Evaluating Surgical Complexity of Endoscopic Hysterectomy: An Inter-rater and Intra-rater Agreement Study of Novel Scoring Tool.

STUDY OBJECTIVE: Evaluate inter-rater and intrarater reliability of a novel scoring tool for surgical complexity assessment of endoscopic hysterectomy. DESIGN: Validation study. SETTING: Academic medical center. PARTICIPANTS: Total of 11 academic obstetrician-gynecologists with varying years of postresidency training, clinical practice, and surgical volumes. INTERVENTIONS: Application of a novel scoring tool to evaluate surgical complexity of 150 sets of images taken in a standardized fashion before surgical intervention (global pelvis, anterior cul-de-sac, posterior cul-de-sac, right adnexa, left adnexa). Using only these images, raters were asked to assess uterine size, number, and location of myomas, adnexal and uterine mobility, need for ureterolysis, and presence of endometriosis or adhesions in relevant locations. Surgical complexity was staged on a scale of 1 to 4 (low to high complexity). MEASUREMENTS AND MAIN RESULTS: Number of postresidency years in practice for participating surgeons ranged from 2 to 15, with an average of 8 years. A total of 8 obstetrician-gynecologists (72.7%) had completed a fellowship in minimally invasive gynecologic surgery. Six (54.6%) reported an annual volume of >50 hysterectomies. Raters reported that 95.4% of the images were satisfactory for assessment. Of the 150 sets of images, most were found to be stage 1 to 2 complexity (stage 1: 23.8%, stage 2: 41.6%, stage 3: 32.8%, stage 4: 1.8%). The level of inter-rater agreement regarding stage 1 to 2 vs 3 to 4 complexity was moderate (κ = 0.49; 95% confidence interval [CI], 0.42-0.56). Moderate inter-rater agreement was also found between surgeon raters with an annual hysterectomy volume >50 (κ = 0.49; 95% CI, 0.40-0.57) as well as between surgeon raters with fellowship experience (κ = 0.50; 95% CI, 0.42-0.58). Intrarater agreement averaged 80.2% among all raters and also achieved moderate agreement (mean weighted κ = 0.53; range, 0.38-0.72). CONCLUSION: This novel scoring tool uses clinical assessment of preintervention anatomic images to stratify the surgical complexity of endoscopic hysterectomy. It has rich and comprehensive evaluation capabilities and achieved moderate inter-rater and intrarater agreement. The tool can be used in conjunction with or instead of traditional markers of surgical complexity such as uterine weight, estimated blood loss, and operative time.

Characteristics Associated with Prolonged Length of Stay after Myomectomy for Uterine Myomas.

STUDY OBJECTIVE: To identify factors contributing to prolonged hospitalization for women undergoing myomectomy for uterine myomas. PATIENTS: Women undergoing myomectomy for uterine myomas during 2014 to 2016 were identified by the Current Procedural Terminology code. DESIGN: Retrospective population-based analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. SETTING: Data from the American College of Surgeons National Surgical Quality Improvement Project. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was length of stay longer than the median (1 day). Preoperative, intraoperative, and postoperative variables were examined to determine predictors for prolonged length of stay (LOS). Seven thousand five hundred thirty-one women underwent abdominal or laparoscopic myomectomy for uterine myomas. Nonwhite race (black: odds ratio [OR] = 2.25; 95% confidence interval [CI], 2.01-2.51; Asian: OR = 1.54; 95% CI, 1.27-1.85; other/unknown: OR = 2.82; 95% CI, 2.43-3.27), preoperative hematocrit <38% (OR = 1.38; 95% CI, 1.26-1.52), body mass index ≥30.1 kg/m2 (OR = 1.36; 95% CI, 1.21-1.53), preoperative blood transfusion (OR = 3.70; 95% CI, 2.03-6.74), perioperative blood transfusion (OR = 6.64; 95% CI, 4.76-9.27), removal of ≥5 myomas (OR = 1.47; 95% CI, 1.28-1.70), and operative time >120 minutes (121-150 minutes: OR = 1.42; 95% CI, 1.15-1.77; 151-180 minutes: OR = 1.59; 95% CI, 1.24-2.03; ≥181 minutes: OR = 1.36; 95% CI, 1.10-1.69) predicted prolonged LOS. Laparoscopy protected against prolonged LOS (OR = 0.11; 95% CI, 0.09-0.13). CONCLUSIONS: Limited potentially modifiable perioperative factors contributing to prolonged LOS for abdominal or laparoscopic myomectomy were identified and suggest areas for targeted interventions.

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.

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.