Feasibility and Perioperative Outcomes of Minimally Invasive Higher Order Myomectomy.

STUDY OBJECTIVE: To investigate perioperative outcomes of minimally invasive higher order myomectomy as defined by removal of 10 or more fibroids. DESIGN: A retrospective cohort study between January 2018 and December 2022. SETTING: A tertiary academic medical center. PATIENTS: Women who underwent minimally invasive myomectomy via laparoscopic or robotic approach. INTERVENTIONS: Surgical intervention in the form of minimally invasive myomectomy. MEASUREMENTS AND MAIN RESULTS: A total of 735 women met inclusion criteria of whom 578 had fewer than 10 fibroids removed, and 157 patients had 10 or more removed (average number of fibroids removed 3.8 vs 14.7, p <.001; specimen's weight 317.4 g vs 371.0 g, p = .07). Body mass index was similar in both groups (p = .66) and patients with higher order myomectomy were more likely to have a history of myomectomy (12.0% vs 26.8%, p <.001). The average estimated blood loss (EBL) was 246 mL vs 470 mL in each group (p <.001). There were no significant differences in packed red blood cell transfusion (1.0% vs 0.6%, p = .65), conversion to laparotomy (0.5% vs 0.6%, p = .86), or complications including visceral injury, wound complication, venous thromboembolism, ileus, or readmission (5.9% vs 4.5%, p = .49). The hospital length of stay was similar in both groups (0.5 days vs 0.5 days, p = .63). On linear regression analysis, after adjusting for specimen's weight, operative time, and history of myomectomy, EBL remained significantly higher in patients with 10 or more fibroids removed (p = .02). CONCLUSION: EBL is increased in higher order myomectomy; however, blood transfusions, conversion to laparotomy, complication rates, and length of hospital stay did not differ compared with patients with fewer than 10 fibroids removed, highlighting the feasibility of minimally invasive higher order myomectomy.

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.

Utilization and cost of cell salvage in minimally invasive myomectomy.

OBJECTIVE: To assess the utilization and cost of intraoperative cell salvage (ICS) in minimally invasive myomectomy. STUDY DESIGN: Retrospective cohort study of patients who underwent minimally invasive myomectomy at a quaternary care academic hospital. Patients were classified into: ICS setup vs no ICS setup, ICS setup with reinfusion vs ICS setup without reinfusion. RESULTS: Of 382 patients who underwent minimally invasive myomectomy, 67 (17.5 %) had ICS setup, 30 (44.8 %) of those patients reinfused. Median volume of reinfusion per patient was 300 mL (range 125-1000 mL). Patients who ultimately underwent ICS reinfusion, compared to those with ICS setup only, had significantly larger mean maximum fibroid size (9.8 cm vs 8.0 cm, p = 0.02), higher median total specimen weight (367 vs 304 g, p = 0.03), higher median estimated blood loss (575 vs 300 mL, p < 0.0001), longer mean operative time (261 vs 215 min, p = 0.04). No perioperative complications were associated with ICS. Higher costs are associated with universal use or complete lack of ICS; lowest cost is associated with ICS setup only for those ultimately reinfused. CONCLUSION: ICS might reduce requirements for allogeneic blood transfusions in patients undergoing minimally invasive myomectomy, and may contribute to cost savings. Uterine and maximum fibroid sizes are possible preoperative indicators for patients who require cell salvage reinfusion.

Risk Factors for Postoperative Narcotic Use in Benign, Minimally-Invasive Gynecologic Surgery.

Background and Objectives: To evaluate postoperative opioid use after benign minimally-invasive gynecologic surgery and assess the impact of a patient educational intervention regarding proper opioid use/disposal. Methods: Educational pamphlets were provided preoperatively. Patients underwent hysterectomy, myomectomy, or other laparoscopic procedures. Opioid prescriptions were standardized with 25 tablets oxycodone 5mg for hysterectomy/myomectomy, 10 tablets oxycodone 5mg for LSC (oral morphine equivalents were maintained for alternatives). Pill diaries were reviewed and patient surveys completed during postoperative visits. Results: Of 106 consented patients, 65 (61%) completed their pill diaries. Median opioid use was 35 OME for hysterectomy (∼5 oxycodone tablets; IQR 11.25-102.5), 30 OME for myomectomy (∼4 tablets; IQR 15-75), and 18.75 OME for laparoscopy (∼3 tablets; IQR 7.5-48.75). Median last post-operative day (d) of use was 3d for hysterectomy (IQR 2, 8), 4d for myomectomy (IQR 1, 7), and 2d for laparoscopy (IQR 0.5-3.5). One patient (myomectomy) required a refill of 5mg oxycodone. No difference was found between total opioid use and presence of pelvic pain, chronic pain disorders, or psychiatric co-morbidities. Overall satisfaction with pain control (>4 on a 5-point Likert scale) was 91% for hysterectomy, 100% for myomectomy, 83% for laparoscopy. Of the 33 patients who read the pamphlet, 32(97%) felt it increased their awareness. Conclusion: Most patients required <10 oxycodone 5mg tablets, regardless of procedure with excellent patient satisfaction. A patient education pamphlet is a simple method to increase knowledge regarding the opioid epidemic and facilitate proper medication disposal.

A Phase I Clinical Trial to Assess Safety and Tolerability of Injectable Collagenase in Women with Symptomatic Uterine Fibroids.

Uterine fibroids feature excessive deposition of types I and III collagen. Previous ex vivo studies showed an FDA-approved collagenase (EN3835)-digested types I and III collagen fibers in fibroid tissues; however, collagenase had not been evaluated in vivo for effects on uterine fibroids. The objective was to assess the safety and tolerability of collagenase injection directly into uterine fibroids. This was a prospective, open label, dose escalation study. The study participants were fifteen women aged 35-50 years with symptomatic uterine fibroids planning to undergo hysterectomy. Three subjects received saline and methylene blue, three subjects received a fixed dose of EN3835, and 9 subjects received stepped, increasing dosages of EN3835, all by transvaginal, ultrasound-guided injections. Primary outcome measures were safety and tolerability of the injection and change in collagen content between treated and control tissues. There were no significant adverse events following injection of EN3835 into uterine fibroids. Masson's trichrome stains revealed a 39% reduction in collagen content in treated samples compared to controls (p <0.05). Second harmonic generation (SHG) analysis showed treated samples to have a 21% reduction in density of collagen compared to controls. Picrosirius-stained collagenase-treated fibroids showed collagen fibers to be shorter and less dense compared to controls. Subjects reported a decrease in fibroid-related pain on the McGill Pain Questionnaire after study drug injection in Group 2 at both 4-8 days and 60-90 days post-injection. The findings indicated that injection of collagenase was safe and well tolerated. These results support further clinical investigation of collagenase as a minimally invasive treatment of uterine fibroids. NCT0289848.

Predictors of Minimally Invasive Myomectomy in the National Inpatient Sample Database, 2010-2014.

BACKGROUND AND OBJECTIVES: This study aims to characterize the utilization of minimally invasive myomectomy in the United States and to identify the patient and hospital factors associated with surgical approach to myomectomy. METHODS: This is a cross-sectional study using the National Inpatient Sample database. We extracted women aged 18-50 years who underwent open and minimally invasive (laparoscopic and robotic) myomectomy (MIM) from January 1, 2010-December 31, 2014. Descriptive statistics were obtained for patient and hospital characteristics. We then performed multivariable logistic regression to examine the association of patient (age, race, insurance status, median household income) and hospital (bed size, teaching status, for-profit status, census region, cases volume) characteristics with the likelihood of undergoing MIM. RESULTS: Of 114,850 myomectomy cases, 8,330 (7%) underwent MIM and 106,520 (93%) were open. Over time, the proportion of MIM remained very low and slightly decreased from 8.2% in 2010 to 6.1% in 2014 (p-for-trend: 0.001). Most hospitals performed few MIM per year, with 50% performing five or less, and 25% performing three or fewer per year. African American, Hispanic, and women of other races were less likely to undergo MIM compared to Caucasian women (adjusted odds ration [OR] 0.57, 95% confidence interval [CI] 0.50-0.64; 0.71, 95% CI 0.60-0.83; 0.62, 95% CI 0.52-0.74, respectively). Women in the West (adjusted odds ratio (aOR) 1.23, 95% CI 1.04-1.46) and Midwest (aOR 1.27, 95% CI 1.07-1.52) had higher odds of undergoing MIM. CONCLUSION: MIM appears to be an underutilized modality, accounting for less than10% of myomectomies. This underutilization disproportionally affects minority women.

Demonstration of Safe Entry Techniques for Laparoscopy.

STUDY OBJECTIVE: To demonstrate different techniques, and detail the considerations for obtaining primary laparoscopic access in gynecologic surgery. DESIGN: Video demonstration of the techniques with narrated discussion of each method. SETTING: The methods for primary entry in laparoscopy vary by location and technique [1,2]. There are inherent risks with any mode of primary entry, and the risks are also specific to each technique [3-6]. The choice for primary entry depends on the patient's anatomy, surgical history, pathology, and surgeon preference [1,2]. INTERVENTIONS: This video reviews considerations for choosing the safest entry point and tips for proper entry technique [4,7-10]. The entry sites reviewed include the umbilicus, left upper quadrant, right upper quadrant, and supraumbilical [11]. The entry technique can be either open (Hasson), closed (Veress), or by direct laparoscopic visualization [9,10,12-14]. CONCLUSION: No single laparoscopic entry technique is superior [3]. The safest and most successful entry method will vary by case characteristics and surgeon training.

Simvastatin ameliorates altered mechanotransduction in uterine leiomyoma cells.

BACKGROUND: Uterine leiomyomas, the most common tumors of the female reproductive system, are characterized by excessive deposition of disordered stiff extracellular matrix and fundamental alteration in the mechanical signaling pathways. Specifically, these alterations affect the normal dynamic state of responsiveness to mechanical cues in the extracellular environment. These mechanical cues are converted through integrins, cell membrane receptors, to biochemical signals including cytoskeletal signaling pathways to maintain mechanical homeostasis. Leiomyoma cells overexpress ß1 integrin and other downstream mechanical signaling proteins. We previously reported that simvastatin, an antihyperlipidemic drug, has antileiomyoma effects through cellular, animal model, and epidemiologic studies. OBJECTIVE: This study aimed to examine the hypothesis that simvastatin might influence altered mechanotransduction in leiomyoma cells. STUDY DESIGN: This is a laboratory-based experimental study. Primary leiomyoma cells were isolated from 5 patients who underwent hysterectomy at the Department of Gynecology and Obstetrics of the Johns Hopkins University Hospital. Primary and immortalized human uterine leiomyoma cells were treated with simvastatin at increasing concentrations (0.001, 0.01, 0.1, and 1 µM, or control) for 48 hours. Protein and mRNA levels of ß1 integrin and extracellular matrix components involved in mechanical signaling were quantified by quantitative real-time polymerase chain reaction, western blotting, and immunofluorescence. In addition, we examined the effect of simvastatin on the activity of Ras homolog family member A using pull-down assay and gel contraction. RESULTS: We found that simvastatin significantly reduced the protein expression of ß1 integrin by 44% and type I collagen by 60% compared with untreated leiomyoma cells. Simvastatin-treated cells reduced phosphorylation of focal adhesion kinase down to 26%-60% of control, whereas it increased total focal adhesion kinase protein expression. Using a Ras homolog family member A pull-down activation assay, we observed reduced levels of active Ras homolog family member A in simvastatin-treated cells by 45%-85% compared with control. Consistent with impaired Ras homolog family member A activation, simvastatin treatment reduced tumor gel contraction where gel area was 122%-153% larger than control. Furthermore, simvastatin treatment led to reduced levels of mechanical signaling proteins involved in ß1 integrin downstream signaling, such as A-kinase anchor protein 13, Rho-associated protein kinase 1, myosin light-chain kinase, and cyclin D1. CONCLUSION: The results of this study suggest a possible therapeutic role of simvastatin in restoring the altered state of mechanotransduction signaling in leiomyoma. Collectively, these findings are aligned with previous epidemiologic studies and other reports and support the need for clinical trials.

Cardiometabolic Risk Factors and Benign Gynecologic Disorders.

IMPORTANCE: While it has long been known that polycystic ovarian syndrome is associated with cardiometabolic risk factors (CMRFs), there is emerging evidence that other benign gynecologic conditions, such as uterine leiomyomas, endometriosis, and even hysterectomy without oophorectomy, can be associated with CMRFs. Understanding the evidence and mechanisms of these associations can lead to novel preventive and therapeutic interventions. OBJECTIVE: This article discusses the evidence and the potential mechanisms mediating the association between CMRFs and benign gynecologic disorders. EVIDENCE ACQUISITION: We reviewed PubMed, EMBASE, Scopus, and Google Scholar databases to obtain plausible clinical and biological evidence, including hormonal, immunologic, inflammatory, growth factor-related, genetic, epigenetic, atherogenic, vitamin D-related, and dietary factors. RESULTS: Cardiometabolic risk factors appear to contribute to uterine leiomyoma pathogenesis. For example, obesity can modulate leiomyomatous cellular proliferation and extracellular matrix deposition through hyperestrogenic states, chronic inflammation, insulin resistance, and adipokines. On the other hand, endometriosis has been shown to induce systemic inflammation, thereby increasing cardiometabolic risks, for example, through inducing atherosclerotic changes. CONCLUSION AND RELEVANCE: Clinical implications of these associations are 2-fold. First, screening and early modification of CMRFs can be part of a preventive strategy for uterine leiomyomas and hysterectomy. Second, patients diagnosed with uterine leiomyomas or endometriosis can be screened and closely followed for CMRFs and cardiovascular disease.

Litigations Involving Ureteral Injury Related to Minimally Invasive Gynecologic Surgery: Lessons Learned from a Legal Literature Review.

Ureteral injury is a known complication of minimally invasive gynecologic surgery. Despite being discussed preoperatively and included in consent forms, litigations that involve such injury continue to be prevalent. Our aim was to review all major litigations involving ureteral injuries related to minimally invasive gynecologic surgery to determine the most common allegations from plaintiffs and highlight factors that aided defendants. We used Lexis Nexis, a comprehensive legal database, to search all publicly available federal- and state-level cases on ureteral injury related to gynecologic surgeries. Fifty-nine cases resulted from our search. Of these cases, 19 were deemed pertinent to our question. These 19 cases occurred between 1993 and 2018. The most common allegations included medical negligence, lack of informed consent, and medical battery. Eight of 19 cases (42%) were decided in favor of the defendants, 3 of 19 cases (16%) in favor of the plaintiffs, and the remaining cases proceeded to further trial or are ongoing. The monetary compensation to a plaintiff was as high as $426,079.50. Meticulous documentation, comprehensive consent procedure, timely postoperative evaluation, and the use of immediate postoperative cystoscopy were the critical factors that aided the defendants. Meticulous documentation, a comprehensive consent procedure, timely postoperative evaluation, and the use of immediate postoperative cystoscopy can aid minimally invasive gynecologic surgeons involved in litigations involving ureteral injury.

The sticky business of adhesion prevention in minimally invasive gynecologic surgery.

PURPOSE OF REVIEW: The negative impact of postoperative adhesions has long been recognized, but available options for prevention remain limited. Minimally invasive surgery is associated with decreased adhesion formation due to meticulous dissection with gentile tissue handling, improved hemostasis, and limiting exposure to reactive foreign material; however, there is conflicting evidence on the clinical significance of adhesion-related disease when compared to open surgery. Laparoscopic surgery does not guarantee the prevention of adhesions because longer operative times and high insufflation pressure can promote adhesion formation. Adhesion barriers have been available since the 1980s, but uptake among surgeons remains low and there is no clear evidence that they reduce clinically significant outcomes such as chronic pain or infertility. In this article, we review the ongoing magnitude of adhesion-related complications in gynecologic surgery, currently available interventions and new research toward more effective adhesion prevention. RECENT FINDINGS: Recent literature provides updated epidemiologic data and estimates of healthcare costs associated with adhesion-related complications. There have been important advances in our understanding of normal peritoneal healing and the pathophysiology of adhesions. Adhesion barriers continue to be tested for safety and effectiveness and new agents have shown promise in clinical studies. Finally, there are many experimental studies of new materials and pharmacologic and biologic prevention agents. SUMMARY: There is great interest in new adhesion prevention technologies, but new agents are unlikely to be available for clinical use for many years. High-quality effectiveness and outcomes-related research is still needed.

Advantages of robotics in benign gynecologic surgery.

PURPOSE OF REVIEW: The purpose of this article is to review the literature and discuss the advantages of robotics in benign gynecologic surgery. RECENT FINDINGS: Minimally invasive surgery has become the preferred route over abdominal surgery. The laparoscopic or robotic approach is recommended when vaginal surgery is not feasible. Thus far, robotic gynecologic surgery data have demonstrated feasibility, safety, and equivalent clinical outcomes in comparison with laparoscopy and better clinical outcomes compared with laparotomy. Robotics was developed to overcome challenges of laparoscopy and has led to technological advantages such as improved ergonomics, visualization with three-dimensional capabilities, dexterity and range of motion with instrument articulation, and tremor filtration. To date, applications of robotics in benign gynecology include hysterectomy, myomectomy, endometriosis surgery, sacrocolpopexy, adnexal surgery, tubal reanastomosis, and cerclage. Though further data are needed, robotics may provide additional benefits over other approaches in the obese patient population and in higher complexity cases. Challenges that arose in the earlier adoption stage such as the steep learning curve, costs, and operative times are becoming more optimized with greater experience, with implementation of robotics in high-volume centers and with improved training of surgeons and robotic teams. Robotic laparoendoscopic single-site surgery, albeit still in its infancy where technical advantages compared with laparoscopic single-site surgery are still unclear, may provide a cost-reducing option compared with multiport robotics. The cost may even approach that of laparoscopy while still conferring similar perioperative outcomes. SUMMARY: Advances in robotic technology such as the single-site platform and telesurgery, have the potential to revolutionize the field of minimally invasive gynecologic surgery. Higher quality evidence is needed to determine the advantages and disadvantages of robotic surgery in benign gynecologic surgery. Conclusions on the benefits and risks of robotic surgery should be made with caution given limited data, especially when compared with other routes. Route of surgery selection should take into consideration the surgeons' skill and comfort level that allows for the highest level of safety and efficiency. Ultimately, the robotic device is an additional minimally invasive surgical tool that can further the goal of minimizing laparotomy in gynecology.

The increasing use of robot-assisted approach for hysterectomy results in decreasing rates of abdominal hysterectomy and traditional laparoscopic hysterectomy.

PURPOSE: To compare the frequency of minimally invasive surgical approach to hysterectomy between two time periods, during which the use of the robotic technique has rapidly increased. METHODS: This study is a retrospective review of 623 consecutive patients who underwent hysterectomy for benign indications at the Division of Minimally Invasive Gynecologic Surgery via laparoscopic, robotic, laparotomy, mini-laparotomy and vaginal approaches from July 2004 to June 2010. "Early period" refers to the first 311 patients, and "late period" refers to the remaining 312 patients. RESULTS: The characteristics of patients from the early and late periods were comparable in terms of age, BMI and uterine weight. The rates of hysterectomy by laparotomy, traditional laparoscopy, robotic, vaginal, and mini-laparotomy were significantly different between the early and late periods (17.7 to 5.4%, 39.5 to 17.6%, 23.8 to 64.1%, 5.8 to 4.8% and 13.2 to 8%, respectively, P < 0.01), with the overall rates of hysterectomies completed via a minimally invasive approach increasing from 82.3 to 94.6%, respectively (P < 0.01). There were no differences in surgical complications between the two periods. CONCLUSION: Increased utilization of a robotic approach to hysterectomy correlates with decreasing rates of abdominal hysterectomy concurrent with decreasing rates of traditional laparoscopic hysterectomy. This shift in surgical approach to hysterectomy, while beneficial in increasing the rates of minimally invasive approach to hysterectomy, may have significant economic implications due to the higher cost of robotic surgery.

Perioperative outcomes of robotic versus laparoscopic hysterectomy for benign disease.

BACKGROUND AND OBJECTIVES: We compared the perioperative outcomes of hysterectomy performed by robotic (RH) versus laparoscopic (LH) routes for benign indications using the Dindo-Clavien scale for classification of the surgical complications. METHODS: Retrospective chart review of all patients who underwent robotic (n=288) and laparoscopic (n=257) hysterectomies by minimally invasive surgeons at the University of Michigan from March 2001 until June 2010. RESULTS: Age, body mass index, operative time, and estimated blood loss were not statistically different between groups. The RH subgroup had a larger uterine weight (LH 186.4±130.6 g vs RH 234.9±193.9 g, P=.001), higher prevalence of severe adhesions (13.2% vs 23.3%, respectively, P=.003), and stage III-IV endometriosis (4.7% vs 15.3%, respectively, P<.05). There were no differences in the rates of Dindo-Clavien grade I, grade II, and grade III surgical complications between the RH and LH groups (9.7%, 13.2%, and 3.1%, respectively, in the RH group vs 6.2%, 9.3%, and 5.8%, respectively, in the LH group, P>.05). However, the rates of urinary tract infection were higher in the RH group (LH 2.7% vs RH 6.9%, P=.02), whereas the conversion to laparotomy rate was higher in the LH group (LH 6.2% vs RH 1.7%, P=.007). CONCLUSIONS: Perioperative outcomes for laparoscopic and robotic hysterectomy for benign indications appear to be equivalent.

Comparison of 2 minimally invasive routes for hysterectomy of large uteri.

OBJECTIVE: To compare the perioperative outcomes associated with 2 minimally invasive surgical routes for the hysterectomy of large fibroid uteri. METHODS: Retrospective review of 84 women undergoing hysterectomy via minilaparotomy (n=54) or robot-assisted laparoscopy (n=30) for uteri weighing at least 500g. Outcome measures included hemorrhage (blood loss of 500mL or more) and postoperative length of stay. RESULTS: Unadjusted mean blood loss (560.2±507.4mL versus 165.0±257.5mL, P<0.001), rate of hemorrhage (40.7% versus 6.7%, P=0.001, odds ratio 6.1 [95% confidence interval 1.5-24.2]), and rate of blood transfusion (14.8% versus 0%, P=0.03 ) were all higher with minilaparotomy than with robot-assisted surgery, while the median postoperative stay was significantly shorter with robotic surgery (2 [range 1-4] days versus 1 [range 0-7] days, P<0.01). After adjusting for differences in uterine weight using a multivariate linear regression analysis, the mean blood loss and the rate of hemorrhage were no longer significantly different between the 2 groups. CONCLUSION: The minilaparotomy approach may be used to remove very large uteri and does not require specialized and expensive equipment, or advanced endoscopic training. The robotic approach, when feasible, allows for early postoperative discharge.

Risk factors for postoperative urinary retention after laparoscopic and robotic hysterectomy for benign indications.

OBJECTIVE: To estimate the occurrence of postoperative urinary retention after traditional laparoscopic and robotic hysterectomy. METHODS: We performed a chart review of all patients who underwent total or supracervical hysterectomy using a laparoscopic (n=253) or robotic approach (n=281) from March 2001 until June 2010 for benign indications at the division for minimally invasive surgery. Urinary retention was defined as the inability to spontaneously void or as incomplete voiding requiring either self-catheterization or Foley catheter replacement in the first postoperative week. RESULTS: Urinary retention occurred in 7.3% (95% confidence interval [CI] 5.2-9.8%) of women and was more than twice as common among women who underwent robotic hysterectomy compared with laparoscopic hysterectomy (10.3%, 95% CI 7.0-14.5% compared with 4.0%, 95% CI 1.9-7.1%, P=.005). No statistically significant differences in those with and without urinary retention were seen in age, body mass index, smoking status, number of prior cesarean deliveries, operative time, presence of severe adhesions, or findings of endometriosis. In a multivariable logistic regression analysis, only the robotic approach relative to traditional laparoscopic approach was found to be significantly associated with urinary retention (odds ratio 2.6, 95% CI 1.2-5.6). Postoperative urinary retention was associated with a higher incidence of lower urinary tract infection, occurring in 15.4% (95% CI 5.9-30.5%) of cases compared with 4.0% (95% CI 2.5-6.2%) of those without urinary retention (P=.008). CONCLUSION: Transient urinary retention is relatively more common after robotic hysterectomy when compared with laparoscopic hysterectomy. We postulate that more aggressive bladder dissection performed with robot assistance may be associated with an increased risk of urinary retention.