Economic evaluation of different routes of surgery for the management of endometrial cancer: a retrospective cohort study.

OBJECTIVES: The benefits of minimally invasive surgery (MIS) for endometrial carcinoma (EC) are well established although the financial impact of robotic-assisted hysterectomy (RH) compared with laparoscopic hysterectomy (LH) is disputed. DESIGN: Retrospective cohort study. SETTING: English National Health Service hospitals 2011-2017/2018. PARTICIPANTS: 35 304 women having a hysterectomy for EC identified from Hospital Episode Statistics. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the association between route of surgery on cost at intervention, 30, 90 and 365 days for women undergoing an open hysterectomy (OH) or MIS (LH/RH) for EC in England. The average marginal effect was calculated to compare RH versus OH and RH versus LH which adjusted for any differences in the characteristics of the surgical approaches. Secondary outcomes were to analyse costing data for each surgical approach by age, Charlson Comorbidity Index (CCI) and hospital MIS rate classification. RESULTS: A total of 35 304 procedures were performed, 20 405 (57.8%) were MIS (LH: 18 604 and RH: 1801), 14 291 (40.5%) OH. Mean cost for LH was significantly less than RH, whereas RH was significantly less than OH at intervention, 30, 90 and 365 days (p<0.001). Over time, patients who underwent RH had increasing CCI scores and by the 2015/2016 year had a higher average CCI than LH. Comparing the cost of LH and RH against CCI score identified that the costs closely reflected the patients' CCI. Increasing disparity was also seen between the MIS and OH costs with rising age. When exploring the association between provider volume, MIS rate and surgical costs, there was an association with the higher the MIS rate the lower the average cost. CONCLUSIONS: Further research is needed to investigate costs in matched patient cohorts to determine the optimum surgical modality in different populations.

Surgical trends, outcomes and disparities in minimal invasive surgery for patients with endometrial cancer in England: a retrospective cohort study.

OBJECTIVE: To examine surgical outcomes and trends in the implementation of minimally invasive surgery (MIS) use for endometrial cancer (EC). DESIGN: Retrospective cohort study. SETTING: English National Health Service hospitals 2011-2017/2018. POPULATION: 35 304 patients having a hysterectomy for EC identified from Hospital Episode Statistics. METHODS: Univariate and multivariate analyses compared MIS to open hysterectomy (OH) by assessing the association between demographic, clinical and hospital characteristics by using logistic regression. A propensity score was created, to control for confounding factors including demographics, clinical and hospital characteristics, from a logistic regression which enabled the inverse probability weighting of treatment to be applied in order to compare outcomes of treatment. MAIN OUTCOME MEASURES: The association between route of surgery on perioperative morbidity and mortality. RESULTS: The MIS rate rose from 40.3% in 2011 to 68.7% in 2017/2018, however, there was significant geographical variation (p<0.001). The overall 90-day mortality was significantly higher with OH versus MIS (OR 0.34, 95% CI 0.18 to 0.62, p=0.0002). MIS rates were significantly lower in patients from the lowest socioeconomic group (LSEG) compared with patients from the highest group (HSEG) (55.4% vs 59.9%, p<0.01), and in the black population as compared with white and Asian populations (40.4% vs 58.6% and 56.0%, p<0.0001). When patients from LSEG and black patients were treated in hospitals with high MIS rates, the MIS rate increased close to that of the HSEG and white patients (81.0% and 74.1% vs 83.2% and 82.6%). CONCLUSIONS: Further investigation is needed to understand the barriers to MIS and improve access so that as many patients as possible can benefit from the reduced morbidity/mortality associated with MIS.

Impact of Obesity on Surgeon Ergonomics in Robotic and Straight-Stick Laparoscopic Surgery.

STUDY OBJECTIVE: Work-related musculoskeletal symptoms (WMSs) are reported to be increasing in surgeons performing minimally invasive procedures. Therefore, we investigated the use of inertial measurement units (IMUs) and electromyography (EMG) sensor recorders to record real-time information on the muscle movement/activity required to perform training exercises in simulated in normal and high body mass index (BMI) models. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Four consultant gynecologic oncology surgeons experienced in complex straight-stick (SS) laparoscopic and robotically assisted (RA) surgery. INTERVENTIONS: Three exercises (hoops onto pegs and wire chase) using SS and RA surgery on 2 abdominal models: normal BMI and high BMI. MEASUREMENTS AND MAIN RESULTS: We measured time to complete exercise and surgeon muscle movement/activity. The time to complete all exercises was significantly lower for RA surgery as compared with SS laparoscopy (p <.05 or better). The movement of the surgeons' core was significantly greater in high BMI SS laparoscopy compared with normal BMI SS laparoscopy for exercises 1 and 2 (p <.001). Muscle usage, as determined by EMG peak, was significantly higher in normal BMI SS laparoscopy and even higher in high BMI SS laparoscopy but was generally flat for all normal and high BMI RA surgery exercises (p <.05 or better). CONCLUSION: Detailed real-time information can be collected through IMUs/EMG sensors. Our results indicate that RA surgery requires less surgeon movements and muscle activity to complete tasks compared with SS laparoscopy, particularly in a high BMI model. The implications of these results are that RA surgery in high BMI patients may therefore have less physical impact on the surgeon compared with SS laparoscopy and may result in lower WMS rates.

The British Gynaecological Cancer Society Delphi consultation exercise on expected standards of practice for doctors specializing in the area of gynecological oncology.

OBJECTIVE: To determine a set of auditable standards applicable to physicians working in the area of gynecological oncology, which could be implemented as accreditation criteria for the revalidation procedure. DESIGN: A 3-round Delphi consultation exercise. SETTING: British Gynaecological Cancer Society (BGCS) members and delegates at the 2006 and 2007 Annual BGCS conferences Population 35 BGCS members, 72 delegates attending the 2006 BGCS conference and 120 delegates attending the 2007 conference. METHODS: A preliminary Delphi consultation of members was performed electronically to determine the contents of the final Delphi questionnaires. Prioritization was achieved by scoring each parameter on a 5-point Likert scale. MAIN OUTCOME MEASURE: The mean score awarded to each benchmarking parameter and the identification of parameters scoring 4 or above 75% or more of the respondents. RESULTS: The first round contained responses from 68 participants in stage 1 and 72 in stage 2. The second round included 120 participants. Nine of the auditable standards in first round and 10 in the second round achieved a score of 4 or above 75% or more of the participants and were therefore considered to be essential for revalidation. The selected criteria focused on an individual clinician's caseload and performance, multidisciplinary team working and continued professional development. CONCLUSIONS: This study has used the Delphi technique to identify auditable standards which could be used in the revalidation process of physicians working in the area of gynecological cancer.