Long-term economic outcomes of ureteral injury in the United States.

OBJECTIVES: Ureteral injuries (UIs) during surgical procedures can have serious consequences for patients. Although UIs can result in substantial clinical burden, few studies report the impact of these injuries on payer reimbursement and patient cost-sharing. This retrospective study evaluated 30-day, 90-day, and 1-year healthcare resource utilization for patients with UIs and estimated patient and payer costs. METHODS: Patients aged ≥ 12 years who underwent abdominopelvic surgery from January 2016 to December 2018 were identified in a United States claims database. Patients were followed for 1 year to estimate all-cause healthcare visits and costs for patients and payers. Surgeries resulting in UIs within 30 days from the surgery date were matched to surgeries without UIs to estimate UI-attributable visits and costs. RESULTS: Five hundred and twenty-two patients with UIs were included. Almost a third (29.9%) of patients with UIs had outpatient surgery. Patients with UIs had slightly more healthcare visits and a 15.3% higher 30-day hospital readmission rate than patients without UIs. Patient costs due to UIs were not statistically significant, but annual payer costs attributable to UIs were $38,859 (95% CI = 28,142-49,576), largely driven by inpatient costs. CONCLUSIONS: UIs add substantial cost for payers and result in more healthcare visits for patients. These findings highlight the importance of including inpatient and outpatient settings for UI prevention. Although UIs are rare, the associated patient and payer burdens are high; thus, protocols or techniques are needed to recognize and avert UIs as current guideline recommendations are lacking.

Though not common, injuries to the ureters, which carry urine from the kidneys to the bladder, can occur during surgeries on the abdomen. Ureter injuries can lead to discomfort, pain, infection, and death. Patients with ureter injuries can also require additional care from doctors, leading to increased costs for both patients and insurance companies. The researchers in this study calculated the costs of ureter injuries at 30-days, 90-days, and 1-year after surgery using anonymous information from insurance claims from patients who received abdominal surgery.Compared with patients who did not have a ureter injury from surgery, a higher percentage of those with ureter injuries had healthcare visits in the year following surgery and a greater chance of being readmitted to the hospital in the 30 days after surgery. Costs for both patients and insurance companies increased in the year after surgery. Insurance companies paid almost $39,000 more on average per patient with ureter injury in the year after surgery compared with costs for patients who did not have ureter injuries. Patients with ureter injuries paid approximately $1,000 more out-of-pocket in the year after surgery compared with patients without ureter injuries.This study showed that ureter injuries increased costs for both patients and insurance companies. Patients with ureter injuries needed more healthcare and the insurance companies for those patients had higher financial costs. Though ureter injuries are uncommon, this study supports efforts to minimize their occurrence to prevent these impacts on patients and the healthcare system.

Abdominopelvic Surgery: Intraoperative Ureteral Injury and Prophylaxis in the United States, 2015-2019.

INTRODUCTION: Preoperative ureteral catheterization/stenting (stenting) and intraoperative diagnostic cystoscopy (cystoscopy) may help prevent or identify intraoperative ureteral injuries (IUIs) during abdominopelvic surgery. In order to provide a comprehensive, single source of data for health care decision makers, this study aimed to catalog the incidence of IUI and rates of stenting and cystoscopy across a wide spectrum of abdominopelvic surgeries. METHODS: We conducted a retrospective cohort analysis of United States (US) hospital data (October 2015-December 2019). IUI rates and stenting/cystoscopy use were investigated for gastrointestinal, gynecological, and other abdominopelvic surgeries. IUI risk factors were identified using multivariable logistic regression. RESULTS: Among approximately 2.5 million included surgeries, IUIs occurred in 0.88% of gastrointestinal, 0.29% of gynecological, and 1.17% of other abdominopelvic surgeries. Aggregate rates varied by setting and for some surgery types were higher than previously reported, especially in certain higher-risk colorectal procedures. Prophylactic measures were generally employed at a relatively low frequency, with cystoscopy used in 1.8% of gynecological procedures and stenting used in 5.3% of gastrointestinal and 2.3% of other abdominopelvic surgeries. In multivariate analyses, stenting and cystoscopy use, but not surgical approach, were associated with a higher risk of IUI. Risk factors associated with stenting or cystoscopy, as well as those for IUI, largely mirrored the variables reported in the literature, including patient demographics (older age, non-White race, male sex, higher comorbidity), practice settings, and established IUI risk factors (diverticulitis, endometriosis). CONCLUSION: Use of stenting and cystoscopy largely varied by surgery type, as did rates of IUI. The relatively low use of prophylactic measures suggests there may be an unmet need for a safe, convenient method of injury prophylaxis in abdominopelvic surgeries. Development of new tools, technology, and/or techniques is needed to help surgeons identify the ureter and avoid IUI and the resulting complications.

Senhance Robotic Platform System for Gynecological Surgery.

BACKGROUND AND OBJECTIVES: Laparoscopic hysterectomy provides patients and surgeons with benefits of less pain, quicker recovery, and better scar cosmesis. Previously, robotic surgical hysterectomy was reserved for patients with complicated disease issues. The objective of this case series was evaluating a new robotic surgical platform, Senhance Surgical System, as a surgical tool in common gynecological procedures. METHODS: The clinic routinely collects surgical and outcome data for all patients and procedures. Data on robotic surgery in hysterectomy, salpingectomy, endometriosis excision, and lysis of adhesions was evaluated. RESULTS: Fifteen consecutive patients that underwent gynecological surgery using the Senhance System were assessed. Average age was 47.27 years (31 - 63 years). Ten procedures were robotic total laparoscopic hysterectomy and 14 of 15 procedures had at least one salpingectomy. Average blood loss was 52.7 mL (10 - 100 mL). Pain scores at discharge averaged 1.42 and 2.73 at two weeks post-surgery. Minimal pain medication was used. Patient satisfaction with the surgery was 98% and satisfaction with scarring was 100%. Return to normal activities and to work averaged 7.93 and 11.1 days respectively. The haptic feedback and the platform visualization of the procedure was useful. The system provided more surgeon control over both camera and tools compared to previously used robotic systems and traditional laparoscopic surgery. CONCLUSION: This initial experience with Senhance Surgical System provided a stable, precise surgical technique with enhanced visualization within the confined space of the abdomen during gynecological surgery. The initial results suggest high patient satisfaction with gynecological surgery and resulting scars. Further study is needed to validate the findings.

The Origin and Evolution of the HARMONIC® Scalpel.

When Jacques and Pierre Curie first researched ultrasonic energy and piezoelectric effects in the 1880s, they likely had no idea of the profound impact it would eventually have on surgical patients. Today in operating rooms around the world, ultrasonic energy is used for tissue manipulation, dissection, cutting, and coagulation. Surgeons including but not limited to the specialties of gynecology, general surgery, colorectal, thoracic, breast, and bariatric have activated ultrasonic energy in thousands of patients. As a mainstay surgical energy device, patients have benefited from the ultrasonic versatility of its cutting and coagulating effects. The ability of ultrasonic energy to be used near vital organs with precision by adjusting for tissue tension, power settings, and activation time has accounted for its safety and clinical outcomes. This overview of the mechanics of ultrasonic energy and the evolution of the HARMONIC® (UltraCision, Providence, Rhode Island, now owned by Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) surgical tools since 1988 provides readers an understanding of this energy platform and its distinct advantages. Clinical implications of key research and clinical studies are explored and discussed with a focus on patient and surgical outcomes. Research in a variety of fields and tissues is presented with a special emphasis on the gynecological patient.

Shared Decision-Making to Improve Patient Engagement in Minimally Invasive Hysterectomy.

Shared decision-making (SDM) between the patient and physician is receiving increased attention as a way to improve patient satisfaction and value of care. Having a readily implemented tool available to inform conversation may enable SDM at a high-volume gynecologic surgery practice. Our objective was to evaluate the impact of an SDM tool on patients' decision to have minimally invasive gynecology surgery. We conducted a feasibility study using the SDM tool plus a follow-up survey for 100 patients recommended to undergo minimally invasive hysterectomy. Nearly all patients (97%) indicated that they were satisfied with their decision to undergo a minimally invasive procedure, including laparoscopic total and supracervical hysterectomy with or without the aid of the robotic platform. Anecdotally, patients expressed appreciation for the provided materials and the presentation of care options. For the care provider, use of the SDM tool did not add substantial time to the visit. Knowing that comprehensive information was provided to all patients was reassuring. Implementing a shared decision-making model in a gynecological practice is feasible and increases awareness and engagement, as well as satisfaction, among patients electing to have a hysterectomy.

McCarus Minimally Invasive Hysterectomy: 20 Years' Experience-Lessons Learned.

The advancement of surgical innovation for both devices and techniques has directly impacted the number of hysterectomy options available to patients. These advancements have led to an expansion of options that has been exceptionally impactful for minimally invasive surgery. For individuals who are diagnosed with a health condition or disease that requires a hysterectomy, these advances allow the surgeon to consider an expanded variety of procedures that may improve patients' outcomes and accommodate patient preferences. Automated suturing devices, improved energy systems, specialized mini-laparoscopic tissue handling instruments, and novel uterine manipulators, among other devices, all work together to provide hysterectomy options with cosmetically pleasing results from an aesthetic perspective. They also provide excellent medical outcomes from a surgeon's perspective. Patients are no longer subjected to large incisional scars from total abdominal hysterectomies that were commonly performed 25 years ago. All gynecological surgeons are obligated to provide patients with improved hysterectomy options that fit the indications and clinical needs of their patients. As the laparoscopic approach to a hysterectomy became the standard of care for many, variations in technique to successfully perform a laparoscopic hysterectomy has become a major limiting factor for generalists to incorporate this skillset into their practice. Maintaining the same procedural steps as the abdominal approach is one of the major hurdles that makes the transition to a laparoscopic approach more treacherous. Over 20 years of experience has shaped the McCarus hysterectomy technique described here into a safe and reproducible procedure that prioritizes the patient's aesthetic preferences while also providing optimal patient outcomes. The implementation of unique devices and instruments further expands the surgeon's technical skills and augments the procedure to make it an effective and preferable choice.

The McCarus-Volker ForniSee®: A Novel Trans-illuminating Colpotomy Device and Uterine Manipulator for Use in Conventional and Robotic-Assisted Laparoscopic Hysterectomy.

PURPOSE: The purpose of this paper is to introduce a novel trans-illuminating culdotomy and uterine manipulator device. MATERIALS AND METHODS: The study was a prospective, non-randomized, non-blinded observational clinical study involving 50 female patients undergoing total laparoscopic hysterectomy (TLH) or laparoscopic supracervical hysterectomy (LSH) for benign indications. The surgeries were performed from March through May 2012 at two institutions. The primary study objectives were to demonstrate the safety and adequate clinical performance of the uterine manipulator device and to illustrate its potential widespread future use in minimally invasive gynecologic procedures. RESULTS: Average patient age was 45.1 years and, of the 50 patients, 33 had undergone previous intra-abdominal surgery. There were no reports of adverse events, difficulty with placement of the instrument, multiple attempts at placement, or difficulty with uterine manipulation. There was only one device-related uterine perforation, and pneumoperitoneum was maintained in all cases during culdotomy. Vaginal tissue left on subjects was less than 5mm. Overall, there were no ureteral injuries, there were two reported incidental cystotomies, and average blood loss was 99.0cc. Postoperative courses were normal for all patients, with only two reported postoperative complications: a possible vaginal cuff abscess and a 2cm vaginal mucosal cuff separation. CONCLUSIONS: The McCarus-Volker ForniSee® (LSI Solutions, Inc., Victor, New York) is a novel trans-illuminating culdotomy device and uterine manipulator that is safe, efficient, functional, and easy to use. Trans-illumination additionally delineates and enhances identification of critical anatomic planes, such as the vesicovaginal junction and cervicovaginal junction.

Reducing Opioid Adverse Events: A Safe Way to Improve Outcomes.

INTRODUCTION: Opioids are commonly used in the postoperative period to manage postsurgical pain. However, adverse side effects of opioids include respiratory depression, urinary retention, pruritus, vomiting, nausea, constipation, and increased risk of falls. Surgical site infiltration with extended release liposomal bupivacaine is effective in the multimodal care plan of managing postsurgical patients. The purpose of the present study was to examine the possible effects of liposomal bupivacaine on postoperative opioid adverse events following open hernia repair and laparoscopic colon resection surgery. MATERIALS AND METHODS: The study population comprised 82 patients who had undergone open hernia repair or a laparoscopic colon resection. Forty-five of the 82 patients were treated with liposomal bupivacaine. Data were examined retrospectively from January 1, 2012 to August 31, 2012 in comparison with historical controls. Adverse opioid events measured included constipation, pruritus, vomiting, nausea, urinary retention, respiratory depression and fall risk. Statistical tools used were the Mann-Whitney U test, Pearson's chi-squared test, and Fisher's exact test. RESULTS: The addition of liposomal bupivacaine did significantly (p<0.05) reduce urinary retention and respiratory depression. Additionally, from the perspective of hospital safety there was a significant reduction in patients at high risk of falls, from 16% to 8.4% as well as an increase in patients at low risk of falls, from 37.6% to 48.7%. CONCLUSION: The findings of this study demonstrate that using liposomal bupivacaine can significantly reduce high-risk fall patients, increase low-risk fall patients as well as decrease urinary retention and respiratory depression in the postoperative setting. Given heightened consideration of the impact of sentinel events on hospital reimbursement since health care reforms in 2014, these results are important because they can mitigate complications associated with opioids in postsurgical pain management, and thereby reduce the costs of hospitalization.

"Big Operations Using Mini Instruments": The Evolution of Mini Laparoscopy in the Surgical Realm.

Laparoscopy using miniature (2-3.5 mm) instruments was introduced in the late 1980s and early 1990s. Though mini laparoscopy (Mini) created new opportunities for surgical diagnosis and therapy, the limitations of early instruments inhibited widespread adoption. This is no longer the case. Mini is enjoying a renaissance, due to several factors: the maturation of minimally invasive surgery (MIS), the failure of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) platforms to achieve early expectations, and the recent significant improvements in Mini instrument functionality and durability. As a result, Mini is being increasingly applied to pediatric and adult procedures across specialties. To assess the current status of Mini laparoscopy, the Society of Laparoendoscopic Surgeons (SLS) and the Florida Hospital Nicholson Center convened an international symposium in February 2015. This report shares highlights from that symposium, "Big Operations Using Mini Instruments."

Scar assessment for patients undergoing minimal invasive hysterectomy.

Surgical innovations have positively impacted the way hysterectomy procedures are performed by surgeons and the results experienced by patients. Patients with benign disease requiring a hysterectomy are no longer subjected to living with a large incisional scar that was common only 20 years ago. With the advent of minimally invasive surgery, surgeons can now provide hysterectomy patients with cosmetically pleasing results. To better understand the impact of surgical scars from hysterectomy incisions, 200 subjects answered a surgical incision questionnaire. Cosmetic issues (i.e., hysterectomy scars) were self-reported as important in 93% of subjects, of which 24% indicated this was extremely important. Of these same subjects, 11% indicated they were extremely bothered about their current scars. Subject interest in surgery without scars was 92% and 45% noted extreme interest. Concern about the surgical incision appearance was cited by 85% of subjects. Familiarity about incisions associated with the different hysterectomy procedures resulted in 26% of subjects who were not at all familiar. Low placed incision locations were considered cosmetically superior by 86% of the subjects. The least desirable incision location was above the belly button (69%) whereas the most desirable incision location was below the bikini line (68%). Discussion about the location, number, and incision size prior to surgery was cited to be important by 93% of subjects. Study subjects show there is value in discussing the number and placement of surgical incisions prior to surgery. Cosmesis of the surgical scars is a concern for many women, but most subjects knew little about the hysterectomy incision options. Based on these findings, surgeons can improve patient satisfaction scores by discussing incisional placement and surgical options prior to the procedure.

McCarus Cosmetic Hysterectomy™ - a patient-centric approach.

As patients are diagnosed with a health condition that requires a hysterectomy, surgical recommendations are generally discussed. Surgical options for a variety of procedures have expanded greatly in the past decade because of the development of innovations including, but not limited to, robots, advanced bipolar energy systems, HD cameras, single-site access systems, minilaparoscopic instruments, and novel uterine manipulators. These advances allow the surgeon to consider an expanded variety of procedures that may not only improve patient outcomes but also accommodate patient preferences. However, inherent bias directly related to the surgeon's specific view may influence decisions limiting hysterectomy options offered to patients. As general gynecological surgeons, we are not only empowered but also obligated to provide patients with expanded hysterectomy options that fit the indications and clinical needs of our patients. - Cosmetic minimally invasive surgery improved cosmesis compared with standard trocars. - Cosmetic minimally invasive surgery needs no skin or fascial closure. - McCarus Cosmetic Hysterectomy™ affords benefits of minimally invasive surgery. - Cosmetic minimally invasive surgery represents the next evolution in minimally invasive surgery. - Cosmetic minimally invasive surgery allows expansion of hysterectomy options for benign disease.

A randomized, single-blinded pilot study evaluating use of a laparoscope or a cystoscope for cystoscopy during gynecologic surgery.

STUDY OBJECTIVE: To prospectively evaluate time required to perform cystoscopy with a laparoscope or a cystoscope after laparoscopic hysterectomy. Urinary tract symptoms, infection, adverse events, and expense were also evaluated. DESIGN: Randomized, single-blind pilot study (Canadian Task Force classification I). SETTING: Suburban private gynecology group practice and local community hospital. SUBJECTS: Sixty-six subjects scheduled to undergo laparoscopic hysterectomy between January and July 2009. INTERVENTION: Either cystoscopy with a laparoscope or a cystoscope. MEASUREMENTS AND MAIN RESULTS: Subjects were randomized to undergo either form of cystoscopy, and events were reported. Each subject completed self-reported urinary tract symptom questionnaires before surgery and at 2 weeks after surgery. Clean-catch urine samples were obtained before surgery and postoperatively at day 1 and 2 weeks. In the group who underwent laparoscope cystoscopy, a suction-irrigator device, a 5-mm needle-nose suction irrigator tip, and a 5-mm 0-degree video laparoscope were required. In the group who underwent traditional cystoscopy, a 70-degree video telescope with a 17F sleeve, irrigation fluid, and a light source were required. Subjects were followed up for 6 weeks postoperatively. Adverse events were minimal, with 1 in the laparoscope group and 6 in the traditional cystoscope group. Two postoperative urinary tract infections occurred in the traditional cystoscopy group. The mean total procedural time for laparoscope cystoscopy of 137 seconds was statistically less (p < .001) compared with the 296 seconds in the traditional cystoscopy group. Improvements in urinary tract symptom scores improved from baseline, but were not statistically significantly different between the groups. Traditional cystoscopy equipment cost approximately $60 more per subject. CONCLUSION: The study results suggest that laparoscope cystoscopy is more time-efficient and cost-effective than traditional cystoscopy and that the incidence of urinary tract symptoms, infection, and injury did not increase.

Diagnostic laparoscopy and adhesiolysis: does it help with complex abdominal and pelvic pain syndrome (CAPPS) in general surgery?

Abdominal pains secondary to adhesions are a common complaint, but most surgeons do not perform surgery for this complaint unless the patient suffers from a bowel obstruction. The purpose of this evaluation was to determine if lysis of bowel adhesions has a role in the surgical management of adhesions for helping treat abdominal pain. The database of our patients with complex abdominal and pelvic pain syndrome (CAPPS) was reviewed to identify patients who underwent a laparoscopic lysis of adhesion without any organ removal and observe if they had a decrease in the amount of abdominal pain after this procedure. Thirty-one patients completed follow-up at 3, 6, 9, and 12 months. At 6, 9, and 12 months postoperation, there were statistically significant decreases in patients' analog pain scores. We concluded that laparoscopic lysis of adhesions can help decrease adhesion-related pain. The pain from adhesions may involve a more complex pathway toward pain resolution than a simple cutting of scar tissue, such as "phantom pain" following amputation, which takes time to resolve after this type of surgery.

The role of hand assist laparoscopic surgery (HALS) in pelvic surgery for nonmalignant disease.

OBJECTIVE: Hand assist laparoscopic surgery (HALS) is a surgical modality rarely used in benign gynecology. We analyzed nonmalignant pelvic disorders that utilized HALS to see whether there is any benefit over standard laparotomy. METHODS: A case control chart review identified patients who underwent HALS for a variety of benign gynecological conditions from 2004 through 2007. Cases were then compared with a control group of all the patients who underwent similar procedures for the same diagnosis via laparotomy (ELAP) in our center within the same time period. The groups were comparable with respect to age, BMI, and surgical indication. RESULTS: Twenty-nine patients were analyzed: 12 cases (HALS) and 17 controls (ELAP). Each group was broken up into 2 subsets: Group A, older patients who underwent surgery for pelvic organ prolapse or diverticulitis with adnexectomy and Group B, younger patients who underwent surgery for pelvic pain, endometriosis, or both. Hospital stay in Group B was statistically lower in the HALS cases vs. the ELAP controls, (2.9 vs. 5.4 days, P=0.04). All HALS and ELAP patients were then analyzed for overall trends. HALS cases had shorter hospitalization than ELAP controls had (3.3 vs 4.5 days, P=0.035). Estimated blood loss was also less overall in the HALS cases vs. the ELAP controls (175 vs 355.9 mL, P=0.021). There were 2 adverse outcomes reported in Group A of the HALS cases. These 2 patients experienced postoperative hernias though the hand-assist port-site incision. CONCLUSION: Compared with laparotomy, overall, HALS offers the advantage of decreased hospitalization and decreased intraoperative blood loss. Postoperative hernias through the HA port site may be a potential problem with this technique.

Protect the ureters.

From July 1, 2006 to June 30, 2007, 151 patients with complex pelvic pathology underwent placement of lighted ureteral stents by a general surgeon or gynecologist. None of the patients who underwent preprocedure ureteral stent placement had a ureteral injury. The procedures included laparoscopic colorectal surgery (45 pts), hysterectomy/GYN (49 pts), or pelvic adhesions (57 pts). The average time from placement of the stents to start of the operation was 5 minutes (range, 2 to 15). In 6 patients, the stents could not be placed, and all had ureteral pathology that was NOT noted preoperatively. Two patients had ureter injuries at our hospital and did not have ureteral stents placed during the same time period. The cost of the stents is $205. OR time past the first half hour ranges from $560 to $716 for each additional half hour. The time saved from the lighted identification of the ureters versus visual nonstent identification is from zero minutes to 45 minutes. This is an extremely useful procedure that can theoretically reduce ureter injury to zero. In an era in which insurance will not pay for complications related to the original operation and high litigation costs, this procedure should be the standard of care for safely performing complex pelvic surgery.

Hand-assist laparoscopic surgery for the gynecologic surgeon.

BACKGROUND: Hand assist laparoscopy (HALS) is a minimally invasive technique which allows for the placement of the surgeon's non-dominant hand through a hand-port device while maintaining pneumoperitoneum. There is no standardization of this procedure and it is rarely used in gynecology. METHODS: The multidisciplinary team of authors, with experience in minimally invasive pelvic surgery, has developed a practical approach performing HALS over several years. Here we present our technique. CONCLUSIONS: There are several roles for HALS in the world of gynecology and pelvic surgery. Further experience will help improve upon a standard technique.

Fallopian tube prolapse after total laparoscopic hysterectomy.

BACKGROUND: Fallopian tube prolapse is an uncommon but reported complication after laparoscopic hysterectomy. CASE: Fallopian tube prolapse was diagnosed in a patient 6 months after undergoing a total laparoscopic hysterectomy. The presenting symptoms were midline abdominal pain, abdominal distention, and dyspareunia. A laparoscopic approach showed a portion of fallopian tube prolapsed through the vaginal cuff. CONCLUSION: This case suggests that fallopian tube prolapse can occur up to 6 months after a total laparoscopic hysterectomy. Once detected, fallopian tube prolapse can be managed using a laparoscopic approach in select patients.