Predictors of Prolonged Operative Time for Robotic-Assisted Laparoscopic Myomectomy: Development of a Preoperative Calculator for Total Operative Time

Operative Time and Accrual of Postoperative Complications in Minimally Invasive Versus Open Myomectomy

STUDY OBJECTIVE

To compare the prevalence and accrual of 30-day postoperative complications by operative time for open myomectomy (OM) and minimally invasive myomectomy (MIM).

DESIGN

Retrospective cohort study SETTING: Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2021.

PATIENTS

Female patients aged ≥18 years undergoing OM or MIM.

INTERVENTIONS

Patients were categorized into OM and MIM cohorts. Covariates associated with operative time and composite complications were identified using general linear model and chi-square or Fisher's exact test as appropriate. Adjusted spline regression was performed as a test of linearity between operative time and composite complications. Adjusted risk ratios of 30-day postoperative individual, minor, major, and composite complications by 60-minute operative time increments were estimated using Poisson regression with robust error variance.

MEASUREMENTS AND MAIN RESULTS

Of 27 728 patients, 11 071 underwent MIM and 16 657 underwent OM. Mean operative times (SD) were 164.6 (82.0) for MIM and 129.2 (67.0) for OM. Raw composite complication rates were 5.5% for MIM and 15.8% for OM. Adjusted spline regression demonstrated linearity between operative time and relative risk of composite postoperative complications for both MIM and OM. MIM had higher adjusted relative risk (aRR, 95% CI) compared to OM of blood transfusion (1.55, 1.45-1.64 versus 1.29, 1.25-1.34), overall minor complications (1.13, 1.03-1.23 versus 1.01, 0.92-1.10), and overall major complications (1.43, 1.35-1.51 versus 1.27, 1.12-1.32). Operative time had greater impact on risk of composite complications for MIM than OM, reaching aRR 2.0 at 296 minutes versus 461 minutes for OM.

CONCLUSION

OM has a higher overall rate of composite, minor, and major complications compared to MIM. While operative time is independently and linearly associated with postoperative complications with myomectomy regardless of approach, optimizing surgical efficiency for MIM may be more critical than for OM.

Comparison of Surgical Outcomes of Two New Techniques Complementing Robotic Single-Site Myomectomy: Coaxial Robotic Single-Site Myomectomy vs. Hybrid Robotic Single-Site Myomectomy

BACKGROUND

This study aimed to compare surgical outcomes between two new robotic single-site myomectomy (RSSM)-complementary techniques: coaxial robotic single-site myomectomy (Coaxial-RSSM) and hybrid robotic single-site myomectomy (Hybrid-RSSM).

METHODS

Medical records for 132 women undergoing Coaxial-RSSM and 150 undergoing Hybrid-RSSM, consecutively, were retrospectively reviewed. Patient characteristics and surgical outcomes were assessed and compared after propensity score matching (PSM).

RESULTS

In the outcomes of PSM, the Coaxial-RSSM group showed significantly reduced blood loss (79.71 vs. 163.75 mL, p < 0.001) and reduced hospital duration (4.18 ± 0.62 vs. 4.63 ± 0.90) relative to the Hybrid-RSSM group. Conversely, Hybrid-RSSM allowed for a shorter operative time compared with Coaxial-RSSM (119.19 vs. 156.01 min, p = 0.007). No conversions to conventional laparoscopy or laparotomy or any need for the multi-site robotic approach occurred in either group. Postoperative complications, including ileus, fever, and wound dehiscence, showed no statistically significant differences between the two groups.

CONCLUSIONS

Blood loss was lower with Coaxial-RSSM, and operative time was shorter for Hybrid-RSSM. A follow-up prospective study is warranted for more comprehensive comparison of surgical outcomes between the two techniques.

Lack of Validity of Absolute Percentage Errors in Estimated Operating Room Case Durations as a Measure of Operating Room Performance: A Focused Narrative Review

Commonly reported end points for operating room (OR) and surgical scheduling performance are the percentages of estimated OR times whose absolute values differ from the actual OR times by ≥15%, or by various intervals from ≥5 to ≥60 minutes. We show that these metrics are invalid assessments of OR performance. Specifically, from 19 relevant articles, multiple OR management decisions that would increase OR efficiency or productivity would also increase the absolute percentage error of the estimated case durations. Instead, OR managers should check the mean bias of estimated OR times (ie, systematic underestimation or overestimation), a valid and reliable metric.

Multi-Port Robotic-Assisted Laparoscopic Myomectomy: A Systematic Review and Meta-Analysis of Comparative Clinical and Fertility Outcomes

BACKGROUND

Uterine fibroids are the most frequently diagnosed gynaecological tumours, and they often require surgical treatment (conventional laparoscopic myomectomy-CLM). The introduction and evolution of robotic-assisted laparoscopic myomectomy (RALM) in the early 2000s has expanded the range of minimally invasive options for the majority of cases. This study aims to compare RALM with CLM and abdominal myomectomy (AM).

METHODS AND MATERIALS

Fifty-three eligible studies adhered to the pre-established inclusion criteria and were subsequently evaluated for risk of bias and statistical heterogeneity.

RESULTS

The available comparative studies were compared using surgical outcomes, namely blood loss, complication rate, transfusion rate, operation duration, conversion to laparotomy, and length of hospitalisation. RALM was significantly superior to AM in all assessed parameters other than operation duration. RALM and CLM performed similarly in most parameters; however, RALM was associated with reduced intra-operative bleeding in patients with small fibroids and had lower rates of conversion to laparotomy, proving RALM as a safer overall approach.

CONCLUSION

The robotic approach for surgical treatment of uterine fibroids is a safe, effective, and viable approach, which is constantly being improved and may soon acquire widespread adoption and prove to be superior to CLM in certain patient subgroups.

Safety of Same-Day Discharge Versus Hospital Admission in Minimally Invasive Myomectomy

STUDY OBJECTIVE

To compare postoperative complication rates between same-day discharge patients and patients admitted to hospital after minimally invasive myomectomy, stratified by patient demographics and perioperative variables including myoma burden.

DESIGN

Retrospective cohort study. Setting Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2019.

PATIENTS

Female patients aged ≥18 years undergoing minimally invasive myomectomy.

INTERVENTIONS

Patients were categorized into either the same-day discharge or admitted patient cohort. Univariate comparisons of demographics, perioperative variables, and 30-day postoperative complications were performed. Multivariate logistic regression was used to 1) identify demographic and perioperative factors associated with admission, and 2) compare postoperative complication rates of same-day discharge patients with those of admitted patients while adjusting for demographic and perioperative factors.

MEASUREMENTS AND MAIN RESULTS

Eight thousand one hundred patients were recruited during the study period. The overall rate of same-day discharge was 57.2% in 2015 and 65.0% in 2019. The same-day discharge rate was 64.6% for patients with a smaller myoma burden (1-4 fibroids and ≤250 grams, Current Procedural Terminology 58545) and 56.8% for larger myoma burden (≥5 fibroids or >250 grams, Current Procedural Terminology 58546). Age, race, American Society of Anesthesiologists classification III or IV, preoperative hematocrit <36%, hypertension, diabetes, bleeding disorder, and increasing operative time were associated with admission to hospital. After adjusting for these variables, composite postoperative complication rates were similar between admitted patients and patients who were discharged the same day regardless of myoma burden (adjusted OR [aOR], 0.66; 95% confidence interval [CI] 0.18-2.47 for low myoma burden and aOR, 0.91; 95% CI 0.18-4.63 for high myoma burden). Admitted patients with both low (aOR, 9.1; 95% CI 2.27-37.04) and high (aOR, 8.24; 95% CI 1.59-42.49) myoma burdens were significantly more likely to receive a blood transfusion compared to same-day discharge patients.

CONCLUSION

Same-day discharge after minimally invasive myomectomy, regardless of myoma burden, is associated with low complication rates. Our findings may aid in shared decision making on discharge planning.

The role of minimally invasive gynecologic surgeons in the era of subspecialties: when to refer and consult

PURPOSE OF REVIEW

Minimally invasive gynecologic surgery (MIGS) is a subspecialty focus of obstetrics and gynecology with focused expertise on complex benign gynecologic disorders. To date, no formal recommendations have been made in defining a referral system for MIGS. This article reviews the evidence regarding common disorders and procedures and their outcomes, and posits a basis for MIGS referral.

RECENT FINDINGS

In instances where intraoperative and perioperative features may pose clinical challenges to the surgeon and ultimately the patient, the literature suggests the following scenarios may have adverse outcomes, and therefore, benefit from the skills of MIGS subspecialists: fibroids - at least five myomas, myoma size at least 9 cm, and suspected myoma weight at least 500 g; endometriosis - presence of endometrioma(s), suspected stage III/IV endometriosis, and requirement for advanced adjunct procedures; hysterectomy - uteri at least 250 g or 12 weeks estimated size, at least three prior laparotomies, obesity, and complex surgical history with suspected adhesive disease.

SUMMARY

A referral system for MIGS subspecialists has proven benefits for both the gynecologic surgical community as well as the patients and their outcomes. This article provides evidence for collaboration with MIGS especially as it relates to leiomyomatous uteri, endometriosis, and complex hysterectomies.

Rethinking Disparities in Minimally Invasive Myomectomy: Identifying Drivers of Disparate Surgical Approach to Myomectomy Between African American and White Women

STUDY OBJECTIVE

To identify drivers of disparities among patients undergoing surgical management of fibroids when stratified by self-identified patient race.

DESIGN

This is a retrospective IRB-approved chart review of all patients who underwent a myomectomy at a large academic center. Surgical approach to myomectomy was classified as abdominal, laparoscopic, or robotic-assisted laparoscopic. Fibroid burden was quantified preoperatively using uterine volume, intra-operatively by number of fibroids listed on operative report, and postoperatively by fibroid weight from pathology reports.

SETTING

A large tertiary care hospital containing a comprehensive fibroid treatment center.

PATIENTS

265 white patients and 121 African American patients who underwent a myomectomy between January 2012 and October 2018 were included in the study population.

INTERVENTIONS

Abdominal, laparoscopic, and robotic-assisted myomectomy. Laparoscopic and robotic-assisted myomectomy were classified as minimally invasive myomectomy. Multivariable logistic regression models and a propensity score matching algorithm were used to match African American women and white women for fibroid burden.

MEASUREMENTS AND MAIN RESULTS

A total of 386 women were included in the study. African American (AA) (31%; n=121) women had higher fibroid burden (p<0.01) by preoperative imaging (36% with 3 or more) as compared to white women (19% with 3 or more) and operative report (>8 AA: 31% vs. white 13%, p<.01). Despite this, African American women underwent minimally invasive myomectomy at similar rates as compared to white women when adjusted for fibroid burden, BMI, preoperative hematocrit, HTN, and surgical indication (adjusted OR: 1.3, 95% CI: 0.8 to 2.2, p<.01).. Sensitivity analysis using propensity score matching found similar results.

CONCLUSION

In this population, African American women had a higher fibroid burden as compared to white women. When matched for fibroid burden, however, there was no statistically significant difference between rates of minimally invasive myomectomy and abdominal myomectomy. This finding was consistent when controlling for fibroid burden measured by preoperative, intraoperative, or postoperative methods of measurement. Further studies are needed to better characterize this disparity at other hospitals, and to investigate ways to increase access and equity among patients undergoing minimally invasive myomectomy.

The Largest Uterine Leiomyoma Removed by Robotic-Assisted Laparoscopy in the Late Reproductive Age: A Case Report

Uterine leiomyoma is a very common gynecological tumor in the reproductive years. Recent studies have shown that surgical treatment of uterine leiomyoma using robotic-assisted laparoscopic myomectomy (RALM) is associated with significantly fewer complications, lower estimated blood loss, fewer conversions, and less bleeding than conventional laparoscopic myomectomy. This study reports the case of a giant uterine leiomyoma treated using RALM. A 50-year-old woman was referred to our outpatient clinic with progressive abdominal distension. Ultrasonography and magnetic resonance imaging were performed and showed a markedly enlarged uterus containing a 28-cm uterine myoma. RALM confirmed the 28-cm subserosal myoma on the posterior wall of the uterus. The myoma was enucleated, and the myometrial and serosal defect was repaired with a continuous suture using barbed suture materials. The entire myoma was removed using an electric morcellator. The operation lasted for 190 minutes. The total weight of the removed myoma was 3,262 g, and uterine leiomyoma was pathologically diagnosed. There were no postoperative complications. Although the treatment of huge myomas using RALM is controversial and technically demanding, we successfully performed RALM in a patient with a large myoma. This case confirms the efficiency, reliability, and safety of a robotic-assisted laparoscopic approach for removing a huge myoma. In a well-selected case, RALM can be performed by experienced surgeons regardless of the size of fibroids.

Variables that prolong total operative time for robotic-assisted laparoscopic myomectomy: A 10-year tertiary hospital study in Korea

STUDY OBJECTIVE

To identify factors that prolong total operative time (TOT) in robotic-assisted laparoscopic myomectomy (RALM).

DESIGN

Retrospective cohort study.

SETTING

Tertiary university hospital.

PATIENTS

Women who underwent RALM between April 2009 and May 2019 conducted by a single high-volume gynecologic surgeon.

INTERVENTIONS

Patients' demographic data and intraoperative records were obtained. The association between the perioperative characteristics and TOT was analyzed.

MEASUREMENTS AND MAIN RESULTS

A total of 584 cases met the inclusion criteria, with a mean TOT of 231.6 ± 86.7 min. The mean patient age was 36.3 ± 5.5 years, and the patients had a mean of 4.2 ± 4.0 myomas. The dominant myoma had a mean diameter of 7.6 ± 2.6 cm. The mean total weight of the extracted myomas removed was 202.2 ± 152.6 g. From multiple regression analysis, the following perioperative factors were intimately associated with the TOT: ① body mass index, ② the number of myomas, ③ weight of total myomas, ④ location of dominant myoma, ⑤ type of da Vinci robot system, ⑥ endometrial cavity opening during the operation, ⑦ intraoperative blood loss, and ⑧ patient hospitalization period. The number of myoma was most closely related to the TOT, with an R² value of 0.330. All of the above factors with the exception of the type of robot system and location of dominant myoma were related to the console time. Age, parity, history of previous abdominal surgery, surgical indication, diameter, and FIGO classification were not associated with the TOT.

CONCLUSION

With an accurate identification of the perioperative parameters above, we can improve the quality of RALM by counselling, selecting an appropriate patient selection, and preoperative planning.