis was seen in 27% of pathologic specimens and cervicitis in another 27%; 45% showed normal tissue histology. In 6 (55%) cases, symptoms leading to trachelectomy resolved completely after surgery, and the other 5 (45%) patients reported a significant improvement. CONCLUSIONS: Although trachelectomy can be a challenging surgery, our experience suggests that the robotic approach may be a valuable means of achieving safe and reproducible outcomes.