1
|
Mitric C, Sayyid RK, Fleshner NE, Look Hong NJ, Bouchard-Fortier G. Hysterectomy versus chemotherapy for low-risk non-metastatic gestational trophoblastic neoplasia (GTN): A cost-effectiveness analysis. Gynecol Oncol 2024; 187:30-36. [PMID: 38705127 DOI: 10.1016/j.ygyno.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE Determine the cost-effectiveness for hysterectomy versus standard of care single agent chemotherapy for low-risk gestational trophoblastic neoplasia (GTN). METHODS A cost-effectiveness analysis was conducted comparing single agent chemotherapy with hysterectomy using decision analysis and Markov modeling from a healthcare payer perspective in Canada. The base case was a 40-year-old patient with low-risk non-metastatic GTN that completed childbearing. Outcomes were life years (LYs), quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICER), and adjusted 2022 costs (CAD). Discounting was 1.5% annually and the time horizon was the patient's lifetime. Model validation included face validity, deterministic sensitivity analyses, and scenario analysis. RESULTS Mean costs for chemotherapy and hysterectomy arms were $34,507 and $17,363, respectively, while effectiveness measure were 30.37 QALYs and 31.04 LYs versus 30.14 QALYs and 30.82 Lys, respectively. The ICER was $74,526 (USD $54,516) per QALY. Thresholds favoring hysterectomy effectiveness were 30-day hysterectomy mortality below 0.2% and recurrence risk during surveillance above 9.2% (low-risk) and 33.4% (high-risk). Scenario analyses for Dactinomycin and Methotrexate led to similar results. Sensitivity analysis using tornado analysis found the cost to be most influenced by single agent chemotherapy cost and risk of resistance, number of weeks of chemotherapy, and probability of postoperative mortality. CONCLUSION Compared to hysterectomy, single agent chemotherapy as a first-line treatment costs $74,526 for each additional QALY gained. Given that this cost falls below the accepted $100,000 willingness-to-pay threshold and waitlist limitations within public healthcare systems, these results support the continued use of chemotherapy as standard of care approach for low-risk GTN.
Collapse
Affiliation(s)
- Cristina Mitric
- Division of Gynecologic Oncology, Princess Margaret Cancer Center/University Health Network and Sinai Health System, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Rashid K Sayyid
- Department of Surgery, Division of Urology, University of Toronto, Toronto, Ontario, Canada
| | - Neil E Fleshner
- Department of Surgery, Division of Urology, University of Toronto, Toronto, Ontario, Canada
| | - Nicole J Look Hong
- Department of Surgical Oncology, Odette Cancer Centre/ Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Genevieve Bouchard-Fortier
- Division of Gynecologic Oncology, Princess Margaret Cancer Center/University Health Network and Sinai Health System, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
2
|
Long L, He X, Liu Y, Lei C. Effect of two different modalities of hysterectomy on wound infection and wound dehiscence in obese patients. Int Wound J 2024; 21:e14664. [PMID: 38439170 PMCID: PMC10912368 DOI: 10.1111/iwj.14664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 12/29/2023] [Indexed: 03/06/2024] Open
Abstract
This research intended to investigate the influence of the operation of both kinds of hysterectomies in the risk of wound infection and the degree of wound dehiscence. Both of them were open field and laparoscope. In this research, we looked into four databases: PubMed, Web of Science, Embase and Cochrane Library. Research was conducted on various operative methods for hysterectomy in obese patients between 2000 and October 2023. Two independent investigators performed an independent review of the data, established the inclusion and exclusion criteria, and managed the results with Endnote software. It also evaluated the quality of the included literature. Finally, the data were analysed with RevMan 5.3. This study involved 874 cases, 387 cases received laparoscopy and 487 cases received open access operation. Our findings indicate that there is a significant reduction in the rate of post-operative wound infection among those who have received laparoscopy compared with who have received open surgical procedures (odds ratio [OR], 0.04; 95% confidence interval [CI], 0.01-0.15; p < 0.001); There was no statistical difference between the rate of post-operative wound dehiscence and those who received laparotomy compared with those who received open surgical procedures (OR, 0.33; 95% CI, 0.10-1.11; p = 0.07); The estimated amount of blood lost during the operation was less in the laparoscopy group compared with the open procedure (mean difference, -123.72; 95% CI, -215.16 to -32.28; p = 0.008). Generally speaking, the application of laparoscopy to overweight women who have had a hysterectomy results in a reduction in the expected amount of bleeding during surgery and a reduction in the risk of post-operative wound infections.
Collapse
Affiliation(s)
- Ling Long
- Department of Gynecological OncologyChongqing University Cancer Hospital, Chongqing Cancer Institute, Chongqing Cancer HospitalChongqingChina
| | - Xuan He
- Department of Cancer Center, Daping HospitalArmy Medical University (Third Military Medical University)ChongqingChina
| | - Yuyang Liu
- Department of Traditional Chinese Medicine, College of MedicineChangchun University of Traditional Chinese MedicineChongqingChina
| | - Cuirong Lei
- Department of Gynecological OncologyChongqing University Cancer Hospital, Chongqing Cancer Institute, Chongqing Cancer HospitalChongqingChina
| |
Collapse
|
3
|
Kohn JR, Frost AS, Tambovtseva A, Hunt M, Clark K, Wilson C, Borahay MA. Cost drivers for benign hysterectomy within a health care system: Influence of patient, perioperative, and hospital factors. Int J Gynaecol Obstet 2023; 161:616-623. [PMID: 36436911 PMCID: PMC10121734 DOI: 10.1002/ijgo.14593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/28/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To identify patient, perioperative, and hospital factors that drive total hospital charges for benign hysterectomy. METHODS The authors conducted a retrospective cohort study between July 2014 and February 2019 at five academic and community hospitals within an integrated healthcare system in the state of Maryland with a Global Budget Revenue methodology for hospital charges. Predictor variables included patient, perioperative and hospital characteristics. One-way analysis of variance was used to compare charges among approaches. A multiple linear regression model was built to account for the interaction between covariates. RESULTS A total of 2592 patients underwent hysterectomy via laparoscopic (61%), abdominal (16%), robotic (14%), or vaginal (9%) approaches. Before adjusting for covariates, laparoscopic and vaginal approaches had similar charges ($11 637 and $12 229, respectively), while robotic and open approaches had higher charges ($17 535 and $19 099, respectively). After adjusting, charges for open, laparoscopic, and robotic approaches were higher than the vaginal approach ($692, $712, and $1279, respectively). Each operating room minute resulted in an increased cost of $46. Length of stay >23 h was associated with an increase of $865. Year, uterine size, body mass index, additional procedures, and transfusion influenced charges. CONCLUSION Perioperative and hospital characteristics significantly influence hospital charges for benign hysterectomy, more so than nonmodifiable patient characteristics. This provides opportunities to reduce healthcare expenditures, such as improving operating room efficiency and reducing length of stay.
Collapse
Affiliation(s)
- Jaden R. Kohn
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anja S. Frost
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Megan Hunt
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Mostafa A. Borahay
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
4
|
Caffrey RG. Advocating for equitable management of hereditary cancer syndromes. J Genet Couns 2022; 31:584-589. [PMID: 35032082 DOI: 10.1002/jgc4.1548] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 12/06/2021] [Accepted: 12/21/2021] [Indexed: 11/07/2022]
Abstract
The potential for preventive medicine to lead to more equitable health outcomes exists with the inclusion of genetic testing in medicine. Because of the medical implications of genetic testing for hereditary cancer syndromes and the financial cost attached to recommended management, ensuring equitable access to cancer screening and prevention must be made a priority. For patients with Hereditary Breast and Ovarian Cancer (HBOC) syndrome, the benefits of early detection and prevention are clear, significant, and create the opportunity to provide more equitable, personalized, preventive healthcare. Thus, for genetics providers who offer testing access for their patients, it is important to reflect on the ethical responsibility of advocating for access to appropriate management. Cancer genetic counselors can advocate for health equity by providing thorough pre-test genetic counseling, collaborating with other disciplines to coordinate care, lobbying state, and national representatives to pass legislation promoting health equity, and developing a management clinic that helps to ensure follow-up. Equitable access to and benefit from hereditary cancer risk management must be achieved in the pursuit of personalized preventive medicine.
Collapse
|
5
|
MERLIER M, COLLINET P, PIERACHE A, VANDENDRIESSCHE D, DELPORTE V, RUBOD C, COSSON M, GIRAUDET G. IS V-NOTES HYSTERECTOMY AS SAFE AND FEASIBLE AS OUTPATIENT SURGERY COMPARED TO VAGINAL HYSTERECTOMY ? J Minim Invasive Gynecol 2022; 29:665-672. [DOI: 10.1016/j.jmig.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/05/2022] [Accepted: 01/08/2022] [Indexed: 10/19/2022]
|
6
|
Westbay LC, Adams W, Wagner SA, Graziano SC, Dixon A, Tipton MJ, Yang LC. Understanding Patient Interest and Preferences for Same-Day Discharge After Minimally Invasive Hysterectomy. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lauren C. Westbay
- Department of Obstetrics and Gynecology, Loyola University Medical Center, Maywood, Illinois, USA
| | - William Adams
- Department of Public Health Sciences, Maywood, Illinois, USA
| | - Sarah A. Wagner
- Department of Obstetrics and Gynecology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Scott C. Graziano
- Department of Obstetrics and Gynecology, Loyola University Medical Center, Maywood, Illinois, USA
- Stritch School of Medicine Loyola University Chicago, Maywood, Illinois, USA
| | - Alison Dixon
- Department of Obstetrics and Gynecology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Matthew J. Tipton
- Department of Obstetrics and Gynecology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Linda C. Yang
- Department of Obstetrics and Gynecology, Loyola University Medical Center, Maywood, Illinois, USA
| |
Collapse
|
7
|
Vargas Maldonado D, Yi J, Trabuco E. Route of Hysterectomy: Vaginal. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Darlene Vargas Maldonado
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Johnny Yi
- Department of Medical and Surgical Gynecology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Emanuel Trabuco
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
8
|
McBride K, Steffens D, Stanislaus C, Solomon M, Anderson T, Thanigasalam R, Leslie S, Bannon PG. Detailed cost of robotic-assisted surgery in the Australian public health sector: from implementation to a multi-specialty caseload. BMC Health Serv Res 2021; 21:108. [PMID: 33522941 PMCID: PMC7849115 DOI: 10.1186/s12913-021-06105-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/20/2021] [Indexed: 02/07/2023] Open
Abstract
Background A barrier to the uptake of robotic-assisted surgery (RAS) continues to be the perceived high costs. A lack of detailed costing information has made it difficult for public hospitals in particular to determine whether use of the technology is justified. This study aims to provide a detailed description of the patient episode costs and the contribution of RAS specific costs for multiple specialties in the public sector. Methods A retrospective descriptive costing review of all RAS cases undertaken at a large public tertiary referral hospital in Sydney, Australia from August 2016 to December 2018 was completed. This included RAS cases within benign gynaecology, cardiothoracic, colorectal and urology, with the total costs described utilizing various inpatient costing data, and RAS specific implementation, maintenance and consumable costs. Results Of 211 RAS patients, substantial variation was found between specialties with the overall median cost per patient being $19,269 (Interquartile range (IQR): $15,445 to $32,199). The RAS specific costs were $8828 (46%) made up of fixed costs including $4691 (24%) implementation and $2290 (12%) maintenance, both of which are volume dependent; and $1848 (10%) RAS consumable costs. This was in the context of 37% robotic theatre utilisation. Conclusions There is considerable variation across surgical specialties for the cost of RAS. It is important to highlight the different cost components and drivers associated with a RAS program including its dependence on volume and how it fits within funding systems in the public sector. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06105-z.
Collapse
Affiliation(s)
- Kate McBride
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia. .,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Christina Stanislaus
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia
| | - Michael Solomon
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Teresa Anderson
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ruban Thanigasalam
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Scott Leslie
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Paul G Bannon
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,The Baird Institute, Sydney, New South Wales, Australia
| |
Collapse
|
9
|
Retrospective Analysis of Route Selection for Hysterectomy for Benign Indications at Ochsner Baptist Hospital. Ochsner J 2020; 20:368-372. [PMID: 33408573 PMCID: PMC7755548 DOI: 10.31486/toj.20.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Hysterectomy, the most common gynecologic procedure in the United States, can be performed in a number of ways. A shift in surgical practice toward cost-effective and minimally invasive approaches provides an impetus to maximize early training in vaginal surgery for resident physicians. Methods: A total of 62 abdominal, 303 robotic, and 41 vaginal hysterectomies performed between January 1, 2015 and December 31, 2017 at Ochsner Baptist Hospital in New Orleans, LA, that met inclusion criteria were retrospectively reviewed with a previously published route selection algorithm. We applied the algorithm using preoperative and postoperative data collected via medical record review to determine if our practices favor minimally invasive approaches. Results: Analysis using preoperative variables identified 152 robotic cases that were vaginal hysterectomy candidates (50.2%). Postoperative analysis of the same cases identified 127 (41.9%) vaginal hysterectomy candidates. Among abdominal cases, 37 (59.7%) called for a less invasive approach by preoperative findings: 7 (11.3%) vaginal and 30 (48.4%) laparoscopic. The algorithm sorted only 25 of the 62 abdominal cases (40.3%) to the abdominal approach. Conclusion: Use of a hysterectomy route selection algorithm preoperatively improves identification of candidates for minimally invasive hysterectomy.
Collapse
|
10
|
Schmitt JJ, Baker MV, Occhino JA, McGree ME, Weaver AL, Bakkum-Gamez JN, Dowdy SC, Pasupathy KS, Gebhart JB. Prospective Implementation and Evaluation of a Decision-Tree Algorithm for Route of Hysterectomy. Obstet Gynecol 2020; 135:761-769. [PMID: 32168206 PMCID: PMC10947415 DOI: 10.1097/aog.0000000000003725] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the rate of vaginal hysterectomy and outcomes after initiation of a prospective decision-tree algorithm to determine the optimal surgical route of hysterectomy. METHODS A prospective algorithm to determine optimal route of hysterectomy was developed, which uses the following factors: history of laparotomy, uterine size, and vaginal access. The algorithm was implemented at our institution from November 24, 2015, to December 31, 2017, for patients requiring hysterectomy for benign indications. Expected route of hysterectomy was assigned by the algorithm and was compared with the actual route performed to identify compliance compared with deviation. Surgical outcomes were analyzed. RESULTS Of 365 patients who met inclusion criteria, 202 (55.3%) were expected to have a total vaginal hysterectomy, 57 (15.6%) were expected to have an examination under anesthesia followed by total vaginal hysterectomy, 52 (14.2%) were expected to have an examination under anesthesia followed by robotic-assisted total laparoscopic hysterectomy, and 54 (14.8%) were expected to have an abdominal or robotic-laparoscopic route of hysterectomy. Forty-six procedures (12.6%) deviated from the algorithm to a more invasive route (44 robotic, two abdominal). Seven patients had total vaginal hysterectomy when robotic-assisted total laparoscopic hysterectomy or abdominal hysterectomy was expected by the algorithm. Overall, 71% of patients were expected to have a vaginal route of hysterectomy per the algorithm, of whom 81.5% had a total vaginal hysterectomy performed; more than 99% of the total vaginal hysterectomies attempted were successfully completed. CONCLUSION Vaginal surgery is feasible, carries a low complication rate with excellent outcomes, and should have a place in gynecologic surgery. National use of this prospective algorithm may increase the rate of total vaginal hysterectomy and decrease health care costs.
Collapse
Affiliation(s)
- Jennifer J Schmitt
- Female Pelvic Medicine and Reconstructive Surgery, Allina Health, St. Paul, and the Department of Obstetrics and Gynecology, the Division of Biomedical Statistics and Informatics, and the Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Martínez-Maestre MA, Melero-Cortés LM, Coronado PJ, González-Cejudo C, García-Agua N, García-Ruíz AJ, Jódar-Sánchez F. Long term COST-minimization analysis of robot-assisted hysterectomy versus conventional laparoscopic hysterectomy. HEALTH ECONOMICS REVIEW 2019; 9:18. [PMID: 31214891 PMCID: PMC6734326 DOI: 10.1186/s13561-019-0236-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 06/06/2019] [Indexed: 05/07/2023]
Abstract
BACKGROUND The aim of this study is to carry out the economic evaluation, in term of a cost-minimization analysis that considers healthcare costs and indirect costs, of robot-assisted hysterectomy (RAH) compared with conventional laparoscopic hysterectomy (CLH) in female adults scheduled for total laparoscopic hysterectomy for benign conditions. METHODS Cost-minimization analysis based on an analytic observational study of prospective cohorts with a five-year time horizon. Eligible participants were all female adults scheduled for total laparoscopic hysterectomy for benign conditions at tertiary hospital. The economic evaluation was conducted from a Spanish National Health Service and societal perspective, including healthcare costs and indirect costs. The costs are expressed in Euros from the year 2015. RESULTS One hundred sixty nine patients were analyzed, 68 in the RAH group and 101 in the CLH group. Average cost for the RAH group was €8982.42 compared to €8015.14 for the CLH group (incremental cost €967.27; p = 0.054). Healthcare cost is the most important component of total cost and represents 86.4% for the RAH group and 82.3% for the CLH group. The difference of €1169 (p = 0.01) in the average healthcare cost is mainly due to the cost of purchasing and maintaining the equipment (difference of €1206.39 in favor of RAH; p < 0.005). With regard to indirect costs, for patients in the RAH group the costs associated with loss of productivity were lower (difference of €203.42; p = 0.17), while the cost of trips to the hospital was higher (difference of €1.98; p = 0.66) in respect to CLH. CONCLUSIONS Our findings reveal similar effectiveness between RAH and CLH, although CLH is the more efficient option from the point of view of an economic analysis based on cost-minimization.
Collapse
Affiliation(s)
| | | | - Pluvio J. Coronado
- Women’s Health Institute, San Carlos Clinic Hospital, IdISSC, Madrid, Spain
| | | | - Nuria García-Agua
- Health Economics & Rational Use of Drugs, Faculty of Medicine, University of Málaga, Málaga, Spain
- Pharmacoeconomics: Clinical and Economic Evaluation of Pharmaceutical Drugs and Palliative Care, Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain
| | - Antonio J. García-Ruíz
- Health Economics & Rational Use of Drugs, Faculty of Medicine, University of Málaga, Málaga, Spain
- Pharmacoeconomics: Clinical and Economic Evaluation of Pharmaceutical Drugs and Palliative Care, Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain
| | - Francisco Jódar-Sánchez
- Biomedical Informatics, Biomedical Engineering and Health Economy, Institute of Biomedicine of Seville, IBiS/Virgen del Rocío University Hospital / CSIC / University of Seville, Seville, Spain
| |
Collapse
|
12
|
Kaaki B, Lewis E, Takallapally S, Cleveland B. Direct cost of hysterectomy: comparison of robotic versus other routes. J Robot Surg 2019; 14:305-310. [PMID: 31165995 DOI: 10.1007/s11701-019-00982-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 06/03/2019] [Indexed: 11/24/2022]
Abstract
The aim of this study was to investigate the direct cost of robotic hysterectomy in comparison with abdominal, vaginal, and laparoscopic routes past the initial learning curve. We examined a consecutive case series of 348 patients undergoing abdominal (AH), vaginal (VH), laparoscopic (LH), or robotic hysterectomy (RH) for benign conditions between January 2015 and March 2017. The primary outcome was the direct cost of hysterectomy, while the secondary outcome was length of stay. Multiple linear regression was used to examine the cost and length of stay across the four hysterectomy groups after controlling for potential confounding variables. 19 (5.5%) patients underwent AH, 53 (15.2%) LH, and 59 (16.9%) VH, while 217 (62.4%) RH. VH group was the oldest at age 52.1 years (p < 0.01), whereas AH group had the highest BMI at 35.9 kg/m2 (p = 0.03). While colporrhaphy was most frequently performed in VH (81%), mid-urethral sling was most common in RH (30%) (p < 0.01). The average direct cost was $3865 for RH, $4063 for AH, $2791 for VH, and $3818 for LH. Upon multivariate analysis, RH and VH were $650.47 (p < 0.01) and $883.07 (p < 0.01) cheaper, respectively, compared to AH. The average length of stay was the shortest for RH at 10.7 h, followed by LH at 15.5 h, vaginal at 20 h, and abdominal at 51.5 h (p < 0.01). VH has the lowest direct cost, while AH has the highest. Both VH and RH have a significantly lower cost than that of AH. RH has the shortest hospital stay, whereas AH has the longest.
Collapse
Affiliation(s)
- Bilal Kaaki
- Des Moines University, Des Moines, IA, USA. .,Department of Obstetrics and Gynecology, UnityPoint Health, 1825 Logan Ave., Waterloo, IA, 50703, USA.
| | | | | | | |
Collapse
|
13
|
Dandapani HG, Tieu K. The contemporary role of robotics in surgery: A predictive mathematical model on the short-term effectiveness of robotic and laparoscopic surgery. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2019. [DOI: 10.1016/j.lers.2018.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
|
14
|
Sirota I, Tomita SA, Dabney L, Weinberg A, Chuang L. Overcoming barriers to vaginal hysterectomy: An analysis of perioperative outcomes. J Turk Ger Gynecol Assoc 2019; 20:8-14. [PMID: 30209028 PMCID: PMC6501867 DOI: 10.4274/jtgga.galenos.2018.2018.0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective To determine perioperative outcome differences in patients undergoing vaginal hysterectomy based on uterine weight, vaginal delivery, and menopausal state. Material and Methods Retrospective chart review of 452 patients who underwent vaginal hysterectomy performed by a single surgeon. Patients’ age, vaginal delivery, uterine weight, previous pelvic surgery, previous cesarean delivery, removal of ovaries were compared, as well as estimated blood loss (EBL), operating room time (ORT), length of stay, intraoperative complications and postoperative complications. Multivariable logistic regression was used, and all data were analyzed at the level of p<0.05 statistical significance using SAS system software (SAS Institute Inc., Cary, NC), version 9.3. Results The mean age was 57.13±11.52 years and the median vaginal delivery was 2. The uterine weight range was 16.6-1174.5 g (mean 169.79±183.94 g). The incidences of blood transfusion and bladder injury were 3.03% and 0.66%, respectively. Factors shown to be associated with longer ORT included greater uterine weight, removal of ovaries, posterior repair, tension-free vaginal tape sling, prolapse, and EBL >500 mL (p<0.001). The factors associated with EBL >500 mL were greater uterine weight (p=0.001), uterine myomas (p=0.016) and premenopausal state (p=0.014). The factors associated with conversion to laparotomy were greater uterine weight (p<0.001) and premenopausal state (p<0.001). Conclusion Vaginal hysterectomy is a safe and feasible approach for patients desiring hysterectomy regardless of uterine weight and vaginal delivery.
Collapse
Affiliation(s)
- Ido Sirota
- Department of Obstetrics and Gynecology, New York-Presbyterian Queens Weill Cornell Medicine, New York, USA
| | - Shannon A Tomita
- Department of Obstetrics, Gynecology and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, USA,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Lisa Dabney
- Department of Obstetrics, Gynecology and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Alan Weinberg
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Linus Chuang
- Department of Obstetrics and Gynecology, Danbury Hospital – Western Connecticut Health Network, Connecticut, USA
| |
Collapse
|
15
|
Gebhart JB. Opioid prescribing after hysterectomy and route of hysterectomy-opportunities to improve care. Am J Obstet Gynecol 2018; 219:427-429. [PMID: 30444212 DOI: 10.1016/j.ajog.2018.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
|
16
|
Korsholm M, Sørensen J, Mogensen O, Wu C, Karlsen K, Jensen PT. A systematic review about costing methodology in robotic surgery: evidence for low quality in most of the studies. HEALTH ECONOMICS REVIEW 2018; 8:21. [PMID: 30194567 PMCID: PMC6128948 DOI: 10.1186/s13561-018-0207-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/03/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The main objective of this review was to evaluate the methodological design in studies reporting resource use and costs related to robotic surgery in gynecology. METHODS Systematic searches were performed in the databases PubMed, Embase, Scopus, and The Centre for Reviews and Dissemination database for relevant studies before May 2016. The quality of the methodological design was assessed with items regarding methodology from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). The systematic review was reported according to the PRISMA guidelines. RESULTS Thirty-two relevant studies were included. None of the reviewed studied fully complied with the CHEERS methodological checklist. Background and objectives, Target population and subgroups and Setting and location were covered in sufficient details in all studies whereas the Study perspective, Justification of the time horizon, Discount rate, and Estimating resources and costs were covered in less than 50%. Most of the studies (29/32) used the health care sector perspective whereas the societal perspective was applied in three studies. The time horizon was stated in 18/32 of the studies. CONCLUSIONS The methodological quality of studies evaluating costs of robotic surgery was low. The longest follow-up was 4 months and in general, the use of detailed cost data were lacking in most of the investigations. Key determinants, such as purchasing, maintenance costs of the robotic platform, and the use of surgical equipment, were rarely reported. If health care cost analyses lack transparency regarding cost drivers included it may not provide a true foundation for decision-making.
Collapse
Affiliation(s)
- Malene Korsholm
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, Odense University Hospital, Clinical Institute, University of Southern Denmark, Odense, Denmark
- Danish Centre for Health Economics (DaCHE), Department of Public Health, University of Southern Denmark, Odense, Denmark
- Clinical Institute, University of Southern Denmark, Odense, Denmark
- Center of Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Clinical Institute, University of Southern Denmark, Odense, Denmark
- Research Unit of Gynecology and Obstetrics, University of Southern Denmark, Odense University Hospital, Kløvervænget 10, 10th Floor, 5000 Odense, Denmark
| | - Jan Sørensen
- Danish Centre for Health Economics (DaCHE), Department of Public Health, University of Southern Denmark, Odense, Denmark
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ole Mogensen
- Department of Pelvic Cancer, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
- Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Chunsen Wu
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, Odense University Hospital, Clinical Institute, University of Southern Denmark, Odense, Denmark
- Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Kamilla Karlsen
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, Odense University Hospital, Clinical Institute, University of Southern Denmark, Odense, Denmark
- Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Pernille T. Jensen
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, Odense University Hospital, Clinical Institute, University of Southern Denmark, Odense, Denmark
- Clinical Institute, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
17
|
[Vaginal hysterectomy in outpatient procedure: Feasibility and satisfaction study]. ACTA ACUST UNITED AC 2018; 46:65-70. [PMID: 29398522 DOI: 10.1016/j.gofs.2017.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To study the feasibility and patient satisfaction for vaginal hysterectomy in a new outpatient procedure. METHODS This retrospective study was directed in CHU de Saint-Étienne, Loire, France. All patient who underwent a vaginal hysterectomy in outpatient procedure were included from January 2014 and January 2017. Descriptive data were collected and all patients were called back for satisfaction study. RESULTS Sixty-five patients were included. Vaginal hysterectomy was performed for 52.3% for pre-menopause bleeding, 24.6% for prolapse, 15.4% for uterine fibroids and 7.6% diverse. Outpatient procedure was performed in 96.9%. Peroperative outcome from Oslo classification were 1.5% for grade 1 and 1.5% for grade 2. Postoperative complications from Clavien-Dindo classification were: 16.9% grade 1 and 6.2% grade 2. Mean postoperative pain scale was 1.02 between H1 and H3 post-operative and 0.84 between H3-H6. Among the patients, 89.2% were very satisfied, 91.9% recommend the same outpatient procedure and 43.2% assumed their daily life since first day postoperative. CONCLUSION Vaginal hysterectomy in outpatient procedure is today's reality. It is a simple, economic, with few postoperative complications and very high satisfaction scores procedure. Standardized procedure, good patient selection and information are necessary to minimize complications.
Collapse
|
18
|
Schmitt JJ, Occhino JA, Weaver AL, McGree ME, Gebhart JB. Vaginal versus Robotic Hysterectomy for Commonly Cited Relative Contraindications to Vaginal Hysterectomy. J Minim Invasive Gynecol 2017; 24:1158-1169. [DOI: 10.1016/j.jmig.2017.06.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 06/28/2017] [Accepted: 06/30/2017] [Indexed: 11/27/2022]
|
19
|
Arm reduced robotic-assisted laparoscopic hysterectomy with transvaginal cuff closure. Wideochir Inne Tech Maloinwazyjne 2017; 12:271-276. [PMID: 29062448 PMCID: PMC5649497 DOI: 10.5114/wiitm.2017.68772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 04/26/2017] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The use of robotics for benign etiology in gynecology has not proven to be more beneficial when compared to traditional laparoscopy. The major concern regarding robotic hysterectomy stems from its high cost. AIM To evaluate the clinical utility and effectiveness of one-arm reduced robotic-assisted laparoscopic hysterectomy as a cost-effective surgical option for total robotic hysterectomy. MATERIAL AND METHODS A sample population of 54 women who underwent robotic-assisted laparoscopic surgery for benign gynecologic indications was evaluated, and two groups were identified: (1) the two-armed robotic-assisted laparoscopic surgery group (n = 38 patients), and (2) the three-armed robotic-assisted laparoscopic surgery group (n = 16 patients). RESULTS An increased cost was observed when three-armed robotic surgery was employed for benign gynecologic surgery (p < 0.001). The cost reduction observed in the study group was primarily derived from one robotic arm reduction and vaginal closure of the cuff. This cost reduction was achieved without an increase in complication rates or undesirable postoperative outcomes. An estimated profit between $399.5 and $421.5 was made for each patient depending on the suture material chosen for cuff closure. Two-armed surgery resulted in an 18.6% reduction in procedure-specific costs for robotic hysterectomy. CONCLUSIONS Two-armed robotic-assisted laparoscopic hysterectomy appears to be a cost-effective solution for robotic gynecologic surgery. This surgical solution can be performed as effectively as classical three-armed robotic hysterectomies for benign indications without the risk of increased surgical-related morbidities. This approach has the potential to be a widely preferred surgical approach in medical communities where cost reduction is one of the primary determinants of surgery type.
Collapse
|
20
|
Health resource utilization and costs during the first 90 days following robot-assisted hysterectomy. Int Urogynecol J 2017; 29:865-872. [DOI: 10.1007/s00192-017-3432-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 07/13/2017] [Indexed: 10/19/2022]
|
21
|
van Weelden WJ, Gordon BBM, Roovers EA, Kraayenbrink AA, Aalders CIM, Hartog F, Dijkhuizen FPHLJ. Perioperative surgical outcome of conventional and robot-assisted total laparoscopic hysterectomy. GYNECOLOGICAL SURGERY 2017; 14:5. [PMID: 28603473 PMCID: PMC5440536 DOI: 10.1186/s10397-017-1008-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/22/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND To evaluate surgical outcome in a consecutive series of patients with conventional and robot assisted total laparoscopic hysterectomy. METHODS A retrospective cohort study was performed among patients with benign and malignant indications for a laparoscopic hysterectomy. Main surgical outcomes were operation room time and skin to skin operating time, complications, conversions, rehospitalisation and reoperation, estimated blood loss and length of hospital stay. RESULTS A total of 294 patients were evaluated: 123 in the conventional total laparoscopic hysterectomy (TLH) group and 171 in the robot TLH group. After correction for differences in basic demographics with a multivariate linear regression analysis, the skin to skin operating time was a significant 18 minutes shorter in robot assisted TLH compared to conventional TLH (robot assisted TLH 92m, conventional TLH 110m, p0.001). The presence or absence of previous abdominal surgery had a significant influence on the skin to skin operating time as did the body mass index and the weight of the uterus. Complications were not significantly different. The robot TLH group had significantly less blood loss and lower rehospitalisation and reoperation rates. CONCLUSIONS This study compares conventional TLH with robot assisted TLH and shows shorter operating times, less blood loss and lower rehospitalisation and reoperation rates in the robot TLH group.
Collapse
Affiliation(s)
- W. J. van Weelden
- Department of Obstetrics and Gynecology, Rijnstate hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Geert Grooteplein-Zuid 22, 6525 GA Nijmegen, The Netherlands
| | - B. B. M. Gordon
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Geert Grooteplein-Zuid 22, 6525 GA Nijmegen, The Netherlands
| | - E. A. Roovers
- Department of Obstetrics and Gynecology, Rijnstate hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - A. A. Kraayenbrink
- Department of Obstetrics and Gynecology, Rijnstate hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - C. I. M. Aalders
- Department of Obstetrics and Gynecology, Rijnstate hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - F. Hartog
- Department of Obstetrics and Gynecology, Rijnstate hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - F. P. H. L. J. Dijkhuizen
- Department of Obstetrics and Gynecology, Rijnstate hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| |
Collapse
|
22
|
Avondstondt AM, Wallenstein M, D’Adamo CR, Ehsanipoor RM. Change in cost after 5 years of experience with robotic-assisted hysterectomy for the treatment of endometrial cancer. J Robot Surg 2017; 12:93-96. [DOI: 10.1007/s11701-017-0700-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 04/16/2017] [Indexed: 10/19/2022]
|
23
|
Schmitt JJ, Carranza Leon DA, Occhino JA, Weaver AL, Dowdy SC, Bakkum-Gamez JN, Pasupathy KS, Gebhart JB. Determining Optimal Route of Hysterectomy for Benign Indications: Clinical Decision Tree Algorithm. Obstet Gynecol 2017; 129:130-138. [PMID: 27926638 PMCID: PMC5217714 DOI: 10.1097/aog.0000000000001756] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy. METHODS A retrospective postrobot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded the laparoscopic hysterectomy route. A prerobot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated. RESULTS Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the prerobot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the postrobot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%) robot-assisted; and 136 (11.4%) abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when a vaginal approach was expected. Robotic hysterectomies had longer operations (141 compared with 59 minutes, P<.001) and higher rates of surgical site infection (4.7% compared with 0.2%, P<.001) and urinary tract infection (8.1% compared with 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years. CONCLUSION When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.
Collapse
Affiliation(s)
- Jennifer J Schmitt
- Divisions of Gynecologic Surgery, Biomedical Statistics and Informatics, Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Liu WF, Shu HH, Zhao GD, Peng SL, Xiao JF, Zhang GR, Liu KX, Huang WQ. Effect of Parecoxib as an Adjunct to Patient-Controlled Epidural Analgesia after Abdominal Hysterectomy: A Multicenter, Randomized, Placebo-Controlled Trial. PLoS One 2016; 11:e0162589. [PMID: 27622453 PMCID: PMC5021366 DOI: 10.1371/journal.pone.0162589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 08/24/2016] [Indexed: 01/04/2023] Open
Abstract
Objective This multicenter, randomized, placebo-controlled study evaluated the efficacy and side effects of parecoxib during patient-controlled epidural analgesia (PCEA) after abdominal hysterectomy. Methods A total of 240 patients who were scheduled for elective abdominal hysterectomy under combined spinal-epidural anesthesia received PCEA plus postoperative intravenous parecoxib 40 mg or saline every 12 h for 48 h after an initial preoperative dose of parecoxib 40 mg or saline. An epidural loading dose of a mixture of 6 mL of 0.25% ropivacaine and 2 mg morphine was administered 30 min before the end of surgery, and PCEA was initiated using 1.25 mg/mL ropivacaine and 0.05 mg/mL morphine with a 2-mL/h background infusion and 2-mL bolus with a 15-min lockout. The primary end point of this study was the quantification of the PCEA-sparing effect of parecoxib. Results Demographic data were similar between the two groups. Patients in the parecoxib group received significantly fewer self-administrated boluses (0 (0, 3) vs. 7 (2, 15), P < 0.001) and less epidural morphine (5.01 ± 0.44 vs. 5.95 ± 1.29 mg, P < 0.001) but experienced greater pain relief compared with the control group (P < 0.001). Patient global satisfaction was higher in the parecoxib group than the control group (P < 0.001). Length of hospitalization (9.50 ± 2.1, 95% CI 9.12~9.88 vs. 10.41 ± 2.6, 95% CI 9.95~10.87, P = 0.003) and postoperative vomiting (17% vs. 29%, P < 0.05) were also reduced in the parecoxib group. There were no serious adverse effects in either group. Conclusion Our data suggest that adjunctive parecoxib during PCEA following abdominal hysterectomy is safe and efficacious in reducing pain, requirements of epidural analgesics, and side effects. Trial Registration ClinicalTrials.gov (NCT01566669)
Collapse
Affiliation(s)
- Wei-Feng Liu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hai-Hua Shu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guo-Dong Zhao
- Department of Anesthesiology, GuangDong General Hospital and GuangDong Academy of Medical Sciences, Guangzhou, China
| | - Shu-Ling Peng
- Department of Anesthesiology, The Second Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jin-Fang Xiao
- Department of Anesthesiology, NanFang Hospital, Guangzhou, China
| | - Guan-Rong Zhang
- Health Management (Examination) Center, GuangDong General Hospital and GuangDong Academy of Medical Sciences, Guangzhou, China
| | - Ke-Xuan Liu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- * E-mail: (WQH); (KXL)
| | - Wen-Qi Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- * E-mail: (WQH); (KXL)
| |
Collapse
|
25
|
Abstract
Although vaginal hysterectomy has long been championed by the American College of Obstetricians and Gynecologists as the preferred mode of uterine removal, nationwide vaginal hysterectomy utilization has steadily declined. This article reviews the evidence comparing vaginal with other modes of hysterectomy and highlights areas of ongoing controversy regarding contraindications to vaginal surgery, risk of subsequent prolapse development, and impacts of changing hysterectomy trends on resident education.
Collapse
|
26
|
Postoperative appointments: which ones count? Int Urogynecol J 2016; 27:1873-1877. [PMID: 27311601 DOI: 10.1007/s00192-016-3052-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Although postoperative complications in women undergoing reconstructive pelvic surgery (RPS) have been characterized, little is known regarding the timeline of these occurrences. We aimed to determine the timeframe after RPS during which the majority of complications occur, to assist with planning intervals between postoperative visits. METHODS Women undergoing RPS were identified through billing information. Demographic, surgical, and complications data were extracted from electronic medical records. The Pelvic Floor Complication scale is a surgical scale tailored to women undergoing RPS. It contains three subscales: intraoperative, immediately postoperative, and delayed complications. We applied this scale to each postoperative visit (at 2, 6, and 13 weeks). RESULTS 396 women underwent RPS and 125 patients had 179 complications, most of which (66 %) were identified by the 2-week visit. Complications at the 2-week visit consisted of urinary tract infection (UTI; 46 %), wound infection (10.0 %), and urinary retention (9.4 %). The majority of serious complications (venous thromboembolism [VTE], ileus, small bowel obstruction [SBO], readmission, and reoperation [1 incarcerated hernia and 1 sling release]) were diagnosed by 2 weeks. One patient was readmitted for ileus at between 2 and 6 weeks. At between 6 and 13 weeks, 1 patient was readmitted with SBO; 1 VTE was diagnosed; and 1 required reoperation for a prolapsed fallopian tube. In contrast, two thirds of the complications seen at the 13-week visit were due to granulation tissue, suture erosion or mesh erosion. CONCLUSIONS The majority of non-mesh-related complications occur within the first 2 weeks after RPS, whereas mesh and suture complications are more likely to be identified at the 13-week visit.
Collapse
|
27
|
Incorporating robotic-assisted surgery for endometrial cancer staging: Analysis of morbidity and costs. Gynecol Oncol 2016; 141:218-224. [DOI: 10.1016/j.ygyno.2016.02.016] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 11/20/2022]
|
28
|
Tandogdu Z, Vale L, Fraser C, Ramsay C. A Systematic Review of Economic Evaluations of the Use of Robotic Assisted Laparoscopy in Surgery Compared with Open or Laparoscopic Surgery. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:457-67. [PMID: 26239361 DOI: 10.1007/s40258-015-0185-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Robot assisted laparoscopic (RAL) surgery developed to overcome the limitations of laparoscopy to assist in surgical procedures, has high capital and operating costs. Systematically assembled evidence demonstrating its clinical and cost effectiveness would be helpful for its adoption by decision makers. OBJECTIVE To summarise the evidence on the cost-effectiveness of robot-assisted laparoscopic (RAL) surgery compared with relevant alternatives. Methods and results of identified studies were assessed to identify the deficiencies in evidence and areas for further research. METHODS Studies reporting both costs and outcomes for comparisons of RAL with laparoscopy and/or open surgery were systematically identified. Searches were conducted in February 2015 on MEDLINE, EMBASE and NHS EED. Quality of the included studies was assessed against a standard checklist for economic analyses. Length of hospital stay and operating time (determinants of cost), cost of intervention, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were extracted. To aid comparison, costs were converted into a common currency and price year (2014 US dollars). RESULTS Forty-seven eligible studies were identified (full economic evaluation n = 6 and cost analysis n = 41). Economic models were used in 11 (23%) studies. Only three studies used a model considered representative of the disease and clinical pathway with a time-horizon allowing capture of relevant differences in outcomes across strategies. The cost of RAL varied substantially between uses, ranging from US$7011 for hysterectomy to over US$30,000 for radical cystectomy. The majority of estimates were between US$15,000 and US$25,000 per person. In part this difference is explained by the difference between studies in which costs were included. It was also identified to have higher costs than the alternatives it was compared against. Incremental cost per QALY for RAL radical prostatectomy was US$28,801-$31,763 over a 10-year period assuming 200 cases per annum. CONCLUSION The clinical evidence available for RAL overall and used within included studies is limited. RAL surgery costs were consistently higher than open and laparoscopic surgery. Therefore, in adopting the robotic technology decision makers need to take into account the cost effectiveness within their own systems. Economic models generated and published for radical prostatectomy and hysterectomy may be adapted to other health systems if the care pathway is similar to provide locally relevant data.
Collapse
Affiliation(s)
- Zafer Tandogdu
- Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK
- Health Economics Group, Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Luke Vale
- Health Economics Group, Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
| |
Collapse
|
29
|
Colling KP, Glover JK, Statz CA, Geller MA, Beilman GJ. Abdominal Hysterectomy: Reduced Risk of Surgical Site Infection Associated with Robotic and Laparoscopic Technique. Surg Infect (Larchmt) 2015; 16:498-503. [PMID: 26070101 DOI: 10.1089/sur.2014.203] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hysterectomy is one of the most common procedures performed in the United States. New techniques utilizing laparoscopic and robotic technology are becoming increasingly common. It is unknown if these minimally invasive surgical techniques alter the risk of surgical site infections (SSI). METHODS We performed a retrospective review of all patients undergoing abdominal hysterectomy at our institution between January 2011 and June 2013. International Classification of Diseases, Ninth edition (ICD-9) codes and chart review were used to identify patients undergoing hysterectomy by open, laparoscopic, or robotic approach and to identify patients who developed SSI subsequently. Chi-square and analysis of variance (ANOVA) tests were used to identify univariate risk factors and logistic regression was used to perform multivariable analysis. RESULTS During this time period, 986 patients were identified who had undergone abdominal hysterectomy, with 433 receiving open technique (44%), 116 laparoscopic (12%), 407 robotic (41%), and 30 cases that were converted from minimally invasive to open (3%). Patients undergoing laparoscopic-assisted hysterectomy were significantly younger and had lower body mass index (BMI) and American Society of Anesthesiologists (ASA) scores than those undergoing open or robotic hysterectomy. There were no significant differences between patients undergoing open versus robotic hysterectomy. The post-operative hospital stay was significantly longer for open procedures compared with those using laparoscopic or robotic techniques (5.1, 1.7, and 1.6 d, respectively; p<0.0001). The overall rate of SSI after all hysterectomy procedures was 4.2%. More SSI occurred in open cases (6.5%) than laparoscopic (0%) or robotic (2.2%) (p<0.0001). Cases converted to open also had an increased rate of SSI (13.3%). In both univariate and multivariable analyses, open technique, wound class of III/IV, age greater than 75 y, and morbid obesity were all associated with increased risk of SSI. CONCLUSION Laparoscopic and robotic hysterectomies were associated with a significantly lower risk of SSI and shorter hospital stays. Body mass index, advanced age, and wound class were also independent risk factors for SSI.
Collapse
Affiliation(s)
- Kristin P Colling
- 1 Department of Surgery, University of Minnesota Medical Center , Minneapolis, Minnesota
| | - James K Glover
- 1 Department of Surgery, University of Minnesota Medical Center , Minneapolis, Minnesota
| | - Catherine A Statz
- 1 Department of Surgery, University of Minnesota Medical Center , Minneapolis, Minnesota
| | - Melissa A Geller
- 2 Department of Obstetrics and Gynecology, University of Minnesota Medical Center , Minneapolis, Minnesota
| | - Greg J Beilman
- 1 Department of Surgery, University of Minnesota Medical Center , Minneapolis, Minnesota
| |
Collapse
|
30
|
Laparoscopic and vaginal approaches to hysterectomy in the obese. Eur J Obstet Gynecol Reprod Biol 2015; 189:85-90. [PMID: 25898369 DOI: 10.1016/j.ejogrb.2015.02.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 02/14/2015] [Accepted: 02/19/2015] [Indexed: 11/17/2022]
|
31
|
Abstract
PURPOSE OF REVIEW To analyze the recent evidence on robotic hysterectomy while highlighting its benefits and challenges. RECENT FINDINGS Increased rates of robotic hysterectomy have led to decreasing rates of abdominal hysterectomy, after rates of the latter approach have been stagnant for many years. Robotic surgery has also the possible advantage of a relatively short learning curve, even though the case number required to reach proficiency may be actually closer to 100 cases. Recent studies comparing robotic and laparoscopic hysterectomy for benign indications have not demonstrated a clear advantage for either approach in terms of complications, blood loss, and hospital stay. The higher cost of robotic hysterectomy remains a significant disadvantage of this surgical approach, although the total cost may decrease with increasing surgeon's experience (via shorter operative time) and may be offset in some circumstances by reduced hospital stay and cost of complications compared with abdominal hysterectomy. SUMMARY The place of robotic hysterectomy in the gynecologic surgical armamentarium is still evolving. Although recent studies highlight the comparative outcomes of robotic and laparoscopic hysterectomy for benign cases, most surgeons are unlikely to be equally proficient in both techniques. Future studies will need to question whether subgroups of patients with complex benign disease such as endometriosis and pelvic adhesive disease may benefit from the robotic assistance.
Collapse
|
32
|
Laparoscopic versus vaginal hysterectomy for benign indications in women aged 65 years or older. Menopause 2015; 22:32-5. [PMID: 24977457 DOI: 10.1097/gme.0000000000000263] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
33
|
The Outcomes and Cost of Hysterectomy: Comparing Abdominal, Vaginal, Laparoscopic, and Robotic Approaches. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2014. [DOI: 10.1007/s13669-014-0098-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|