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McCall SJ, Mansour S, Khazaal J, Kayem G, DeJong J, Chahine R. Obstetric and haematological management and outcomes of women with placenta accreta spectrum by planned or urgent delivery: Secondary data analysis of a public referral hospital in Lebanon. PLoS One 2024; 19:e0302366. [PMID: 38718031 PMCID: PMC11078361 DOI: 10.1371/journal.pone.0302366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Lebanon has a high caesarean section use and consequently, placenta accreta spectrum (PAS) is becoming more common. OBJECTIVES To compare maternal characteristics, management, and outcomes of women with PAS by planned or urgent delivery at a major public referral hospital in Lebanon. DESIGN Secondary data analysis of prospectively collected data. SETTING Rafik Hariri University Hospital (public referral hospital), Beirut, Lebanon. PARTICIPANTS 159 pregnant and postpartum women with confirmed PAS between 2007-2020. MAIN OUTCOME MEASURES Maternal characteristics, management, and maternal and neonatal outcomes. RESULTS Out of the 159 women with PAS included, 107 (67.3%) underwent planned caesarean delivery and 52 (32.7%) had urgent delivery. Women who underwent urgent delivery for PAS management were more likely to experience antenatal vaginal bleeding compared to those in the planned group (55.8% vs 28.0%, p<0.001). Median gestational age at delivery was significantly lower for the urgent group compared to the planned (34 vs. 36 weeks, p<0.001). There were no significant differences in terms of blood transfusion rates and major maternal morbidity between the two groups; however, median estimated blood loss was significantly higher for women with urgent delivery (1500ml vs. 1200ml, p = 0.011). Furthermore, the urgent delivery group had a significantly lower birth weight (2177.5g vs. 2560g, p<0.001) with higher rates of neonatal intensive care unit (NICU) admission (53.7% vs 23.8%, p<0.001) and perinatal mortality (18.5% vs 3.8%, p = 0.005). CONCLUSION Urgent delivery among women with PAS is associated with worse maternal and neonatal outcomes compared to the planned approach. Therefore, early referral of women with known or suspected PAS to specialized centres is highly desirable to maximise optimal outcomes for both women and infants.
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Affiliation(s)
- Stephen J. McCall
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Sara Mansour
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Janoub Khazaal
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon
| | - Gilles Kayem
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
- Paris University, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Paediatric Epidemiology Research Team, EPOPé, INSERM, Paris, France
- Department of Obstetrics and Gynecology, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jocelyn DeJong
- Faculty of Health Sciences, Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
| | - Rabih Chahine
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon
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Terplan M. Asleep at the wheel: leadership in obstetrics and gynecology. Am J Obstet Gynecol 2024; 230:103. [PMID: 37572836 DOI: 10.1016/j.ajog.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/26/2023] [Accepted: 08/07/2023] [Indexed: 08/14/2023]
Affiliation(s)
- Mishka Terplan
- Friends Research Institute Inc, 1040 Park Ave, Baltimore 21201, CA.
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Tummers FHMP, Peltenburg SI, Metzemaekers J, Jansen FW, Blikkendaal MD. Evaluation of the effect of previous endometriosis surgery on clinical and surgical outcomes of subsequent endometriosis surgery. Arch Gynecol Obstet 2023; 308:1531-1541. [PMID: 37639036 PMCID: PMC10520192 DOI: 10.1007/s00404-023-07193-4] [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: 05/23/2023] [Accepted: 08/13/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE Patients often undergo repeat surgery for endometriosis, due to recurrent or residual disease. Previous surgery is often considered a risk factor for worse surgical outcome. However, data are scarce concerning the influence of subsequent endometriosis surgery. METHODS A retrospective study in a centre of expertise for endometriosis was conducted. All endometriosis subtypes and intra-operative steps were included. Detailed information regarding surgical history of patients was collected. Surgical time, intra-operative steps and major post-operative complications were obtained as outcome measures. RESULTS 595 patients were included, of which 45.9% had previous endometriosis surgery. 7.9% had major post-operative complications and 4.4% intra-operative complications. The patient journey showed a median of 3 years between previous endometriosis surgeries. Each previous therapeutic laparotomic surgery resulted on average in 13 additional minutes (p = 0.013) of surgical time. Additionally, it resulted in more frequent performance of adhesiolysis (OR 2.96, p < 0.001) and in a higher risk for intra-operative complications (OR 1.81, p = 0.045), however no higher risk for major post-operative complications (OR 1.29, p = 0.418). Previous therapeutic laparoscopic endometriosis surgery, laparotomic and laparoscopic non-endometriosis surgery showed no association with surgical outcomes. Regardless of previous surgery, disc and segmental bowel resection showed a higher risk for major post-operative complications (OR 3.64, p = 0.017 respectively OR 3.50, p < 0.001). CONCLUSION Previous therapeutic laparotomic endometriosis surgery shows an association with longer surgical time, the need to perform adhesiolysis, and more intra-operative complications in the subsequent surgery for endometriosis. However, in a centre of expertise with experienced surgeons, no increased risk of major post-operative complications was observed.
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Affiliation(s)
| | - Sophie I Peltenburg
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen Metzemaekers
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frank Willem Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Mathijs D Blikkendaal
- Endometriosis Center, Haaglanden Medical Center, The Hague, The Netherlands
- Nederlandse Endometriose Kliniek, Reinier de Graaf Hospital, Delft, The Netherlands
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Wieslander CK, Grimes CL, Balk EM, Hobson DTG, Ringel NE, Sanses TVD, Singh R, Richardson ML, Lipetskaia L, Gupta A, White AB, Orejuela F, Meriwether K, Antosh DD. Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review. Obstet Gynecol 2023; 142:1044-1054. [PMID: 37826848 DOI: 10.1097/aog.0000000000005389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/30/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications. DATA SOURCES PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022. METHODS OF STUDY SELECTION The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies. TABULATION, INTEGRATION, AND RESULTS Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy. CONCLUSION Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021234511.
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Affiliation(s)
- Cecilia K Wieslander
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California; the Division of Urogynecology & Reconstructive Pelvic Surgery, Departments of Obstetrics and Gynecology and Urology, New York Medical College, Valhalla, New York; the Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, Michigan; the Division of Urogynecology & Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Howard University College of Medicine, Washington, DC; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Florida Health, Jacksonville, Florida; Occom Health, Newton, Massachusetts; the Division of Urogynecology & Reconstructive Pelvic Surgery, Cooper Health University, Cooper Medical School at Rowan University, Camden, New Jersey; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Louisville Health, Louisville, Kentucky; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Texas at Austin Dell Medical School, Austin, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Baylor College of Medicine, the Division of Urogynecology, Department of Obstetrics & Gynecology, Houston Methodist Hospital, Houston, Texas; and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of New Mexico, Albuquerque, New Mexico
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Temkin SM, Terplan M. Levels of Gynecologic Care: A Task Force Consensus Statement. Obstet Gynecol 2023; 142:993-994. [PMID: 37734102 DOI: 10.1097/aog.0000000000005363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
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Breitkopf D, Banks E, Chelmow D, Lara-Torre E, McCue K, Ogburn T, Pfeifer S, Anderson T, Valea FA. Levels of Gynecologic Care: A Task Force Consensus Statement. Obstet Gynecol 2023; 141:1036-1045. [PMID: 37486649 DOI: 10.1097/aog.0000000000005173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/16/2023] [Indexed: 07/25/2023]
Abstract
Systems of care have been established for obstetrics, trauma, and neonatology. An American College of Obstetricians and Gynecologists Presidential Task Force was established to develop a care system for gynecologic surgery. A group of experts who represent diverse perspectives in gynecologic practice proposed definitions of levels of gynecologic care using the Delphi method. The goal is to improve the quality of gynecologic surgical care performed in the United States by providing a framework of minimal institutional requirements for each level. Subgroups developed draft criteria for each level of care. The entire Task Force then met to reach consensus regarding the levels of care final definitions and parameters. The levels of gynecologic care framework focuses on systems of care by considering institutional resources and expertise, providing guidance on the provision of care in appropriate level facilities. These levels were defined by the ability to care for patients of increasing risk, complexity, and comorbidities, organizing gynecologic care around hospital capability. This framework can also be used to inform the escalation of care to appropriate facilities by identifying patients at risk and guiding them to facilities with the skills, expertise, and capabilities to safely and effectively meet their needs. The levels of gynecologic care framework is intended for use by patients, hospitals, and clinicians in the United States to guide where elective surgery can be done most safely and effectively by specialists and subspecialists in obstetrics and gynecology. The key features of the levels of gynecologic care include ensuring provision of risk-appropriate care and regionalization of care by facility capabilities.
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Affiliation(s)
- Daniel Breitkopf
- Departments of Obstetrics and Gynecology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, New York University Long Island School of Medicine, Mineola, New York, Virginia Commonwealth University School of Medicine, Richmond, Virginia, Virginia Tech-Carilion School of Medicine, Roanoke, Virginia, Kaiser Permanente Medical Center, Sacramento, California, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, Weill-Cornell School of Medicine, New York, New York, Vanderbilt School of Medicine, Nashville, Tennessee, and Zucker School of Medicine/Northwell Health Cancer Institute, New Hyde Park, New York
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7
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Whiteside JL, Tumin D, Hohmann SF, Harris A. Determinants of Cost for Outpatient Hysterectomy for Benign Indications in a Nationwide Sample. Obstet Gynecol 2023; 141:765-772. [PMID: 36897129 DOI: 10.1097/aog.0000000000005109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/22/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To identify surgeon-level variation in cost to produce an outpatient hysterectomy for benign indications in the United States. METHODS A sample of patients undergoing outpatient hysterectomy in October 2015 to December 2021, excluding those with a diagnosis of gynecologic malignancy, was obtained from the Vizient Clinical Database. The primary outcome was total direct hysterectomy cost, which is a modeled cost to produce care. Patient, hospital, and surgeon covariates were analyzed with mixed-effects regression, which included surgeon-level random effects to capture unobserved differences influencing cost variation. RESULTS The final sample included 264,717 cases performed by 5,153 surgeons. The median total direct cost of hysterectomy was $4,705 (interquartile range $3,522-6,234). Cost was highest for robotic hysterectomy ($5,412) and lowest for vaginal hysterectomy ($4,147). After all variables were included in the regression model, approach was the strongest of the observed predictors, but 60.5% of the variance in costs was attributable to unexplained surgeon-level differences, implying a difference in costs between the 10th and 90th percentiles of surgeons of $4,063. CONCLUSION The largest observed determinant of cost to produce an outpatient hysterectomy for benign indications in the United States is approach, but differences in cost are attributable primarily to unexplained differences among surgeons. Standardization of surgical approach and technique and surgeon awareness of surgical supply costs could address these unexplained cost variations.
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Affiliation(s)
- James L Whiteside
- Department of Obstetrics and Gynecology and the Department of Pediatrics, East Carolina University, Brody School of Medicine, Greenville, North Carolina, and Vizient Inc, Center for Advanced Analytics and Informatics, and the Department of Health Systems Management, Rush University, Chicago, Illinois
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Warring SK, Narasimhulu DM, Kumar A, Langstraat CL, Weaver AL, McGree ME, Cliby WA. Next Steps Toward Reducing Surgical Morbidity After Complex Cytoreductive Surgery in Fit Surgical Patients. J Gynecol Surg 2023. [DOI: 10.1089/gyn.2022.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Affiliation(s)
- Simrit K. Warring
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amanika Kumar
- Division of Gynecologic Oncology, and Rochester, Minnesota, USA
| | | | - Amy L. Weaver
- Division of Clinical Trials and Biostatistics, Rochester, Minnesota, USA
| | - Michaela E. McGree
- Division of Clinical Trials and Biostatistics, Rochester, Minnesota, USA
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Ha B, Morrill MY, Salim AM, Stram D, Weiss E. Differences in Surgical Complications for Stage 1 Phalloplasty With Concurrent Versus Asynchronous Hysterectomy in Transmasculine Patients. Perm J 2022; 26:49-55. [PMID: 36245082 PMCID: PMC9761287 DOI: 10.7812/tpp/22.054] [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: 01/25/2023]
Abstract
Background The authors sought to compare the perioperative morbidity of Stage 1 phalloplasty with asynchronous vs concurrent hysterectomy among transmasculine patients. Methods This retrospective study included transmasculine patients undergoing Stage 1 phalloplasty with either asynchronous or concurrent hysterectomy at Kaiser Permanente Northern California from January 1, 2017, to September 9, 2019. The primary outcome was differences in surgical site infection rates. Secondary outcomes included perioperative and other postoperative complications. Comparisons of demographics and outcomes were made by F-tests and Fisher's exact tests. A p value of < 0.05 was considered statistically significant. Results Of 66 transmasculine patients undergoing Stage 1 phalloplasty, 32 (48%) had an asynchronous hysterectomy and 34 (52%) had a concurrent hysterectomy. Overall, surgical site infection rates were low, and there were no significant differences between groups. Patients who had undergone asynchronous hysterectomy had more neourethral complications with Stage 1 phalloplasty than those undergoing concurrent procedures (28% vs 3%, p < 0.05). There were no significant differences in estimated blood loss, length of stay, urinary tract infection, overactive bladder or narcotic use between groups. Conclusion Overall, there were no differences between groups in most postoperative complication rates. Although more neourethral complications were found in those undergoing asynchronous hysterectomy prior to Stage I phalloplasty, this may be partially explained by increasing surgeon experience over time given this difference did not remain statistically significant after the first year of the study period. Gynecologists seeking to provide comprehensive and inclusive care to transmasculine patients should take these findings into consideration when counseling patients planning genital gender affirmation surgery.
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Affiliation(s)
- Barbara Ha
- 1Obstetrics & Gynecology, Kaiser Permanente, San Francisco, CA, USA,Barbara Ha, MD, MSPH
| | - Michelle Y Morrill
- 2Female Pelvic Medicine & Reconstructive Surgery, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Ali M Salim
- 3Plastic Surgery, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Douglas Stram
- 4Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Erica Weiss
- 5Obstetrics & Gynecology, Kaiser Permanente Northern California, San Francisco, CA, USA
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Madhvani K, Garcia SF, Fernandez-Felix BM, Zamora J, Carpenter T, Khan KS. Predicting major complications in patients undergoing laparoscopic and open hysterectomy for benign indications. CMAJ 2022; 194:E1306-E1317. [PMID: 36191941 PMCID: PMC9529570 DOI: 10.1503/cmaj.220914] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Hysterectomy, the most common gynecological operation, requires surgeons to counsel women about their operative risks. We aimed to develop and validate multivariable logistic regression models to predict major complications of laparoscopic or abdominal hysterectomy for benign conditions. METHODS We obtained routinely collected health administrative data from the English National Health Service (NHS) from 2011 to 2018. We defined major complications based on core outcomes for postoperative complications including ureteric, gastrointestinal and vascular injury, and wound complications. We specified 11 predictors a priori. We used internal-external cross-validation to evaluate discrimination and calibration across 7 NHS regions in the development cohort. We validated the final models using data from an additional NHS region. RESULTS We found that major complications occurred in 4.4% (3037/68 599) of laparoscopic and 4.9% (6201/125 971) of abdominal hysterectomies. Our models showed consistent discrimination in the development cohort (laparoscopic, C-statistic 0.61, 95% confidence interval [CI] 0.60 to 0.62; abdominal, C-statistic 0.67, 95% CI 0.64 to 0.70) and similar or better discrimination in the validation cohort (laparoscopic, C-statistic 0.67, 95% CI 0.65 to 0.69; abdominal, C-statistic 0.67, 95% CI 0.65 to 0.69). Adhesions were most predictive of complications in both models (laparoscopic, odds ratio [OR] 1.92, 95% CI 1.73 to 2.13; abdominal, OR 2.46, 95% CI 2.27 to 2.66). Other factors predictive of complications included adenomyosis in the laparoscopic model, and Asian ethnicity and diabetes in the abdominal model. Protective factors included age and diagnoses of menstrual disorders or benign adnexal mass in both models and diagnosis of fibroids in the abdominal model. INTERPRETATION Personalized risk estimates from these models, which showed moderate discrimination, can inform clinical decision-making for people with benign conditions who may require hysterectomy.
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Affiliation(s)
- Krupa Madhvani
- Barts and the London School of Medicine and Dentistry (Madhvani), Queen Mary University of London, London, UK; University Hospitals Dorset (Carpenter), NHS Foundation Trust, UK; Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS) (Fernandez Garcia, Fernandez-Felix, Zamora); CIBER Epidemiology and Public Health (Fernandez-Felix, Zamora, Khan), Madrid, Spain; WHO Collaborating Centre for Global Women's Health (Zamora), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Department of Preventative Medicine and Public Health (Khan), Faculty of Medicine, University of Granada, Spain
| | - Silvia Fernandez Garcia
- Barts and the London School of Medicine and Dentistry (Madhvani), Queen Mary University of London, London, UK; University Hospitals Dorset (Carpenter), NHS Foundation Trust, UK; Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS) (Fernandez Garcia, Fernandez-Felix, Zamora); CIBER Epidemiology and Public Health (Fernandez-Felix, Zamora, Khan), Madrid, Spain; WHO Collaborating Centre for Global Women's Health (Zamora), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Department of Preventative Medicine and Public Health (Khan), Faculty of Medicine, University of Granada, Spain
| | - Borja M Fernandez-Felix
- Barts and the London School of Medicine and Dentistry (Madhvani), Queen Mary University of London, London, UK; University Hospitals Dorset (Carpenter), NHS Foundation Trust, UK; Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS) (Fernandez Garcia, Fernandez-Felix, Zamora); CIBER Epidemiology and Public Health (Fernandez-Felix, Zamora, Khan), Madrid, Spain; WHO Collaborating Centre for Global Women's Health (Zamora), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Department of Preventative Medicine and Public Health (Khan), Faculty of Medicine, University of Granada, Spain
| | - Javier Zamora
- Barts and the London School of Medicine and Dentistry (Madhvani), Queen Mary University of London, London, UK; University Hospitals Dorset (Carpenter), NHS Foundation Trust, UK; Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS) (Fernandez Garcia, Fernandez-Felix, Zamora); CIBER Epidemiology and Public Health (Fernandez-Felix, Zamora, Khan), Madrid, Spain; WHO Collaborating Centre for Global Women's Health (Zamora), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Department of Preventative Medicine and Public Health (Khan), Faculty of Medicine, University of Granada, Spain
| | - Tyrone Carpenter
- Barts and the London School of Medicine and Dentistry (Madhvani), Queen Mary University of London, London, UK; University Hospitals Dorset (Carpenter), NHS Foundation Trust, UK; Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS) (Fernandez Garcia, Fernandez-Felix, Zamora); CIBER Epidemiology and Public Health (Fernandez-Felix, Zamora, Khan), Madrid, Spain; WHO Collaborating Centre for Global Women's Health (Zamora), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Department of Preventative Medicine and Public Health (Khan), Faculty of Medicine, University of Granada, Spain
| | - Khalid S Khan
- Barts and the London School of Medicine and Dentistry (Madhvani), Queen Mary University of London, London, UK; University Hospitals Dorset (Carpenter), NHS Foundation Trust, UK; Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS) (Fernandez Garcia, Fernandez-Felix, Zamora); CIBER Epidemiology and Public Health (Fernandez-Felix, Zamora, Khan), Madrid, Spain; WHO Collaborating Centre for Global Women's Health (Zamora), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Department of Preventative Medicine and Public Health (Khan), Faculty of Medicine, University of Granada, Spain
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Accuracy of Surgeon Self-Reflection on Hysterectomy Quality Metrics. Obstet Gynecol 2022; 140:39-47. [DOI: 10.1097/aog.0000000000004841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/13/2022] [Indexed: 11/27/2022]
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Very Low Rates of Ureteral Injury in Laparoscopic Hysterectomy Performed by Fellowship-Trained Minimally Invasive Gynecologic Surgeons. J Minim Invasive Gynecol 2022; 29:1099-1103. [PMID: 35691546 DOI: 10.1016/j.jmig.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/31/2022] [Accepted: 06/04/2022] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE The objective of this case series is to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons. DESIGN A retrospective chart review was performed, evaluating laparoscopic hysterectomy cases between 2009-2019 performed exclusively by fellowship-trained surgeons. SETTING Division of Minimally Invasive Gynecologic Surgery (MIGS) at the Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital, a Harvard Medical School teaching hospital in Boston. PATIENTS All patients undergoing laparoscopic hysterectomy by one of five surgeons with fellowship training in Minimally Invasive Gynecologic Surgery (MIGS). INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS: A total of 5,160 cases were performed by MIGS surgeons between 2009-2019 at our institution. Out of these cases, 2,345 were laparoscopic hysterectomy cases with available intraoperative and postoperative documentation. Most patients had prior surgeries and the most common indications for hysterectomy included uterine fibroids, pelvic pain/endometriosis, and abnormal uterine bleeding. At the time of hysterectomy, 1 ureteral injury (0.04%) was noted. No additional delayed ureteral injuries were observed. The majority of patients were discharged home the same day (64.9%) and did not have any postoperative complications (63.9%) as designated by the Clavien-Dindo classification. CONCLUSION Ureteral injury, while rare, is more prevalent in gynecologic surgery as compared to other surgical disciplines that have some focus in the pelvis. No study to date has evaluated the effect of surgical training and volume on rates of ureteral injuries. This study retrospectively examined ureteral injury rates for one group of high-volume fellowship-trained surgeons and found their rates to be lower than the national average. Proposals are presented for optimizing training and delivery of gynecologic surgical care to minimize complications.
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Hong CX, Kamdar NS, Morgan DM. Predictors of same-day discharge following benign minimally invasive hysterectomy. Am J Obstet Gynecol 2022; 227:320.e1-320.e9. [PMID: 35580633 DOI: 10.1016/j.ajog.2022.05.026] [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: 01/03/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Same-day discharge following minimally invasive hysterectomy has been shown to be safe and feasible in select populations, but many nonclinical factors influencing same-day discharge remain unexplored. OBJECTIVE To develop prediction models for same-day discharge following minimally invasive hysterectomy using both clinical and nonclinical attributes and to compare model concordance of individual attribute groups. STUDY DESIGN We performed a retrospective study of patients who underwent elective minimally invasive hysterectomy for benign gynecologic indications at 69 hospitals in a statewide quality improvement collaborative between 2012 and 2019. Potential predictors of same-day discharge were determined a priori and placed into 1 of 7 attribute groupings: intraoperative, surgeon, hospital, surgical timing, patient clinical, patient socioeconomic, and patient geographic attributes. To account for clustering of same-day discharge practices among surgeons and within hospitals, hierarchical multivariable logistic regression models were fitted using predictors from each attribute group individually and all predictors in a composite model. Receiver operator characteristic curves were generated for each model. The Hanley-McNeil test was used for comparisons, 95% confidence intervals for the areas under the receiver operator characteristic curve were calculated, and a P value of <.05 was considered significant. RESULTS Of the 23,513 patients in our study, 5062 (21.5%) had same-day discharge. The composite model had an area under the receiver operator characteristic curve of 0.770 (95% confidence interval, 0.763-0.777). Among models using factors from individual attribute groups, the model using intraoperative attributes had the highest concordance for same-day discharge (area under the receiver operator characteristic curve, 0.720; 95% confidence interval, 0.712-0.727). The models using surgeon and hospital attributes were the second and third most concordant, respectively (area under the receiver operator characteristic curve, 0.678; 95% confidence interval, 0.670-0.685; area under the receiver operator characteristic curve, 0.655; 95% confidence interval, 0.656-0.664). Models using surgical timing and patient clinical, socioeconomic, and geographic attributes had poor predictive ability (all areas under the receiver operator characteristic curve <0.6). CONCLUSION Clinical and nonclinical attributes contributed to a composite prediction model with good discrimination in predicting same-day discharge following minimally invasive hysterectomy. Factors related to intraoperative, hospital, and surgeon attributes produced models with the strongest predictive ability. Focusing on these attributes may aid efforts to improve utilization of same-day discharge following minimally invasive hysterectomy.
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14
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McCormack L, Nesbitt-Hawes E, Deans R, Alonso A, Lim C, Li F, Knapman B, Abbott JA. A review of gynaecological surgical practices for trainees and certified specialists in Australia by volume using MBS and AIHW databases. Aust N Z J Obstet Gynaecol 2022; 62:574-580. [PMID: 35474508 PMCID: PMC9542106 DOI: 10.1111/ajo.13523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a finite volume of surgery performed annually by trainees and certified specialists alike. The detailed assessment of this surgical substrate is important, since it guides true exposure in gynaecological surgical training and practice after fellowship. AIMS This study quantifies the volume and profile of major gynaecological surgical procedures performed in Australia within a specified five-year period and discusses the implications for training and practice. MATERIALS AND METHODS Australian Institute of Health and Welfare data were examined to quantify the total number of major gynaecological procedures performed between 2013 and 2018. Medicare data were analysed to quantify the number of billed procedures. These data were compared with published Australian RANZCOG trainees and operative gynaecologists, to estimate the potential annual average exposure for each procedure. RESULTS Major open, laparoscopic and vaginal surgeries constitute less than 27% of the 600 000 gynaecological procedures performed annually in Australia. Most major gynaecological surgeries are performed at rates lower than 12 cases per year for both trainees and specialists. Over the study period, laparotomies, vaginal hysterectomies and continence procedures decreased, and operative laparoscopies and laparoscopic hysterectomies increased. CONCLUSIONS The volume of available major gynaecological procedures in Australia may not allow sufficient exposure for optimal training and practice for all trainees and specialists in operative gynaecology. This shortfall may compromise the ability to obtain and maintain proficiency in some core gynaecological operative procedures.
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Affiliation(s)
- Lalla McCormack
- Gynaecologic Research and Clinical Evaluation (GRACE) group, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Erin Nesbitt-Hawes
- Gynaecologic Research and Clinical Evaluation (GRACE) group, Royal Hospital for Women, Sydney, New South Wales, Australia.,School of Clinical Medicine, UNSW, Sydney, New South Wales, Australia
| | - Rebecca Deans
- Gynaecologic Research and Clinical Evaluation (GRACE) group, Royal Hospital for Women, Sydney, New South Wales, Australia.,School of Clinical Medicine, UNSW, Sydney, New South Wales, Australia
| | - Anais Alonso
- Gynaecologic Research and Clinical Evaluation (GRACE) group, Royal Hospital for Women, Sydney, New South Wales, Australia.,School of Clinical Medicine, UNSW, Sydney, New South Wales, Australia
| | - Claire Lim
- Gynaecologic Research and Clinical Evaluation (GRACE) group, Royal Hospital for Women, Sydney, New South Wales, Australia.,School of Clinical Medicine, UNSW, Sydney, New South Wales, Australia
| | - Fiona Li
- Gynaecologic Research and Clinical Evaluation (GRACE) group, Royal Hospital for Women, Sydney, New South Wales, Australia.,School of Clinical Medicine, UNSW, Sydney, New South Wales, Australia
| | - Blake Knapman
- Gynaecologic Research and Clinical Evaluation (GRACE) group, Royal Hospital for Women, Sydney, New South Wales, Australia.,School of Clinical Medicine, UNSW, Sydney, New South Wales, Australia
| | - Jason A Abbott
- Gynaecologic Research and Clinical Evaluation (GRACE) group, Royal Hospital for Women, Sydney, New South Wales, Australia.,School of Clinical Medicine, UNSW, Sydney, New South Wales, Australia
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15
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McCall SJ, Deneux-Tharaux C, Sentilhes L, Ramakrishnan R, Collins SL, Seco A, Kurinczuk JJ, Knight M, Kayem G. Placenta accreta spectrum - variations in clinical practice and maternal morbidity between the UK and France: a population-based comparative study. BJOG 2022; 129:1676-1685. [PMID: 35384244 PMCID: PMC9544707 DOI: 10.1111/1471-0528.17169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/15/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022]
Abstract
Objective To compare the management and outcomes of women with placenta accreta spectrum (PAS) in France and the UK. Design Two population‐based cohorts. Setting All obstetrician‐led hospitals in the UK and maternity hospitals in eight French regions. Population A cohort of 219 women with PAS in France and a cohort of 154 women with PAS in the UK. Methods The management and outcomes of women with PAS were compared between the UK and France. Main outcome measures Median blood loss, severe postpartum haemorrhage (≥3 l), postpartum infection and damage to surrounding organs. Results The management of PAS differed between the two countries: a larger proportion of women with PAS in the UK had a caesarean hysterectomy compared with France (43% vs 26%, p < 0.001), whereas in France a larger proportion of women with PAS received a uterus‐preserving approach compared with the UK (36% vs 19%, p < 0.001). The total median blood loss in the UK was 3 l (IQR 1.7–6.5 l), compared with 1 l (IQR 0.5–2.5 l) in France; more women with PAS had a severe postpartum haemorrhage (PPH) in the UK compared with women with PAS in France (58% vs 21%, p < 0.001) [Correction added on 06 May 2022, after first online publication: ‘24 hour’ has been changed to ‘total’ in the preceding sentence]. There was no difference between the UK and French populations for postpartum infection or organ damage. Conclusions The UK and France have very different approaches to managing PAS, with more women in France receiving a uterine‐conserving approach and more women in the UK undergoing caesarean hysterectomy. A life‐threatening haemorrhage was more common in the UK than in France, which may be the result of differential management and/or the organisation of the healthcare systems. In women with placenta accreta spectrum, severe haemorrhage was more common in the UK than in France. Tweetable abstract In women with placenta accreta spectrum, severe haemorrhage was more common in the UK than in France. In women with placenta accreta spectrum, severe haemorrhage was more common in the UK than in France. Linked article: This article is commented on by Amarnath Bhide, pp. 1686 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471-0528.17170.
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Affiliation(s)
- Stephen J McCall
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Université de Paris, CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris, France.,Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Catherine Deneux-Tharaux
- Université de Paris, CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK.,Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
| | - Aurélien Seco
- Clinical Research Unit, Paris-Descartes Necker/Cochin, Paris, France
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Gilles Kayem
- Université de Paris, CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris, France.,Hôpital Trousseau, Assistance Publique -Hôpitaux de Paris (APHP), Sorbonne Université, Paris, France
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16
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Gender Equity in Gynecologic Surgery: Lessons from History, Strengthening the Future. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00307-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Minimally invasive hysterectomy for benign indications-surgical volume matters: a retrospective cohort study comparing complications of robotic-assisted and conventional laparoscopic hysterectomies. J Robot Surg 2022; 16:1199-1207. [PMID: 34981444 DOI: 10.1007/s11701-021-01340-2] [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: 09/21/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022]
Abstract
The objective of this study was to evaluate the incidence of perioperative complications in robotic-assisted hysterectomies performed by high-volume robotic surgeons compared to conventional laparoscopic hysterectomies performed by all gynecologic surgeons. This retrospective cohort study was performed at a single-center community based hospital and medical center. A total of 332 patients who underwent hysterectomy for benign indications were included in this study. Half of these patients (n = 166) underwent conventional laparoscopic hysterectomy and the other half underwent a robotic-assisted laparoscopic hysterectomy. The main outcome measures included composite complication rate, estimated blood loss (EBL), and hospital length of stay (LOS). Median (IQR) EBL was significantly lower for robotic hysterectomy [22.5 (30) mL] compared to laparoscopic hysterectomy [100 (150) mL, p < 0.0001]. LOS was significantly shorter for robotic hysterectomy (1.0 ± 0.2 day) compared to laparoscopic hysterectomy (1.2 ± 0.7 days, p = 0.04). Despite averaging 3.0 (IQR 1.0) concomitant procedures compared to 0 (IQR 1.0) for the conventional laparoscopic hysterectomies, the incidence of any type of complication was lower in the robotic hysterectomy group (2 vs. 6%, p = 0.05). Finally, in a logistic regression model controlling for multiple confounders, robotic-assisted hysterectomy was less likely to result in a perioperative complication compared to traditional laparoscopic hysterectomy [odds ratio (95% CI) = 0.2 (0.1, 0.90), p = 0.04]. In conclusion, robotic-assisted hysterectomy may reduce complications compared with conventional laparoscopic hysterectomy when performed by high volume surgeons, especially in the setting of other concomitant gynecologic surgeries.
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18
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Madhvani K, Fernandez-Felix BM, Zamora J, Carpenter T, Khan KS. Personalising the risk of conversion from laparoscopic to open hysterectomy in benign conditions: Development and external validation of risk prediction models. BJOG 2021; 129:1141-1150. [PMID: 34877785 DOI: 10.1111/1471-0528.17043] [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: 06/25/2021] [Revised: 09/24/2021] [Accepted: 10/06/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To develop and validate novel prediction models to personalise the risk of conversion from laparoscopic to open hysterectomy in benign conditions. DESIGN Retrospective cohort study. SETTINGS English NHS Hospitals between 2011 and 2018. POPULATION 68 752 women undergoing laparoscopic hysterectomy for benign conditions. METHODS We developed two multivariable logistic models using readily available clinical information, one for the pre-operative setting and another for operative decision-making using additional surgical information, using 2011-2016 data in five regions (24 806 women). We validated them (a) temporally in the same regions using 2017-2018 data (12 438 women); (b) geographically in the same time-period using data from three different regions (22 024 women); and (c) temporally and geographically using 2017-2018 data in three different regions (9484 women). MAIN OUTCOME MEASURES Conversion from laparoscopic to open hysterectomy. RESULTS Conversions occurred in 6.8% (1687/24 806) of hysterectomies in the development group, and in 5.5% (681/12 438) in the temporal, 5.9% (1297/22 204) in the geographical and 5.2% (488/9484) in the temporal and geographical validation groups. In the development cohort, the area under the receiver operating characteristic curve values for the pre-operative and operative models were 0.65 and 0.67, respectively. In the validation cohorts the corresponding values were 0.65 and 0.66 (temporal), 0.66 and 0.68 (geographical) and 0.65 and 0.68 (temporal and geographical), respectively. Factors predictive of conversion included age, Asian ethnicity, obesity, fibroids, adenomyosis, endometriosis and adhesions. Adhesions were the most predictive (odds ratio 2.54, 95% confidence interval 2.22-2.90). CONCLUSION The models for predicting conversions showed acceptable performance and transferability. TWEETABLE ABSTRACT Novel tool to personalise the risk of conversion from laparoscopic to open hysterectomy in benign conditions.
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Affiliation(s)
- Krupa Madhvani
- Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Borja M Fernandez-Felix
- Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS) and CIBER Epidemiology and Public Health, Madrid, Spain
| | - Javier Zamora
- Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS) and CIBER Epidemiology and Public Health, Madrid, Spain
| | | | - Khalid S Khan
- Department of Preventative Medicine and Public Health, Faculty of Medicine, University of Granada, Granada, Spain
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19
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Ravlo M, Moen MH, Bukholm IRK, Lieng M, Vanky E. Ureteric injuries during hysterectomy-A Norwegian retrospective study of occurrence and claims for compensation over an 11-year period. Acta Obstet Gynecol Scand 2021; 101:68-76. [PMID: 34766333 DOI: 10.1111/aogs.14293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Ureteric injury is a rare but serious, iatrogenic complication of hysterectomy. The risk depends on indication for surgery, predisposing risk factors, and peroperative conditions. Our aims were to evaluate and learn from compensation claims to The Norwegian System of Patient Injury Compensation (NPE) for ureteric injury occurring during hysterectomies to predict risk factors, time of identification, symptoms, and consequences, and to relate these cases to injuries registered in The Norwegian Patient Registry. MATERIAL AND METHODS A retrospective study of ureteric injuries occurring during hysterectomies, reported to NPE and the Norwegian Patient Registry from 2009 through 2019. RESULTS During the study period, 53 096 hysterectomies were registered in The Norwegian Patient Registry, of which ureteric injury was documented in 643 (1.2%). More ureteric injuries were registered in large hospital trusts than in small trusts (1.3% vs. 0.7%, p < 0.05). NPE received 69 claims due to ureteric injury occurring during hysterectomy, comprising 11% of all injuries in the study period. Compensation was approved for 15%. Women who claimed compensation were younger (48.1 ± 8.9 years vs. 55.1 ± 13.6 years, p < 0.01), more likely to have had a benign diagnosis (89.9% vs. 52.1%, p < 0.01), and more likely to have had the ureteric injury recognized after discharge (58.0% vs. 33.0%, p < 0.001) compared with non-complainants. Identification of the ureters during the hysterectomy was documented in 30% of the NPE patient files. Additional information for the NPE cases included the following. The most common symptoms of unidentified injury were pain (77%), fever (12%), urinary leakage (13%), and anuria (8%). Re-operation was necessary in 77% of the cases, and 10% of the women lost one kidney. Long-term consequences after repair, such as loss of a kidney or persistent pain, were seen in 17%. No women died because of the injury. CONCLUSIONS The incidence of ureteric injury occurring during hysterectomy in Norway was 1.2%; 11% involved a claim for compensation, and 15% of these had their case approved. Most ureteric injuries were not recognized during the hysterectomy. Documentation of peroperative identification of the ureters during hysterectomy was often missing. Vigilance to pain as a postoperative symptom of peroperative unrecognized ureteric injury may result in earlier diagnosis and treatment.
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Affiliation(s)
- Merethe Ravlo
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Obstetrics and Gynecology, St. Olav's Hospital, University Hospital of Trondheim, Norway
| | - Mette Haase Moen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Marit Lieng
- Division of Gynecology and Obstetrics, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eszter Vanky
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Obstetrics and Gynecology, St. Olav's Hospital, University Hospital of Trondheim, Norway
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20
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Tummers FHMP, Hoebink J, Driessen SRC, Jansen FW, Twijnstra ARH. Decline in surgeon volume after successful implementation of advanced laparoscopic surgery in gynecology: An undesired side effect? Acta Obstet Gynecol Scand 2021; 100:2082-2090. [PMID: 34490608 DOI: 10.1111/aogs.14242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/13/2021] [Accepted: 08/08/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The implementation of advanced minimally invasive surgical (MIS) techniques has broadened. An extensive body of literature shows that high hospital and surgeon volumes lead to better patient outcomes. However, no information is available regarding volume trends in the post-implementation phase of MIS. This study investigated these trends and poses suggestions to adjust these developments. This knowledge can provide guidance to optimize patient safe performance of new surgical techniques. MATERIAL AND METHODS A national retrospective cohort study in the Netherlands. The number of advanced laparoscopic (level 3 and 4) and robotic procedures and the number of gynecologists performing them were collected through a web-based questionnaire to determine hospital and gynecological surgeon volume. These volumes were compared with our previously collected data from 2012. RESULTS The response rate was 85%. Hospitals produced larger volumes for advanced laparoscopic and robotic procedures. However, still 63% of the hospitals perform low-volume level 4 laparoscopic procedures. Additionally, gynecological surgeon volumes appeared to decrease for level 3 procedures, as the group of gynecologists performing fewer than 20 procedures expanded (64% vs. 44% in 2012), with 15% of the gynecologists performing fewer than ten procedures. Despite an increase in surgeon volumes for level 4 laparoscopy and robotic surgery, volumes continued to be low, as still 49% of gynecologists performed fewer than 10 level 4 procedures per year and 41% performed fewer than 20 robotic procedures per year. CONCLUSIONS The broad implementation of advanced MIS procedures resulted in an increasing number of these procedures with increasing hospital volumes. However, as a side-effect, a disproportionate rise in number of gynecologists performing these procedures was observed. Therefore, surgeon volumes remain low and even decreased for some procedures. Centralization of complex procedures and training of specialized MIS gynecologists could improve surgeon volumes and therefore consequently enhance patient safety.
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Affiliation(s)
| | - Jasmin Hoebink
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sara R C Driessen
- Department of Gynecology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Frank Willem Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Bio Mechanical Engineering, Delft University of Technology, Delft, The Netherlands
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21
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Khalil S, Kossl K, Pasik S, Brodman M, Ascher-Walsh C. Quality metrics in minimally invasive gynecologic surgery. Curr Opin Obstet Gynecol 2021; 33:305-310. [PMID: 34016819 DOI: 10.1097/gco.0000000000000716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Quality improvement and patient safety are relevant to the advancement of clinical care, particularly in the field of minimally invasive gynecologic surgery (MIGS). Although safety and feasibility of MIGS have been established, identification of quality metrics in this field is also necessary. RECENT FINDINGS Surgical quality improvement has focused on national overarching measures to reduce mortality, surgical site infections (SSIs), and complications. Quality improvement in minimally invasive surgery has additionally led to advancements in postoperative patient recovery and long-term outcomes. Process measures in minimally invasive surgery include use of bundles and enhanced recovery after surgery (ERAS) programs. However, procedure-specific quality metrics for MIGS outcomes are poorly defined at this time. SUMMARY Quality metrics in minimally invasive gynecology are well defined for structural measures and select process measures. Creation of relevant benchmarks for outcome measures in minimally invasive gynecologic surgery are needed.
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Affiliation(s)
- Susan Khalil
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Hospital New York
| | - Kelsey Kossl
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Hospital New York
| | | | - Michael Brodman
- Division of Minimally Invasive Gynecologic Surgery, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Mount Sinai Hospital, New York, New York
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22
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Disparities in Access to High-Volume Surgeons Within High-Volume Hospitals for Hysterectomy. Obstet Gynecol 2021; 138:208-217. [PMID: 34237769 DOI: 10.1097/aog.0000000000004456] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/01/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine access to high-volume surgeons in comparison with low-volume surgeons who perform hysterectomies within high-volume hospitals and to compare perioperative morbidity and mortality between high-volume and low-volume surgeons within these centers. METHODS Women who underwent hysterectomy in New York State between 2000 and 2014 at a high-volume (top quartile by volume) hospital were included. Surgeons were classified into quartiles based on average annual hysterectomy volume. Multivariable models were used to determine characteristics associated with treatment by a low-volume surgeon in comparison with a high-volume surgeon and to estimate the association between physician volume, and morbidity and mortality. RESULTS A total of 300,586 patients cared for by 5,505 surgeons at 59 hospitals were identified. Women treated by low-volume surgeons, in comparison with high-volume surgeons, were more often Black (19.4% vs 14.3%; adjusted odds ratio [aOR] 1.26; 95% CI 1.09-1.46) and had Medicare insurance (20.6% vs 14.5%; aOR 1.22; 95% CI 1.04-1.42). Low-volume surgeons were more likely to perform both emergent-urgent procedures (26.1% vs 6.4%; aOR 3.91; 95% CI 3.26-4.69) and abdominal hysterectomy, compared with minimally invasive hysterectomy (77.8% vs 54.7%; aOR 1.91; 95% CI 1.62-2.24). Compared with patients cared for by high-volume surgeons, those operated on by low-volume surgeons had increased risk of a complication (31.0% vs 10.3%; adjusted risk ratios [aRR] 1.84; 95% CI 1.71-1.98) and mortality (2.2% vs 0.2%; aRR 3.04; 95% CI 2.20-4.21). In sensitivity analyses, differences in morbidity and mortality remained for emergent-urgent procedures, elective operations, cancer surgery, and noncancer procedures. CONCLUSION Socioeconomic disparities remain in access to high-volume surgeons within high-volume hospitals for hysterectomy. Patients who undergo hysterectomy at a high-volume hospital by a low-volume surgeon are at substantially greater risk for perioperative morbidity and mortality.
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23
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The Volume-Outcome Paradigm for Gynecologic Surgery: Clinical and Policy Implications. Clin Obstet Gynecol 2021; 63:252-265. [PMID: 31929332 DOI: 10.1097/grf.0000000000000518] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Studies over the past decade have clearly demonstrated an association between high surgeon and hospital volume and improved outcomes for women undergoing gynecologic surgical procedures. In contrast to procedures associated with higher morbidity, the association between higher volume and improved outcomes is often modest for gynecologic surgeries. The lower magnitude of this association has limited actionable policy changes for gynecologic surgery. These data have been driving initiatives such as regionalization of care, targeted quality improvement at low volume centers and volume-based credentialing in gynecology.
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24
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Brunes M, Forsgren C, Warnqvist A, Ek M, Johannesson U. Assessment of surgeon and hospital volume for robot-assisted and laparoscopic benign hysterectomy in Sweden. Acta Obstet Gynecol Scand 2021; 100:1730-1739. [PMID: 33895985 DOI: 10.1111/aogs.14166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/25/2021] [Accepted: 04/12/2021] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The study aims to analyze differences between robot-assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon and hospital volume. MATERIAL AND METHODS All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo-oophorectomy from January 1, 2015 to December 31, 2017 (n = 12 386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses. RESULTS TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios [aOR] 2.8, 95% CI 1.3-5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2-2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2-25.4), a higher blood loss (200-500 mL aOR 3.5, 95% CI 2.7-4.7; > 500 mL aOR 7.6, 95% CI 4.0-14.6) and a longer operative time (1-2 h aOR 16.7 95% CI 10.2-27.5; >2 h aOR 47.6, 95% CI 27.9-81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4-0.9). CONCLUSIONS RATLH led to better perioperative outcome and higher patient satisfaction 1 year after surgery. These outcome differences were slightly more pronounced in very low-volume surgeons but persisted across all surgeon volume groups.
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Affiliation(s)
- Malin Brunes
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynecology at Södersjukhuset, Stockholm, Sweden
| | - Catharina Forsgren
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynecology at Danderyd Hospital, Stockholm, Sweden
| | - Anna Warnqvist
- Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marion Ek
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynecology at Södersjukhuset, Stockholm, Sweden
| | - Ulrika Johannesson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynecology at Danderyd Hospital, Stockholm, Sweden
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Wen T, Liao L, Kern-Goldberger A, Guglielminotti J, Gyamfi-Bannerman C, Wright JD, D'Alton ME, Friedman AM. Risk for and temporal trends in cesarean surgical complications. J Matern Fetal Neonatal Med 2021; 35:6489-6497. [PMID: 33910462 DOI: 10.1080/14767058.2021.1916461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE It is possible that in the setting of increasing patient comorbidity and obesity, risk for surgical injury and need for reoperation is increasing. It is also possible that with differential uptake of evidence-based recommendations and increasing prevalence of risk factors such as obesity, risk for surgical site complications is increasing. The objective of this study was to evaluate trends in, risk factors for, and racial disparities related to cesarean complications. METHODS This repeated cross-sectional study evaluated cesarean deliveries in the 2002-2014 National Inpatient Sample for women age 15-54. The primary outcome was a cesarean surgical complication composite including (i) surgical injuries, (ii) reoperation, and (iii) surgical site complications. Surgical injuries, reoperation, and surgical site complications were additionally evaluated individually as outcomes. Univariable and multivariable log linear regression models including demographic, clinical, and hospital factors were performed to assess risk for outcomes with unadjusted and adjusted risk ratios (aRR) with 95% confidence intervals (CI) as measures of association. Temporal trends were estimated using average annual percentage change from a joinpoint regression model. A stratified analysis was performed restricted to non-Hispanic black women. Data was weighted to provide national estimates. RESULTS A total of 16.2 million estimated cesarean deliveries (3.2 million unweighted cesarean deliveries) from 2002 to 2014 were included in this analysis. The prevalence of the cesarean surgical complication composite was 1.14%, surgical site complications occurred in 0.60%, surgical injuries in 0.49%, and reoperations in 0.10%. Comparing the end of the study (2012-2014) to the beginning of the study (2002-2003), adjusted risk for the composite was similar (aRR 0.93, 95% CI 0.92, 0.95). In comparison, surgical site complication risk was lower at the end of the study (aRR 0.77, 95% CI 0.75, 0.79) while risks for surgical injury (aRR 1.18, 95% CI 1.15, 1.22) and reoperation (1.18, 95% CI 1.10, 1.26) were higher. Non-Hispanic black women were at increased risk for surgical site complications (aRR 1.83, 95% CI 1.80, 1.87) and reoperation (aRR 1.44, 95% CI 1.37, 1.51), but not surgical injury (aRR 0.99, 95% CI 0.97, 1.02). In analyses stratified for non-Hispanic black women, there was a reduction in risk for surgical site complications at the end of the study period compared to the beginning similar to the primary analysis (aRR 0.76, 95% 0.72, 0.81) with a modest decrease in overall risk for the composite outcome (aRR 0.85, 95% CI 0.81, 0.89). CONCLUSION A decrease in risk for surgical site complications was offset by slightly increased risk for surgical injury and reoperation in adjusted analyses. Among non-Hispanic black women, surgical site complication risk decreased proportionately with this group still at significantly higher overall risk.
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Affiliation(s)
- Timothy Wen
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Lillian Liao
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Adina Kern-Goldberger
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jean Guglielminotti
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
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Coussons H, Feldstein J, McCarus S. Senhance surgical system in benign hysterectomy: A real-world comparative assessment of case times and instrument costs versus da Vinci robotics and laparoscopic-assisted vaginal hysterectomy procedures. Int J Med Robot 2021; 17:e2261. [PMID: 33860631 DOI: 10.1002/rcs.2261] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Comparison of retrospective, learning curve benign hysterectomy cost and case time data from Senhance total laparoscopic hysterectomy (TLH) cases with similar da Vinci robot cases and laparoscopic-assisted vaginal hysterectomy (LAVH) cases. METHODS Instrument costs, console time, and case time analysis from six surgeons at four U.S. and European hospitals compared with retrospective, sequential da Vinci TLH and standard laparoscopic LAVH cases extracted from the CAVAlytics database. RESULTS Senhance Gyn surgeons in their learning curve when compared to da Vinci learning curve Gyn surgeons achieved lower median instrument costs ($559 vs. $1393, respectively, p < 0.001) with comparable console times (91.5 vs. 96 min, p = 0.898); Senhance and LAVH case costs were comparable ($559 vs. $498, p = 0.336). CONCLUSION In benign hysterectomy, the Senhance system may present a lower-cost approach with equivalent case times compared with similar da Vinci robotic cases.
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Affiliation(s)
| | - Josh Feldstein
- CAVA Robotics International, Amherst, Massachusetts, USA
| | - Steve McCarus
- AdventHealth Winter Park Hospital, Winter Park, Florida, USA
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Johanson ML, Lieng M. Changes in route of hysterectomy in Norway since introduction of robotic approach. Facts Views Vis Obgyn 2021; 13:35-40. [PMID: 33889859 PMCID: PMC8051195 DOI: 10.52054/fvvo.13.1.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION From 2008, several Norwegian Health Trusts have acquired surgical robotic systems, and robotic hysterectomy accounted for 15 % of all hysterectomies performed in Norway in 2018. Robotic assisted hysterectomy is costly, and there is no evidence that the clinical outcome of robotic assisted hysterectomy is superior compared to the outcomes following other minimal invasive hysterectomies such as vaginal and laparoscopic hysterectomies. The objectives of this study were to describe the implementation of robotic hysterectomy and changes in other hysterectomy approaches, such as open abdominal, laparoscopic and vaginal hysterectomy in hospitals with and without robotic systems for hysterectomy. METHODS Quantitative study based on hysterectomy data between 2010 to 2018 from the Norwegian Patient Registry. RESULTS 9 out of 19 health trusts performed robotic assisted hysterectomy during the study period. The rate of abdominal hysterectomies declined during the study period, both in the health trusts with and without available surgical robotic systems. The rate of other minimally invasive hysterectomies also declined in some health trusts after the implementation of robotic assisted hysterectomy. DISCUSSION Robotic hysterectomy has been implemented and is increasing in Norway without a thorough evaluation of the effect on patient safety and possible economic consequences. According to our findings, it appears that the implementation of robotic hysterectomy has not had a significant impact on the use of open abdominal hysterectomy. Although associated with increased costs and a lack of evidence of improved clinical outcomes for women, robotic hysterectomy has furthermore to some extent replaced other minimal invasive hysterectomies.
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Affiliation(s)
- M L Johanson
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - M Lieng
- Division of Gynecology and Obstetrics, Oslo University Hospital, 0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
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Brown O, Mou T, Kenton K, Sheyn D, Bretschneider CE. Racial disparities in complications and costs after surgery for pelvic organ prolapse. Int Urogynecol J 2021; 33:385-395. [PMID: 33755740 DOI: 10.1007/s00192-021-04726-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/04/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The study objective was to examine the impact of race on inpatient complications and costs after inpatient surgery for pelvic organ prolapse (POP). METHODS In this retrospective cohort study, we identified women who underwent surgery for POP between 2012 and 2014. Patient demographics, outcomes, hospital characteristics, and hospital costs were extracted. Demographic and clinical characteristics were compared by race using Kruskal-Wallis for continuous variables and Chi-squared test for categorical variables. Multivariate logistic and linear regressions were used to identify variables associated with increased complications and costs respectively. RESULTS A total of 29,347 women with a median age of 62 years underwent inpatient surgery for POP between 2012 and 2014. There were 4,419 women (15%) who had at least one in-hospital postoperative complication. Rates of any postoperative complication were significantly higher among Black women (20%) than among white, Hispanic, and women of other races (16%, 11%, and 13% respectively, p < 0.01). The median total cost associated with surgeries for POP was $8,267 (IQR $6,008-$11,734). After multivariate analyses controlled for potential confounders, postoperative complications remained independently associated with Black race (aOR 1.21) whereas Hispanic and other races were associated with decreased odds of complications (aOR 0.62, and aOR 0.77) relative to white race. After controlling for confounders, Hispanic women had lower associated hospital costs. CONCLUSIONS Black women undergoing inpatient surgery for POP had a 21% increase in the odds of complications, but no difference in costs compared with white women, whereas Hispanic women had the lowest odds of complications and lowest costs.
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Affiliation(s)
- Oluwateniola Brown
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, 250 E Superior Street, Suite 05-2370, Chicago, IL, 60611, USA.
| | - Tsung Mou
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, 250 E Superior Street, Suite 05-2370, Chicago, IL, 60611, USA
| | - Kimberly Kenton
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, 250 E Superior Street, Suite 05-2370, Chicago, IL, 60611, USA
| | - David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Metro Health Medical Center, Cleveland, OH, USA
| | - C Emi Bretschneider
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, 250 E Superior Street, Suite 05-2370, Chicago, IL, 60611, USA
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Validation of Transvaginal Hysterectomy Surgical Model - Modification of the Flowerpot Model to Improve Vesicovaginal Plane Simulation. J Minim Invasive Gynecol 2021; 28:1526-1530. [PMID: 33359289 DOI: 10.1016/j.jmig.2020.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/04/2020] [Accepted: 12/20/2020] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To establish face and construct validity for a novel variation of American College of Obstetrics and Gynecology "Flowerpot Model" for transvaginal hysterectomy (TVH) surgical simulation with improved vesicovaginal dissection during surgical education simulation. DESIGN Cross-sectional face and construct validation study using the "Flowerpot Model." The vesicovaginal dissection plane was modified to include additional felt and balloon materials to simulate the bladder. SETTING Single academic center. PARTICIPANTS Fourteen residents and fellows, postgraduate year (PGY) 2 to 6, subdivided into junior (n = 8) with ≤10 prior TVH surgeries and senior groups (n = 6) with >10 prior TVH surgeries performed. INTERVENTIONS All subjects watched a brief introductory video and then were filmed simulating a TVH. MEASUREMENTS AND MAIN RESULTS For face validity, subjects completed an anatomic checklist and pre/post simulation satisfaction survey. For construct validation, 2 independent, blinded expert surgeons (M.A. and J.M.) graded films using the Global Rating Scale of Operative Performance (GRS). Primary outcome was mean GRS between groups. The junior group consisted of PGY 2 to 3 with ≤ 10 prior TVH, median 7.5 (interquartile range [IQR] 6.75) and senior group PGY 3 to 6 with >10 TVH, median 19 (IQR 10) (p <.01). Subjects were "satisfied" or "very satisfied" with bladder and anterior peritoneal fold simulation (92%) and found vesicovaginal dissection "realistic" (100%). GRS score was significantly different between groups (juniors, 19.5 [IQR 5] vs seniors, 28.5 [IQR 8.5]; p = .048). Intergrader correlation was high (ρ = 0.87, p <.01). Surgeon volume of prior TVH was not significantly correlated to average GRS score, ρ = 0.49 (p = .10). The model improved comfort and confidence scores in the junior group more than senior group (p = .04), but senior group still had higher post simulation confidence scores than the junior group (p = .02). CONCLUSION Face and construct validity with the modified Flowerpot Model was demonstrated. This low fidelity model is capable of simulation of a TVH with a novel vesicovaginal dissection. Prior surgical experience was not correlated to GRS score or time to procedure completion.
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Pollack LM, Lowder JL, Keller M, Chang SH, Gehlert SJ, Olsen MA. Racial/Ethnic Differences in the Risk of Surgical Complications and Posthysterectomy Hospitalization among Women Undergoing Hysterectomy for Benign Conditions. J Minim Invasive Gynecol 2021; 28:1022-1032.e12. [PMID: 33395578 DOI: 10.1016/j.jmig.2020.12.032] [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: 08/07/2020] [Revised: 11/25/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE Evaluate whether 30- and 90-day surgical complication and postoperative hospitalization rates after hysterectomy for benign conditions differ by race/ethnicity and whether the differences remain after controlling for patient, hospital, and surgical characteristics. DESIGN Retrospective cohort study using administrative data. The exposure was race/ethnicity. The outcomes included 5 different surgical complications/categories and posthysterectomy inpatient hospitalization, all identified through 30 and 90 days after hysterectomy hospital discharge, with the exception of hemorrhage/hematoma, which was only identified through 30 days. To examine the association between race/ethnicity and each outcome, we used logistic regression with clustering of procedures within hospitals, adjusting for patient and hospital characteristics and surgical approach. SETTING Multistate, including Florida and New York. PATIENTS Women aged ≥18 years who underwent hysterectomy for benign conditions using State Inpatient Databases and State Ambulatory Surgery Databases. INTERVENTIONS Hysterectomy for benign conditions. MEASUREMENTS AND MAIN RESULTS We included 183 697 women undergoing hysterectomy for benign conditions from January 2011 to September 2014. In analysis, adjusting for surgery route and other factors, black race was associated with increased risk of 30-day digestive system complications (multivariable adjusted odds ratio [aOR], 1.98; 95% confidence interval [CI], 1.78-2.21), surgical-site infection (aOR, 1.34; 95% CI, 1.18-1.53), posthysterectomy hospitalization (aOR, 1.31; 95% CI, 1.22-1.40), and urologic complications (aOR, 1.16; 95% CI, 1.01-1.34) compared with white race. Asian/Pacific Islander race was associated with increased risk of 30-day urologic complications (aOR, 1.48; 95% CI, 1.08-2.03), intraoperative injury to abdominal/pelvic organs (aOR, 1.46; 95% CI, 1.23-1.75), and hemorrhage/hematoma (aOR, 1.33; 95% CI, 1.06-1.67) compared with white race. Hispanic ethnicity was associated with increased risk of 30-day posthysterectomy hospitalization (aOR, 1.11; 95% CI, 1.02-1.20) compared with white race. All findings were similar at 90 days. CONCLUSION Black and Asian/Pacific Islander women had higher risk of some 30- and 90-day surgical complications after hysterectomy than white women. Black and Hispanic women had higher risk of posthysterectomy hospitalization. Intervention strategies aimed at identifying and better managing disparities in pre-existing conditions/comorbidities could reduce racial/ethnic differences in outcomes.
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Affiliation(s)
- Lisa M Pollack
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert).
| | - Jerry L Lowder
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Matt Keller
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Sarah J Gehlert
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Margaret A Olsen
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
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Needs Assessment for Lower Urinary Tract Injury Curriculum for FPMRS Fellowships. Female Pelvic Med Reconstr Surg 2020; 26:e83-e90. [PMID: 33002896 DOI: 10.1097/spv.0000000000000928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine the level and types of training Accreditation Council for Graduate Medical Education-accredited programs use for female pelvic medicine and reconstructive surgery (FPMRS) fellows' education on lower urinary tract injuries (LUTIs). METHODS Two surveys were developed to assess the need for LUTI curriculum from both program director (PD) and fellow vantages through a multistage process, including review by knowledgeable colleagues, cognitive interviews, and pilot testing. Surveys were distributed in an electronic link via e-mail to graduating fellows and program directors from each of the 58 Accreditation Council for Graduate Medical Education-accredited FPMRS programs. RESULTS Thirty-four graduating FPMRS fellows (71%) and 39 FPMRS PDs (67%) completed the survey. Both PDs and fellows responded that both the evaluation and management of LUTI were necessary to FPMRS training. The majority of PDs use a combination of didactics and hands-on learning in the operating room (60% and 71%). Only 40% and 30% incorporate simulation into the curriculum to address LUTI. Graduating fellows report low numbers of procedures to evaluate and manage LUTI. Specifically, only 15% of fellows graduate with greater than 2 ureteral reimplantations and 44% graduate with no minimally invasive abdominal vesicovaginal fistula repairs. The majority of graduating fellows reported feeling prepared to evaluate for LUTI, but nearly one third do not feel ready to independently manage LUTI upon graduation. CONCLUSIONS FPMRS PDs and fellows agree that the evaluation and management of LUTI are important; however, most programs use only didactics and hands-on learning in the operating room with extremely low case volumes, leading to decreased proficiency.
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Delara R, Misal M, Yi J, Girardo M, Wasson M. Barriers to Referral to Fellowship-trained Minimally Invasive Gynecologic Surgery Subspecialists. J Minim Invasive Gynecol 2020; 28:872-880. [PMID: 32805461 DOI: 10.1016/j.jmig.2020.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/05/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To determine patterns and barriers for referral to fellowship-trained minimally invasive gynecologic surgeons. DESIGN Questionnaire. SETTING United States and its territories and Canada. PARTICIPANTS Actively practicing general obstetrician/gynecologists (OB/GYNs). INTERVENTIONS Internet-based survey. MEASUREMENTS AND MAIN RESULTS Of 157 respondents, 144 (91.7%) general OB/GYNs were included. Subspecialty fellowship training resulted in the exclusion of 13 (8.3%) respondents. A total of 86 respondents (59.7%) considered referral to fellowship-trained minimally invasive gynecologic surgery (MIGS) subspecialists. The top 3 cited reasons for nonreferral were adequate residency training (n = 84, 58.3%), preference for continuity of care (n = 48, 33.3%), and preference for referral to other subspecialists (n = 46, 31.9%). The top 3 cited reasons for referral to MIGS subspecialists were complex pathology (n = 92, 63.9%), complex medical and/or surgical history (n = 76, 52.8%), and out of scope of practice (n = 53, 36.8%). If providers required intraoperative assistance, respondents consulted an OB/GYN colleague with comparable training (n = 50, 34.7%), gynecologic oncologist (n = 48, 33.3%), or non-OB/GYN surgical subspecialist (n = 33, 22.9%). Factors that were not associated with the decision to refer to MIGS subspecialists included years in practice (p = .13), additional training experiences beyond residency (p = .45), and number of hysterectomies performed by laparotomy (p = .69). Self-reported high-volume surgeons (p <.01) were less likely to refer. In contrast, providers who self-reported as low-volume surgeons (p = .02) and were aware of MIGS subspecialists in the community (p <.01) were more likely to consider referral. Respondents reported using a laparoscopic approach to hysterectomy most frequently (n = 79, 54.9%). In contrast, 36.8% preferred the laparoscopic route for themselves or their partner, whereas 48.6% preferred the vaginal approach. CONCLUSION Most of the general OB/GYNs would consider referral to fellowship-trained MIGS subspecialists. Providers who reported adequate residency training and those who preferred continuity of care or referral to other surgical subspecialists were less likely to refer to MIGS subspecialists.
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Affiliation(s)
- Ritchie Delara
- From the Department of Medical and Surgical Gynecology (Drs. Delara, Misal, Yi, and Wasson).
| | - Meenal Misal
- From the Department of Medical and Surgical Gynecology (Drs. Delara, Misal, Yi, and Wasson)
| | - Johnny Yi
- From the Department of Medical and Surgical Gynecology (Drs. Delara, Misal, Yi, and Wasson)
| | - Marlene Girardo
- Division of Biostatistics, Department of Health Sciences Research (Dr. Girardo), Mayo Clinic, Phoenix, Arizona
| | - Megan Wasson
- From the Department of Medical and Surgical Gynecology (Drs. Delara, Misal, Yi, and Wasson)
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Radiation and hormonal therapy for primary treatment of stage I endometrial cancer and long-term survival. Gynecol Oncol 2020; 158:331-338. [DOI: 10.1016/j.ygyno.2020.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/13/2020] [Indexed: 12/29/2022]
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Comparing Surgical Experience and Skill Using a High-Fidelity, Total Laparoscopic Hysterectomy Model. Obstet Gynecol 2020; 136:97-108. [DOI: 10.1097/aog.0000000000003897] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Klebanoff JS, Marfori CQ, Vargas MV, Amdur RL, Wu CZ, Moawad GN. Ob/Gyn resident self-perceived preparedness for minimally invasive surgery. BMC MEDICAL EDUCATION 2020; 20:185. [PMID: 32503585 PMCID: PMC7275515 DOI: 10.1186/s12909-020-02090-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/25/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Very little is known regarding the readiness of senior U.S. Ob/Gyn residents to perform minimally invasive surgery. This study aims to evaluate the self-perceived readiness of senior Ob/Gyn residents to perform complex minimally invasive gynecologic surgery as well as their perceptions of the minimally invasive gynecologic surgery subspecialty. METHODS We performed a national survey study of 3rd and 4th year Ob/Gyn residents. A novel 58-item survey was developed and sent to residency program directors and coordinators with the request to forward the survey link along to their senior residents. RESULTS We received 158 survey responses with 84 (53.2%) responses coming from 4th year residents and 74 (46.8%) responses from 3rd year residents. Residents who train with graduates of a fellowship in minimally invasive gynecologic surgery felt significantly more prepared to perform minimally invasive surgery compared to residents without this exposure in their training. The majority of senior residents (71.5%) feel their residency training adequately prepared them to be a competent minimally invasive gynecologic surgeon. However, only 50% feel prepared to perform a laparoscopic hysterectomy on a uterus greater than 12 weeks size, 29% feel prepared to offer a vaginal hysterectomy on a uterus 12-week size or greater, 17% feel comfortable performing a laparoscopic myomectomy, and 12% feel prepared to offer a laparoscopic hysterectomy for a uterus above the umbilicus. CONCLUSIONS The majority of senior U.S. Ob/Gyn residents feel prepared to provide minimally invasive surgery for complex gynecologic cases. However, surgical confidence in specific procedures decreases when surgical complexity increases.
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Affiliation(s)
- Jordan S Klebanoff
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA.
| | - Cherie Q Marfori
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA
| | - Maria V Vargas
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA
| | - Richard L Amdur
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA
| | - Catherine Z Wu
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA
| | - Gaby N Moawad
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA
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Evaluation of the Effect of Surgeon's Operative Volume and Specialty on Likelihood of Revision After Mesh Midurethral Sling Placement. Obstet Gynecol 2020; 133:1099-1108. [PMID: 31135723 PMCID: PMC6553521 DOI: 10.1097/aog.0000000000003275] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
One in 20 women undergo midurethral sling revision within 10 years, and annual operative volume of the inserting surgeon is a risk factor. OBJECTIVE: To estimate rates of revision surgery after insertion of mesh midurethral slings and explore whether physician specialty, annual operative volume, or hospital type are associated with this outcome. METHODS: A population-based retrospective cohort of women undergoing midurethral sling procedures over a 13-year interval (2004–2017) in Alberta, Canada was created using administrative health data. The primary outcome was subsequent surgery for revision of midurethral sling, defined by a composite of surgical procedures. Exposures included annual number of midurethral sling procedures performed by the surgeon, surgeon specialty, facility type, patient age, and concomitant prolapse repair. Mixed effects logistic regression using linear spines was used to test a-priori hypothesis that annual surgical volume would be inversely related in a nonlinear fashion to risk of revision. RESULTS: In the cohort of 19,511 women, cumulative rates of revision surgery were 3.84% (95% CI 3.54–4.17) at 5 years and 5.26% (95% CI 4.82–5.74) at 10 years. The first year after midurethral sling placement was the most vulnerable window, with 0.40% (95% CI 0.31–0.49) undergoing revision within 30 days and 2.15% (95% CI 1.95–3.52) within 1 year. Concomitant prolapse repairs (odds ratio [OR] 1.24, 95% CI 1.04–1.48) and surgeon's annual volume were associated with revision. After 50 cases per year, odds of revision declined with each additional case (OR 0.99/case, 95% CI 0.98–0.99, OR 0.91/10 cases, 95% CI 0.84–0.98) and plateaued at 110 cases per year. Surgeon specialty, hospital type, and patient age were not associated with outcome. CONCLUSION: One in 20 women undergo revision surgery within 10 years after midurethral sling placement. Higher physician surgical volume is associated with decreased risk, with the decline occurring at a threshold of 50 cases annually. Minimum caseload parameters for surgeons performing midurethral sling procedures may improve quality of these procedures.
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Herrinton LJ, Raine-Bennett T, Liu L, Alexeeff SE, Ramos W, Suh-Burgmann B. Outcomes of Robotic Hysterectomy for Treatment of Benign Conditions: Influence of Patient Complexity. Perm J 2019; 24:19.035. [PMID: 31905335 DOI: 10.7812/tpp/19.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Robotic hysterectomy may offer advantages for complex cases over the conventional laparoscopic approach. OBJECTIVE To assess the association of surgical approach (robotic vs conventional) with blood loss, risks of readmission, reoperation, complications, and average operative time. METHODS In a retrospective cohort study, we used the electronic medical records of Kaiser Permanente Northern California, 2011 to 2015, to estimate outcomes of robotic and conventional laparoscopic hysterectomy among women with complex or noncomplex benign disease. Mixed-effects regression models accounted for patient characteristics and surgeon volume. RESULTS The study included 560 robotic and 6785 conventional laparoscopic cases. Overall, 1836 patients (25%) met criteria for being complex. The average operative time was 152 minutes for robotic hysterectomy and 157 minutes for conventional laparoscopic hysterectomy (p < 0.0001). Complex surgical cases averaged 190 minutes and noncomplex cases averaged 144 minutes. The difference in operative time for high-volume surgeons treating complex patients with robotic hysterectomy vs conventional hysterectomy was 21 minutes faster (p < 0.05). After adjustment, the risk of blood loss at least 51 mL was lower for robotic surgery than for conventional surgery for complex and noncomplex patients. Other than risk of urinary tract complications, we observed no differences in the risks of complications or risk of reoperation between robotic and conventional laparoscopy for complex and noncomplex patients. CONCLUSION For women with complex disease, the robotic approach, when used by a higher-volume surgeon, may be associated with shorter operative time and slightly less blood loss, but not with lower risk of complications.
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Affiliation(s)
| | | | | | | | - Wilfredo Ramos
- Department of Obstetrics and Gynecology, Sacramento Medical Center, CA
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Berger AA, Tan-Kim J, Menefee SA. Surgeon volume and reoperation risk after midurethral sling surgery. Am J Obstet Gynecol 2019; 221:523.e1-523.e8. [PMID: 31526790 DOI: 10.1016/j.ajog.2019.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Emerging research supports that fewer complications occur in patients who undergo surgery by higher surgical volume surgeons. The midurethral sling surgery has been involved in recent warnings and litigation, which further supports a need to understand features that enhance its safety and efficacy. OBJECTIVE The purpose of this study was to measure the impact of a surgeon's volume on their patient's rate of reoperation after midurethral sling surgery. STUDY DESIGN This was a retrospective cohort study that evaluated all surgeons who performed synthetic mesh midurethral sling surgery for stress urinary incontinence at a large managed care organization with >4.5 million members from 2005-2016. Physicians Current Procedural Terminology and International Classification of Diseases, version 9/10, codes were used to identify the procedures and the reoperations that were performed. The system-wide medical record was queried for demographic and perioperative data. The primary outcome was the overall reoperation rate after midurethral sling surgery. Concentration curves were used to identify the impact of a surgeon's surgical volume on their rate of reoperation. Demographics, characteristics, and reoperation of patients were compared with the use of chi-square test for categoric variables and Wilcoxon rank sum test for continuous variables. Poisson regression models with a robust error variance were used to calculate the unadjusted and the adjusted risk ratios of reoperation with the use of age, body mass index, marital status, race, parity, vaginal estrogen use, sling type, smoking, diabetes mellitus, and menopausal status as covariates. RESULTS Two hundred twenty-seven surgeons performed 13,404 midurethral sling surgeries over the study period; patients had a mean of 4.4 years of follow up. Higher-volume surgeons (>40 procedures/year, ≥95th percentile) performed 47% of the surgeries in this cohort and had an overall lower rate of reoperation (3.6% vs 4.2%; 95% confidence interval, 0.67-0.94; P=.04) compared with lower-volume surgeons. Higher-volume surgeons had a lower rate of reoperation for surgical failure (2.7% vs 3.6%; 95% confidence interval, 0.55-0.92; P<.01). Rates of reoperation for complications were similar between the 2 groups (1.1% vs 0.9%; 95% confidence interval, 0.82-1.13; P=.32). For patients whose condition required a reoperation secondary to complication, the rates of reoperation for urinary retention (0.9% vs 0.6%; P=.06), mesh exposure (0.2% vs 0.3%; P=.31), hemorrhage/bleeding (0.1% vs 0.0%; P=.11), pain (0.1% vs 0.1%; P=.52), and infection (0.0% vs 0.0%; P=.37) did not differ between higher- and lower-volume surgeons. The risk ratio for reoperation that compared higher- and lower-volume surgeons was 0.83 (95% confidence interval, 0.67-0.98; P=.01) in the adjusted model. CONCLUSION Although the reoperation rates were low for both higher- and lower-volume surgeons, higher-volume surgeons had lower overall rates of reoperation after midurethral sling surgery. This effect is seen most dramatically in reoperation for surgical failure, in which patients who have surgery with a higher-volume surgeon are 25% less likely to have postoperative stress urinary incontinence that leads to reoperation.
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Affiliation(s)
- Alexander A Berger
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of OB/GYN, Kaiser Permanente-San Diego, San Diego, CA; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Science, University of California San Diego, San Diego, CA.
| | - Jasmine Tan-Kim
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of OB/GYN, Kaiser Permanente-San Diego, San Diego, CA
| | - Shawn A Menefee
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of OB/GYN, Kaiser Permanente-San Diego, San Diego, CA
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To Live and Let Dye. Obstet Gynecol 2019; 134:239-240. [PMID: 31306321 DOI: 10.1097/aog.0000000000003385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dottino JA, He W, Sun CC, Zhao H, Fu S, Lu KH, Meyer LA. Centers for Medicare and Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and gynecologic oncology surgical outcomes. Gynecol Oncol 2019; 154:405-410. [PMID: 31208738 DOI: 10.1016/j.ygyno.2019.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national survey of inpatient experience. This study evaluated the association between HCAHPS survey results and outcomes in gynecologic cancer surgery. METHODS This observational study used HCAHPS survey data from 2009 to 2011 to assign hospitals into score terciles. The Nationwide Inpatient Sample (NIS) database was used to identify admissions during the same time period for gynecologic cancer-specific surgeries. Data sources were linked at the hospital level. Postoperative complications, mortality, and prolonged length of stay were compared between higher and lower scoring hospitals. Complications were grouped as 'surgical', 'medical', or 'care team'. Mixed effects models were used to evaluate the associations between hospitals' HCAHPS scores and outcomes after adjustment for patient and hospital-level variables. RESULTS 17,509 linked encounters in 651 hospitals across the U.S. were identified, with 51% uterine, 40% ovarian, and 9% cervical cancer surgical admissions. In-hospital mortality was lower in hospitals in the top HCAHPS score terciles compared to bottom HCAHPS score tercile (odds ratio (OR) 0.54, 95% CI: 0.31-0.94). Surgery in higher scoring HCAHPS hospitals was associated with less 'surgical' complications (OR 0.82, 95% CI 0.69-0.98). No association was found between 'medical', 'care team', overall complications, or prolonged hospitalization (p > 0.05) and HCAHPS scores. CONCLUSIONS Gynecologic oncology surgeries performed in top HCAHPS tercile hospitals were associated with lower in-hospital mortality and surgical complications compared to surgeries performed in bottom tercile hospitals. Associations between HCAHPS scores and other adverse events were not seen.
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Affiliation(s)
- Joseph A Dottino
- Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Weiguo He
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charlotte C Sun
- Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen H Lu
- Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Prevention and management of bowel injury during gynecologic laparoscopy: an update. Curr Opin Obstet Gynecol 2019; 31:245-250. [PMID: 31045654 DOI: 10.1097/gco.0000000000000552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The current article aims to briefly review recent literature on bowel injury in gynecologic surgery with a focus on minimally invasive techniques, strategies for prevention, and management of injury. RECENT FINDINGS Recent reviews describe a low incidence of bowel injury that is likely affected by low rates of reporting and inconsistent definitions. The major risk factor for bowel injury is adhesive disease, and assessment and prevention techniques for the presence of adhesive disease are evolving. When bowel injury occurs, prompt diagnosis and intraoperative repair yields more favorable outcomes than delayed diagnosis. Repair can be performed by a gynecologic surgeon, with or without the help of a consultant depending on the extent of the injury and surgeon comfort. SUMMARY Bowel injury is a potentially catastrophic complication in gynecologic surgery, but its rarity presents a challenge in research. A high index of suspicion and meticulous surgical technique are the cornerstones of managing a bowel injury.
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In Reply. Obstet Gynecol 2019; 133:826. [PMID: 30913179 DOI: 10.1097/aog.0000000000003204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Whiteside JL, Kaeser CT, Ridgeway B. Achieving high value in the surgical approach to hysterectomy. Am J Obstet Gynecol 2019; 220:242-245. [PMID: 30419200 DOI: 10.1016/j.ajog.2018.11.124] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/26/2018] [Accepted: 11/01/2018] [Indexed: 11/29/2022]
Abstract
Value-based care, best clinical outcome relative to cost, is a priority in correcting the high costs for average clinical outcomes of health care delivery in the United States. Hysterectomy represents the most common and identifiable nonobstetric major surgical procedure among women. Surgical approaches to hysterectomy in the United States have changed in recent decades. For benign indications, clinical evidence identifies the superiority of vaginal hysterectomy over all other routes. These conclusions rest on clinical outcomes; however, cost differentials also exist across hysterectomy approaches, with the vaginal approach consistently incurring the lowest overall costs. Taken together, vaginal hysterectomy has the highest value, whereas the robotic (given high costs) and abdominal approaches (given less favorable clinical outcomes) have less value. Traditional laparoscopic hysterectomy holds an intermediate value. Increasing the use of high-value hysterectomy approaches can be achieved by adopting multimodal strategies, with changes in the payment models being the most important.
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Affiliation(s)
- James L Whiteside
- The University of Cincinnati, Department of Obstetrics and Gynecology, Cincinnati, OH.
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