Open Abdominal versus Laparoscopic and Vaginal Hysterectomy: Analysis of a Large United States Payer Measuring Quality and Cost of Care

A comparison of quality outcome measures in patients having a hysterectomy for benign disease: robotic vs. non-robotic approaches

STUDY OBJECTIVE

To measure procedure-related hospital readmissions within 30 days after discharge for patients who have a hysterectomy for benign disease. Secondary outcome quality measures evaluated were cost, estimated blood loss, length of stay and sum of costs associated with readmissions.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Academic community hospital.

PATIENTS

Patients who underwent hysterectomy to treat benign disease from January 2008 to December 2012.

INTERVENTIONS

Patients were grouped according to route of hysterectomy: robotic-assisted laparoscopic hysterectomy (robotic), laparoscopic hysterectomy (laparoscopic), abdominal hysterectomy (open via laparotomy), and vaginal hysterectomy (vaginal).

MEASUREMENTS AND MAIN RESULTS

Inclusion criteria were met by 2554 patients: 601 in the robotic group, 427 in the laparoscopic group, 1194 in the abdominal group, and 332 in the vaginal group. Readmission rates in the robotic cohort were significantly less (p<.05) than in non-robotic cohorts: Robotic (1%), laparoscopic (2.5%), open (3.5%), vaginal (2.4%). Estimated blood loss, length of stay, and sum of readmission costs were also significantly less in the robotic cohort (p<.05) compared with the other 3 cohorts.

CONCLUSION

Patients who undergo robotic-assisted laparoscopic hysterectomy have a significantly lower chance of readmission <30 days after surgery compared with those who undergo laparoscopic, abdominal (open) hysterectomy, and vaginal approaches. Patients in the robotics cohort also experienced a shorter length of stay, less estimated blood loss, and a cost savings associated with readmissions when compared to non-robotic approaches. Prospective registries describing quality outcomes, total sum of costs including 30 days follow-up, as well as patient-related quality of life benefits are recommended to confirm these findings and determine which surgical route offers the highest patient and societal value.

Surgical outcome and cost comparison between total vaginal hysterectomy and laparoscopic hysterectomy for uteri weighing >500 g

STUDY OBJECTIVE

To compare surgical outcomes and overall costs of less invasive methods of hysterectomy to treat benign disease including total vaginal hysterectomy (TVH) and total laparoscopic hysterectomy (TLH) in women with a uterus weighing >500 g.

DESIGN

Retrospective review of medical records (Canadian Task Force classification III).

SETTING

University-associated hospital.

PATIENTS

One hundred three women with a uterus weighing >500 g who had undergone either total vaginal hysterectomy (TVH) (n = 52) or total laparoscopic hysterectomy (TLH) (n = 51).

MEASUREMENTS AND MAIN RESULTS

Cost data were extracted from the hospital billing system. Patient characteristics, surgical outcomes, and hospital costs were compared between the 2 groups. Patient characteristics were similar in both groups except for a history of surgery (TVH 11.5%, and TLH 37.3%; p = .01). Insofar as surgical outcomes, mean (SD) operative time was shorter in the TVH group compared with the TLH group (110.00 [28.68] minutes vs 180.47 [51.32] minutes; p < .001), and hospital stay was longer (8.08 [0.68] days vs 7.45 [1.03] days; p < .001). Other surgical outcomes including estimated blood loss (p = .20) and decrease in hemoglobin (p = .12) did not differ between the 2 groups. Total hospital costs (converted from Korean won to US dollars) were significantly lower in the TVH group than in the TLH group ($2076.59 [$666.58] vs $2744.03 [$715.76]; p < .001).

CONCLUSION

Our data suggest that TVH is a safe and economic procedure even in women with a uterus weighing >500 g. Skilled surgeons should preferentially consider TVH for treatment of benign uterine disease, regardless of uterine size.

Increasing minimally invasive hysterectomy: effect on cost and complications

OBJECTIVE

In a 3-year period, the main mode of access for hysterectomy at Brigham and Women's Hospital changed from abdominal to laparoscopic. We estimated potential effects of this shift on perioperative outcomes and costs.

METHODS

We compared the perioperative outcomes and the cost of care for all hysterectomies performed in 2006 and 2009 at an urban academic tertiary care center using the χ² test or Fisher's exact test for categorical variables and two-sided Student's t test for continuous variables. A multivariate regression analysis was also performed for the major perioperative outcomes across the study groups. Cost data were gathered from the hospital's billing system; the remainder of data was extracted from patients' medical records.

RESULTS

This retrospective study included 2,133 patients. The total number of hysterectomies performed remained stable (1,054 procedures in 2006 compared with 1,079 in 2009) but the relative proportions of abdominal and laparoscopic cases changed markedly during the 3-year period (64.7% to 35.8% for abdominal, P<.001; and 17.7% to 46% for laparoscopic cases, P<.001). The overall rate of intraoperative complications and minor postoperative complications decreased significantly (7.2% to 4%, P<.002; and 18% to 5.7%, P<.001, respectively). Operative costs increased significantly for all procedures aside from robotic hysterectomy, although no significant change was noted in total mean costs.

CONCLUSION

A change from majority abdominal hysterectomy to minimally invasive hysterectomy was accompanied by a significant decrease in procedure-related complications without an increase in total mean costs.

Laparoscopic supracervical hysterectomy (LSH) versus total laparoscopic hysterectomy (TLH): an implementation study in 1,952 patients with an analysis of risk factors for conversion to laparotomy and complications, and of procedure-specific re-operations

PURPOSE

To compare laparoscopic supracervical hysterectomy (LSH) with total laparoscopic hysterectomy (TLH) with regard to relevant surgical parameters and risk factors of conversion to laparotomy and complications.

METHODS

This prospective, open, single-center, interventional study included women with benign gynecologic disease who underwent standardized LSH or TLH. The techniques were compared for conversion rate and mean operating time, hemoglobin drop, hospital stay, and complication rates using descriptive statistics and standard non-parametric statistical tests. Risk factors of conversion and complications were identified by logistic regression analysis.

RESULTS

During January 2003 to December 2010, 1,952 women [mean age (SD): 47.5 (7.2) years] underwent LSH [1,658 (84.9%)] or TLH [294 (15.1%)], mostly (>70%) for uterine fibroids. Significant differences in surgical parameters were observed for conversion rate (LSH/TLH: 2.6/6.5%), mean operating time [87 (34)/103 (36) min], hemoglobin drop [1.3 (0.8)/1.6 (1.0) g/dL], and hospital stay [4.3 (1.5)/4.9 (2.8) days]. Overall intraoperative (0.2/0.7%) and long-term (>6 weeks) post-operative (0.8/1.7%) complication rates did not differ significantly, but the short-term LSH complication rate was significantly lower (0.6 vs. 4.8%). Spotting (LSH, 0.2%) and vaginal cuff dehiscence (TLH, 0.7%) were long-term method-specific complications. Logistic regression showed that uterine weight and extensive adhesiolysis were significant factors for conversion while previous surgery, age, and BMI were not. Major risk factors of short-term complications were age, procedure (LSH/TLH), and extensive adhesions.

CONCLUSIONS

Both procedures proved effective and were well tolerated. LSH performed better than TLH regarding most outcome measures. LSH is associated with very low rates of re-operation and spotting.

eHealth program to empower patients in returning to normal activities and work after gynecological surgery: intervention mapping as a useful method for development

BACKGROUND

Full recovery after gynecological surgery takes much longer than expected regardless of surgical technique or the level of invasiveness. After discharge, detailed convalescence recommendations are not provided to patients typically, and postoperative care is fragmented, poorly coordinated, and given only on demand. For patients, this contributes to irrational beliefs and avoidance of resumption of activities and can result in a prolonged sick leave.

OBJECTIVE

To develop an eHealth intervention that empowers gynecological patients during the perioperative period to obtain timely return to work (RTW) and prevent work disability.

METHODS

The intervention mapping (IM) protocol was used to develop the eHealth intervention. A literature search about behavioral and environmental conditions of prolonged sick leave and delayed RTW in patients was performed. Patients' needs, attitudes, and beliefs regarding postoperative recovery and resumption of work were identified through focus group discussions. Additionally, a literature search was performed to obtain determinants, methods, and strategies for the development of a suitable interactive eHealth intervention to empower patients to return to normal activities after gynecological surgery, including work. Finally, the eHealth intervention was evaluated by focus group participants, medical doctors, and eHealth specialists through questionnaires.

RESULTS

Twenty-one patients participated in the focus group discussions. Sufficient, uniform, and tailored information regarding surgical procedures, complications, and resumption of activities and work were considered most essential. Knowing who to contact in case of mental or physical complaints, and counseling and tools for work reintegration were also considered important. Finally, opportunities to exchange experiences with other patients were a major issue. Considering the determinants of the Attitude-Social influence-self-Efficacy (ASE) model, various strategies based on a combination of theory and evidence were used, resulting in an eHealth intervention with different interactive functionalities including tailored convalescence recommendations and a video to communicate the most common pitfalls during the perioperative period to patients and employers. Fifteen patients in the focus groups, 11 physicians, and 3 eHealth specialists suggested points for improvement to optimize the usability of the eHealth intervention and judged it an approachable, appropriate, and attractive eHealth intervention to empower gynecological patients.

CONCLUSIONS

The IM protocol was a useful method to develop an eHealth intervention based on both theory and evidence. All patients and stakeholders judged the eHealth intervention to be a promising tool to empower gynecological patients during the perioperative period and to help them to return to normal activities and work.

Two-incision minimally invasive vs standard total hip arthroplasty: comparison of component position and hospital costs

Forty-nine patients undergoing 2-incision total hip arthroplasty were matched by age, gender, body mass index, and comorbidity to patients undergoing a standard lateral Hardinge approach. Hospital costs and charges were compared along with length of stay, component position, and complication rates. Component position and complication rates were identical for the 2 groups. However, hospital costs and charges were significantly lower for the 2-incision group, as was length of stay.

Laparoscopic supracervical hysterectomy versus laparoscopic-assisted vaginal hysterectomy

Laparoscopic supracervical hysterectomy demonstrated fewer preoperative complications and lower postoperative costs compared to laparoscopic-assisted vaginal hysterectomy in this report.

Objectives:

To compare the incidence of perioperative complications and postoperative healthcare utilization and costs in laparoscopic supracervical hysterectomy (LSH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) patients.

Methods:

Women ≥18 years with LSH or LAVH were extracted using a large national commercial claims database from 1/1/2007 through 9/30/2008. Outcome was perioperative complications and gynecologic-related postoperative resource use and costs. Multivariate analysis was performed to compare postsurgical outcomes between the cohorts.

Results:

The final sample consisted of 6,198 LSH patients and 14,181 LAVH patients. LSH patients were significantly more likely to have dysfunctional uterine bleeding and leiomyomas and less likely to have endometriosis and prolapse as the primary diagnosis, and also significantly more likely to have a uterus that weighed >250 grams than LAVH patients. Compared with LAVH patients, LSH patients had significantly lower overall infection rates (7.4% versus 6.2%, P=.002) and lower total gynecologic-related postoperative costs ($252 versus $385, P<.001, within 30 days of follow-up and $350 versus $569, P<.001, within 180 days of follow-up). Significant cost differences remained following multivariate adjustment for patient characteristics.

Conclusions:

LSH patients demonstrated fewer perioperative complications and lower GYN-related postoperative costs compared to LAVH patients.

Symptomatic and anatomic 1-year outcomes after robotic and abdominal sacrocolpopexy

OBJECTIVE

The purpose of this study was to compare symptomatic and anatomic outcomes 1 year after robotic vs abdominal sacrocolpopexy.

STUDY DESIGN

Our retrospective cohort study compared women who underwent robotic sacrocolpopexy (RSC) with 1 surgeon to those who underwent abdominal sacrocolpopexy (ASC) as part of the Colpopexy and Urinary Reduction Efforts trial. Our primary outcome was a composite measure of vaginal bulge symptoms or repeat surgery for prolapse.

RESULTS

We studied 447 women (125 with RSC and 322 with ASC). Baseline characteristics were similar. There were no significant differences in surgical failures 1 year after surgery based on our primary composite outcome (7/86 [8%] vs 12/304 [4%]; P = .16). When we considered anatomic failure, there were also no significant differences between RSC and ASC (4/70 [6%] vs 16/289 [6%]; P = .57).

CONCLUSION

One year after sacrocolpopexy, women who underwent RSC have similar symptomatic and anatomic success compared with those women who underwent ASC.

Gynecologic use of Sepraspray Adhesion Barrier for reduction of adhesion development after laparoscopic myomectomy: a pilot study

OBJECTIVE

To assess the safety and efficacy of Sepraspray Adhesion Barrier (a modified hyaluronic acid and carboxymethylcellulose powder) after laparoscopic surgery, in view of both the high efficacy of Seprafilm Adhesion Barrier in reducing postoperative adhesions after open surgical procedures and the difficulty with laparoscopic delivery.

DESIGN

Multicenter, randomized, reviewer-blinded trial.

SETTING

Reproductive endocrinology and infertility clinics.

PATIENT(S)

Women undergoing laparoscopic myomectomy for indications including infertility.

INTERVENTION(S)

Randomization to treatment with (n = 21) or without (n = 20) Sepraspray Adhesion Barrier.

MAIN OUTCOME MEASURE(S)

Postoperative adhesions development was assessed at early second-look laparoscopy. Adhesions were scored using the modified American Fertility Society scoring system.

RESULT(S)

Surgical procedure duration length was 99 versus 102 minutes in the control versus Sepraspray Adhesion Barrier groups, respectively, with the median number of fibroids removed being two in each group and corresponding fibroid weights of 134 ± 103 versus 113 ± 161 g, respectively. Adhesions scores increased in both the control and Sepraspray Adhesion Barrier groups, with larger although nonstatistically significant increases noted in control subjects when evaluating for the anterior uterus, the posterior uterus, and the entire uterus.

CONCLUSION(S)

Laparoscopic application of Sepraspray Adhesion Barrier after myomectomy in this pilot study was associated with a trend toward a reduction in postoperative adhesion development, as well as an encouraging safety profile. Further evaluation is warranted.

CLINICAL TRIAL NUMBER

Sepraspray Adhesion Barrier #NCT00624930.

Gynaecologic Robot-Assisted Cancer and Endoscopic Surgery (GRACES) in a Tertiary Referral Centre

Introduction: Robotic-assisted gynaecologic surgery is gaining popularity and it offers the advantages of laparoscopic surgery whilst overcoming the limitations of operative dexterity. We describe our experience with the first 40 cases operated under the GRACES (Gynaecologic Robot-Assisted Cancer and Endoscopic Surgery) programme at the Department of Obstetrics & Gynecology, National University Hospital, Singapore. Materials and Methods: A review was performed for the first 40 women who had undergone robotic surgery, analysing patient characteristics, surgical timings and surgery-related complications. All cases were performed utilising the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA) with 3 arms and 4 ports. Standardised instrumentation and similar cuff closure techniques were used. Results: Seventeen (56%) were for endometrial cancer and the rest, for benign gynaecological disease. The mean age of the patients was 52.3 years. The average docking time was 11 minutes (SD 0.08). The docking and operative times were analysed in tertiles. Data for patients with endometrial cancer and benign cases were analysed separately. There were 3 cases of complications- cuff dehiscence, bleeding from vaginal cuff and tumour recurrence at vaginal vault. Conclusion: Our caseload has enabled us to replicate the learning curve reported by other centres. We advocate the use of a standard instrument set for the first 20 cases. We propose the following sequence for successful introduction of robot-assisted gynaecologic surgery – basic systems training, followed shortly with a clinical case, and progressive development of clinical competence through a proctoring programme. Key words: Clinical outcomes, Cost effectiveness, Gynaecology, Learning curve, Robotics

Negative attitudes and affect do not predict elective hysterectomy: a prospective analysis from the Study of Women's Health Across the Nation

OBJECTIVE

Cross-sectional studies suggest an association between hysterectomy and negative affect. Using prospective data, we examined the associations of negative affect, attitudes toward aging and menopause, premenstrual symptoms, and vasomotor symptoms with elective hysterectomy in midlife.

METHODS

Data were from the Study of Women's Health Across the Nation, a multisite, community-based prospective cohort study of the menopausal transition (n = 2,818). Annually reported hysterectomy at visits 2 to 9 was verified with medical records when available (71%). Anxiety, perceived stress, depressive symptoms, attitudes toward aging and menopause, vasomotor symptoms, and premenstrual symptoms were assessed at baseline using standardized questions. Cox proportional hazards models were used to relate these variables to subsequent elective hysterectomy. Covariates included demographic variables, menstrual bleeding problems, body mass index, hormone levels, and self-rated health, also assessed at baseline.

RESULTS

Elective hysterectomy was reported by 6% (n = 168) of participants over an 8-year period. Women with hysterectomy were not higher in negative affect or negative attitudes toward aging and menopause compared with women without hysterectomy. Vasomotor symptoms (hazard ratio [HR], 1.44; 95% CI, 1.03-2.01; P = 0.03) and positive attitudes toward aging and menopause (HR, 1.74; 95% CI, 1.04-2.93) at baseline predicted hysterectomy over the 8-year period, controlling for menstrual bleeding problems, site, race/ethnicity, follicle-stimulating hormone, age, education, body mass index, and self-rated health. Menstrual bleeding problems at baseline were the strongest predictor of hysterectomy (HR, 4.30; 95% CI, 2.05-9.05).

CONCLUSIONS

In this prospective examination, negative affect and attitudes were not associated with subsequent hysterectomy. Menstrual bleeding problems were the major determinant of elective hysterectomy.

Predicting the development of stress urinary incontinence 3 years after hysterectomy

Introduction and hypothesis

We aimed to develop a prediction rule to predict the individual risk to develop stress urinary incontinence (SUI) after hysterectomy.

Methods

Prospective observational study with 3-year follow-up among women who underwent abdominal or vaginal hysterectomy for benign conditions, excluding vaginal prolapse, and who did not report SUI before surgery (n = 183). The presence of SUI was assessed using a validated questionnaire.

Results

Significant prognostic factors for de novo SUI were BMI (OR 1.1 per kg/m², 95% CI 1.0–1.2), younger age at time of hysterectomy (OR 0.9 per year, 95% CI 0.8–1.0) and vaginal hysterectomy (OR 2.3, 95% CI 1.0–5.2). Using these variables, we developed the following rule to predict the risk of developing SUI: 32 + BMI − age + (7.5 × route of surgery).

Conclusions

We defined a prediction rule that can be used to counsel patients about their individual risk on developing SUI following hysterectomy.

No more abdominal hysterectomy for myomata using a new minimally-invasive technique

To perform hysterectomy in uterus myomatosus, there are several surgical techniques. For a uterine weight of >1000 g, after a caesarean section and in nullipara per vaginam, the most common surgical technique for hysterectomy in patients is hysterectomy per laparotomiam. A new endoscopical technique developed to treat such patients and to avoid laparotomy is described in this case report: the laparoscopic combined hysterectomy (LACH) using the change-over technique. Adhesiolysis, preparation of the ureters and the bladder and morcellation of the uterus of 2480 g were performed minimally-invasive in two steps, from one side of the patient with a change-over of the OP-team to the other side of the patient. The cervix was removed per vaginam.

Symptomatic pelvic hematoma following transvaginal reconstructive pelvic surgery: incidence, clinical presentation, risk factors, and outcome

OBJECTIVE

To assess the incidence, clinical presentation, risk factors and outcome of symptomatic pelvic hematomas following transvaginal pelvic reconstructive surgery.

MATERIALS AND METHODS

We reviewed the medical records of all women undergoing transvaginal reconstructive pelvic surgery in our institution between January 2006 and July 2009.

RESULTS

462 patients underwent pelvic reconstructive surgery, of whom 28 (6%) presented with symptomatic pelvic hematomas. All cases occurred after transvaginal hysterectomy, 25 (90%) presented with fever, 20 (71%) with pelvic pain and 5 (20%) with urinary retention. All hematomas were diagnosed by ultrasound. They were located at the vaginal cuff in 18 (64%), anterior vaginal wall in six (21%) and posterior vaginal wall in four patients (14%), and had a mean volume of 590 ± 140 cm(3). Laboratory data included leukocytosis (71%), thrombocytosis (57%) and elevated liver enzymes (18%). Nine patients (33%) required ultrasound-guided drainage of the hematoma, which resulted in marked clinical improvement. Surgical outcome was not affected by the presence of pelvic hematoma.

CONCLUSIONS

A postoperative symptomatic pelvic hematoma is not rare and is closely related to transvaginal hysterectomy. Its clinical presentation includes fever, pelvic pain, leukocytosis, thrombocytosis and occasionally liver dysfunction. Surgical outcome is generally unaffected.