- Email: [email protected]
14: Anterior bilateral sacrospinous ligament fixation: A safe route for apical repair
Oral Posters
ajog.org decrease in hysterectomy utilization, the increased use of laparoscopy, and the increased use of outpatient surgery (discussed above), (2) annual increases in payment per case of 3-5% with each surgical approach, both outpatient and inpatient, and (3) the difference in average payments for outpatient versus inpatient hysterectomy—vaginal: $4,015 vs $8,929, laparoscopic assisted vaginal: $6,319 vs $11,289, laparoscopic: $6,307 vs $11,686, and abdominal: $4,659 vs $11,285. CONCLUSION: Between 2010 and 2013, laparoscopy and outpatient surgery emerged as the most common technique and venue for hysterectomy, respectively. Total payments for hysterectomy increased 1% during this time, but this metric does not capture how the practice and finances of hysterectomy are changing.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Kathryn Robison: Nothing to disclose; Derek Bivona: Nothing to disclose; Leise Knoepp: Nothing to disclose; Laurephile Desrosiers: Nothing to disclose; Kristin Miller: Nothing to disclose.
13 The changing practice of hysterectomy and its effect on payments to hospitals among privately insured women in the United States D. M. Morgan1, N. Kamdar1, C. W. Swenson1, E. K. Kobernick1, A. G. Sammarco1, H. Levy3, B. Nallamothu2 1
Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 3 Health Management and Policy, University of Michigan, Ann Arbor, MI 2
OBJECTIVES: Technology is changing the practice of hysterectomy. The objective of this study was to analyze how the emergence of laparoscopy and outpatient surgery has affected utilization and payments for hysterectomy among privately insured women. MATERIALS AND METHODS: Hysterectomies performed between 2010 and 2013 were identified in the Health Care Cost Institute (HCCI), a national dataset with claims for more than 40 million individuals. ICD9 procedure codes in the inpatient and outpatient HCCI files were used to categorize surgical approach as abdominal, laparoscopic, vaginal, or laparoscopic assisted vaginal hysterectomy. Payments made by insurance companies and patients to hospitals were adjusted to 2013 dollars using the Medical Consumer Price Index. RESULTS: Between 2010 and 2013, the hysterectomy rate among insured women decreased 12.5% from 3.94 to 3.45 hysterectomies per 1,000 women. The proportion of laparoscopic hysterectomies increased from 25.8% to 43.4% with concomitant decreases in abdominal (38.5% to 28.0%), vaginal (15.3% to 11.7%), and laparoscopic assisted vaginal (20.4% to 16.9%). These shifts in surgical approach were accompanied by changes in admission type. In 2010, there were 2.61 inpatient and 1.33 outpatient hysterectomies per 1000 women. With each year, the gap between inpatient and outpatient hysterectomy rates narrowed. By 2013, inpatient hysterectomies decreased to 1.49 per 1000 women and outpatient hysterectomies increased to 1.96 per 1000 women. The overall payment in the HCCI claims for hysterectomy increased from $671 million in 2010 to $678 million in 2013. To appreciate these finances, it is important to consider the following trends: (1) the
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Daniel M. Morgan: Nothing to disclose; Neil Kamdar: Nothing to disclose; Carolyn W. Swenson: Nothing to disclose; Emily K. Kobernick: Nothing to disclose; Anne G. Sammarco: Nothing to disclose; Helen Levy: Nothing to disclose; Brahmajee Nallamothu: Nothing to disclose.
14 Anterior bilateral sacrospinous ligament fixation: A safe route for apical repair E. R. Solomon, E. Logan, K. Jones, O. Harmanli Urogynecology and Pelvic Surgery, Baystate Medical Center, Springfield, MA
OBJECTIVES: The objective of our study is to evaluate intraoperative and perioperative complications and observe anatomical changes in patients who have undergone bilateral sacrospinous ligament fixation up to 6 months in the postoperatively. MATERIALS AND METHODS: This is an observational descriptive study using a prospectively collected Urogynecology repository. The study cohort represents all women in our prospective repository who underwent anterior approach bilateral sacrospinous ligament fixation between September 2011 and June 2014. Pelvic organ prolapse quantification scores (POP-Q) were measured preoperatively and at 6 weeks and 6 months post-operatively and were compared. Perioperative complications were also collected and analyzed. RESULTS: From September 2011 until June 2014, there were 144 patients who underwent anterior approach bilateral sacrospinous ligament fixation. The mean age was 57.8 years and the average BMI was 29.6. The majority of patients were white (72.2%), followed by Hispanic (13.2%), African American (5.6%) and “Other” 9.0%. The majority of patients were never smokers (75.7%). Two-thirds of the patients were post- menopausal (69%). Common concomitant procedures performed with bilateral sacrospinous ligament fixation included anterior colporrhaphy (82%), posterior colporrhaphy (65%), sling for stress incontinence (72%), enterocele repair (17%), and paravaginal defect repair (3%). Fifty eight (37%) of the 144 patients underwent concomitant hysterectomy. Table 1 describes the POP-Q points preoperatively and at six weeks and 6 months respectively. One hundred nine patients presented for their 6 week post-operative visit and 68 patients returned for their 6 month postoperative visit. Six months after surgery, patients continued to have post-operative success when comparing pre-operative Aa, Ba, C, Gh, Ap, and Bp points. Perioperative complications included 53(37%) patients discharged home with an indwelling catheter due to urinary retention. One patient (0.7%) required a blood transfusion, three patients (2%) had intraoperative bladder or urethral injuries. In the
S582 American Journal of Obstetrics & Gynecology Supplement to MARCH 2017
Oral Posters
ajog.org postoperative period, four patients (2.8%) had prolonged retention. No patients complained of nerve injury symptoms in the postoperative period. CONCLUSION: Bilateral sacrospinous ligament fixation is a safe, effective strategy to treat pelvic organ prolapse with less concern for potential long term complications such as mesh erosion. It is also a procedure that may benefit patients who do not want treatment of apical prolapse with mesh or other augmenting materials.
MATERIALS AND METHODS: A retrospective, single institution study was performed for patients who underwent LESS from 2007-2015. Univariate analysis was performed with chi-square tests and t-tests; Kaplan-Meier and Cox proportional hazards determined time to hernia development. RESULTS: Eight hundred ninety-eight patients underwent 908 surgeries. The mean age and BMI were 55.7 years and 29.6 kg/m2, respectively. The majority were white (87.9%) and ASA class II/III (95.5%). A total of 36.9% had adnexal masses, 37.3% had endometrial hyperplasia/cancer, 5.4% had ovarian/fallopian tube/peritoneal cancer, 4.4% had cervical dysplasia/cancer, and 28% had risk reduction surgery for genetic syndromes (14.1%) or breast cancer (13.9%). Most women (62.7%) underwent hysterectomy, right and left salpingectomy (86.1% and 86.0%, respectively) and right and left oophorectomy (82.2% and 80.3%, respectively). Rate of adverse outcomes within 30 days, including reoperation (0.1%), intraoperative injury (1.4%), ICU admission (0.4%), VTE (0.3%), and blood transfusion were low (0.8%). The rate of urinary tract infection was 2.8%, higher BMI (p ¼ 0.02), longer OR time (p ¼ 0.02), smoking (p ¼ 0.01), hysterectomy (p ¼ 0.01), and cystoscopy (p ¼ 0.02) increased risk. The rate of cellulitis was 3.5%; higher EBL (p ¼ 0.03) and endometrial cancer (p ¼ 0.02) were predictors. Rate for surgical readmissions was 3.4%, higher EBL (p ¼ 0.03), longer OR time (p ¼ 0.02), chemotherapy alone (p ¼ 0.03) and combined chemotherapy and radiation (p < 0.05) increased risk. Rate of incisional hernia rate was 5.5% (n ¼ 50) with a mean occurrence at 570.2 553.3 days. Higher ASA class (p ¼ 0.04), diabetes (p < 0.001), HTN (p ¼ 0.043), increasing age (p ¼ 0.017; HR ¼ 1.03) and BMI (p < 0.001; HR ¼ 1.08) increased risk of hernia; prior abdominal surgeries (p ¼ 0.24), and hand-assist (p ¼ 0.64) did not. Patients with ASA class III/IV had a 3-year hernia rate of 12.8% (HR ¼ 1.81). CONCLUSION: In this large cohort of patients undergoing LESS, the incidence of short-term adverse outcomes is low. While the rate of incisional hernia was 5.5%, incidence reached 12.3% at three years in high-risk groups. Previous studies with short follow up duration have likely underestimated the risk of hernia, especially in patients with significant comorbidities.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Laura J. Moulton: Nothing to disclose; Amelia M. Jernigan: Nothing to disclose; Chad M. Michener: Nothing to disclose.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Ellen R. Solomon: Nothing to disclose; Emily Logan: Nothing to disclose; Keisha Jones: Nothing to disclose; Oz Harmanli: Nothing to disclose.
15 Laparoendoscopic single-site (LESS) surgery in gynecologic oncology: Short and long term outcomes L. J. Moulton1, A. M. Jernigan2, C. M. Michener2 1 OB/GYN and Women’s Health Institute, Cleveland Clinic Foundation, Cleveland, OH, 2Division of Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, OH
OBJECTIVES: To describe short term outcomes and hernia rates in patients after laparoendoscopic single-site (LESS) in a gynecologic oncology practice.
16 Effect of uterine weight on vaginal hysterectomy perioperative outcomes M. Wasson, P. Magtibay, J. F. Magrina Gynecologic Surgery, Mayo Clinic Arizona, Phoenix, AZ
OBJECTIVES: Vaginal hysterectomy is the recommended approach for patients with benign pathology. When compared to hysterectomies performed via alternative routes, the vaginal approach is associated with decreased perioperative complications, length of hospitalization, and healthcare costs. Increase in uterine size is commonly cited as a relative contraindication to vaginal hysterectomy. The primary objective of this study was to determine the effect of uterine weight on perioperative outcomes among patients undergoing total vaginal hysterectomy. MATERIALS AND METHODS: Consecutive patients undergoing total vaginal hysterectomy between January 1, 2009 and August 31, 2014 were evaluated retrospectively. The primary outcomes were
Supplement to MARCH 2017 American Journal of Obstetrics & Gynecology
S583
ajog.org decrease in hysterectomy utilization, the increased use of laparoscopy, and the increased use of outpatient surgery (discussed above), (2) annual increases in payment per case of 3-5% with each surgical approach, both outpatient and inpatient, and (3) the difference in average payments for outpatient versus inpatient hysterectomy—vaginal: $4,015 vs $8,929, laparoscopic assisted vaginal: $6,319 vs $11,289, laparoscopic: $6,307 vs $11,686, and abdominal: $4,659 vs $11,285. CONCLUSION: Between 2010 and 2013, laparoscopy and outpatient surgery emerged as the most common technique and venue for hysterectomy, respectively. Total payments for hysterectomy increased 1% during this time, but this metric does not capture how the practice and finances of hysterectomy are changing.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Kathryn Robison: Nothing to disclose; Derek Bivona: Nothing to disclose; Leise Knoepp: Nothing to disclose; Laurephile Desrosiers: Nothing to disclose; Kristin Miller: Nothing to disclose.
13 The changing practice of hysterectomy and its effect on payments to hospitals among privately insured women in the United States D. M. Morgan1, N. Kamdar1, C. W. Swenson1, E. K. Kobernick1, A. G. Sammarco1, H. Levy3, B. Nallamothu2 1
Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 3 Health Management and Policy, University of Michigan, Ann Arbor, MI 2
OBJECTIVES: Technology is changing the practice of hysterectomy. The objective of this study was to analyze how the emergence of laparoscopy and outpatient surgery has affected utilization and payments for hysterectomy among privately insured women. MATERIALS AND METHODS: Hysterectomies performed between 2010 and 2013 were identified in the Health Care Cost Institute (HCCI), a national dataset with claims for more than 40 million individuals. ICD9 procedure codes in the inpatient and outpatient HCCI files were used to categorize surgical approach as abdominal, laparoscopic, vaginal, or laparoscopic assisted vaginal hysterectomy. Payments made by insurance companies and patients to hospitals were adjusted to 2013 dollars using the Medical Consumer Price Index. RESULTS: Between 2010 and 2013, the hysterectomy rate among insured women decreased 12.5% from 3.94 to 3.45 hysterectomies per 1,000 women. The proportion of laparoscopic hysterectomies increased from 25.8% to 43.4% with concomitant decreases in abdominal (38.5% to 28.0%), vaginal (15.3% to 11.7%), and laparoscopic assisted vaginal (20.4% to 16.9%). These shifts in surgical approach were accompanied by changes in admission type. In 2010, there were 2.61 inpatient and 1.33 outpatient hysterectomies per 1000 women. With each year, the gap between inpatient and outpatient hysterectomy rates narrowed. By 2013, inpatient hysterectomies decreased to 1.49 per 1000 women and outpatient hysterectomies increased to 1.96 per 1000 women. The overall payment in the HCCI claims for hysterectomy increased from $671 million in 2010 to $678 million in 2013. To appreciate these finances, it is important to consider the following trends: (1) the
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Daniel M. Morgan: Nothing to disclose; Neil Kamdar: Nothing to disclose; Carolyn W. Swenson: Nothing to disclose; Emily K. Kobernick: Nothing to disclose; Anne G. Sammarco: Nothing to disclose; Helen Levy: Nothing to disclose; Brahmajee Nallamothu: Nothing to disclose.
14 Anterior bilateral sacrospinous ligament fixation: A safe route for apical repair E. R. Solomon, E. Logan, K. Jones, O. Harmanli Urogynecology and Pelvic Surgery, Baystate Medical Center, Springfield, MA
OBJECTIVES: The objective of our study is to evaluate intraoperative and perioperative complications and observe anatomical changes in patients who have undergone bilateral sacrospinous ligament fixation up to 6 months in the postoperatively. MATERIALS AND METHODS: This is an observational descriptive study using a prospectively collected Urogynecology repository. The study cohort represents all women in our prospective repository who underwent anterior approach bilateral sacrospinous ligament fixation between September 2011 and June 2014. Pelvic organ prolapse quantification scores (POP-Q) were measured preoperatively and at 6 weeks and 6 months post-operatively and were compared. Perioperative complications were also collected and analyzed. RESULTS: From September 2011 until June 2014, there were 144 patients who underwent anterior approach bilateral sacrospinous ligament fixation. The mean age was 57.8 years and the average BMI was 29.6. The majority of patients were white (72.2%), followed by Hispanic (13.2%), African American (5.6%) and “Other” 9.0%. The majority of patients were never smokers (75.7%). Two-thirds of the patients were post- menopausal (69%). Common concomitant procedures performed with bilateral sacrospinous ligament fixation included anterior colporrhaphy (82%), posterior colporrhaphy (65%), sling for stress incontinence (72%), enterocele repair (17%), and paravaginal defect repair (3%). Fifty eight (37%) of the 144 patients underwent concomitant hysterectomy. Table 1 describes the POP-Q points preoperatively and at six weeks and 6 months respectively. One hundred nine patients presented for their 6 week post-operative visit and 68 patients returned for their 6 month postoperative visit. Six months after surgery, patients continued to have post-operative success when comparing pre-operative Aa, Ba, C, Gh, Ap, and Bp points. Perioperative complications included 53(37%) patients discharged home with an indwelling catheter due to urinary retention. One patient (0.7%) required a blood transfusion, three patients (2%) had intraoperative bladder or urethral injuries. In the
S582 American Journal of Obstetrics & Gynecology Supplement to MARCH 2017
Oral Posters
ajog.org postoperative period, four patients (2.8%) had prolonged retention. No patients complained of nerve injury symptoms in the postoperative period. CONCLUSION: Bilateral sacrospinous ligament fixation is a safe, effective strategy to treat pelvic organ prolapse with less concern for potential long term complications such as mesh erosion. It is also a procedure that may benefit patients who do not want treatment of apical prolapse with mesh or other augmenting materials.
MATERIALS AND METHODS: A retrospective, single institution study was performed for patients who underwent LESS from 2007-2015. Univariate analysis was performed with chi-square tests and t-tests; Kaplan-Meier and Cox proportional hazards determined time to hernia development. RESULTS: Eight hundred ninety-eight patients underwent 908 surgeries. The mean age and BMI were 55.7 years and 29.6 kg/m2, respectively. The majority were white (87.9%) and ASA class II/III (95.5%). A total of 36.9% had adnexal masses, 37.3% had endometrial hyperplasia/cancer, 5.4% had ovarian/fallopian tube/peritoneal cancer, 4.4% had cervical dysplasia/cancer, and 28% had risk reduction surgery for genetic syndromes (14.1%) or breast cancer (13.9%). Most women (62.7%) underwent hysterectomy, right and left salpingectomy (86.1% and 86.0%, respectively) and right and left oophorectomy (82.2% and 80.3%, respectively). Rate of adverse outcomes within 30 days, including reoperation (0.1%), intraoperative injury (1.4%), ICU admission (0.4%), VTE (0.3%), and blood transfusion were low (0.8%). The rate of urinary tract infection was 2.8%, higher BMI (p ¼ 0.02), longer OR time (p ¼ 0.02), smoking (p ¼ 0.01), hysterectomy (p ¼ 0.01), and cystoscopy (p ¼ 0.02) increased risk. The rate of cellulitis was 3.5%; higher EBL (p ¼ 0.03) and endometrial cancer (p ¼ 0.02) were predictors. Rate for surgical readmissions was 3.4%, higher EBL (p ¼ 0.03), longer OR time (p ¼ 0.02), chemotherapy alone (p ¼ 0.03) and combined chemotherapy and radiation (p < 0.05) increased risk. Rate of incisional hernia rate was 5.5% (n ¼ 50) with a mean occurrence at 570.2 553.3 days. Higher ASA class (p ¼ 0.04), diabetes (p < 0.001), HTN (p ¼ 0.043), increasing age (p ¼ 0.017; HR ¼ 1.03) and BMI (p < 0.001; HR ¼ 1.08) increased risk of hernia; prior abdominal surgeries (p ¼ 0.24), and hand-assist (p ¼ 0.64) did not. Patients with ASA class III/IV had a 3-year hernia rate of 12.8% (HR ¼ 1.81). CONCLUSION: In this large cohort of patients undergoing LESS, the incidence of short-term adverse outcomes is low. While the rate of incisional hernia was 5.5%, incidence reached 12.3% at three years in high-risk groups. Previous studies with short follow up duration have likely underestimated the risk of hernia, especially in patients with significant comorbidities.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Laura J. Moulton: Nothing to disclose; Amelia M. Jernigan: Nothing to disclose; Chad M. Michener: Nothing to disclose.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Ellen R. Solomon: Nothing to disclose; Emily Logan: Nothing to disclose; Keisha Jones: Nothing to disclose; Oz Harmanli: Nothing to disclose.
15 Laparoendoscopic single-site (LESS) surgery in gynecologic oncology: Short and long term outcomes L. J. Moulton1, A. M. Jernigan2, C. M. Michener2 1 OB/GYN and Women’s Health Institute, Cleveland Clinic Foundation, Cleveland, OH, 2Division of Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, OH
OBJECTIVES: To describe short term outcomes and hernia rates in patients after laparoendoscopic single-site (LESS) in a gynecologic oncology practice.
16 Effect of uterine weight on vaginal hysterectomy perioperative outcomes M. Wasson, P. Magtibay, J. F. Magrina Gynecologic Surgery, Mayo Clinic Arizona, Phoenix, AZ
OBJECTIVES: Vaginal hysterectomy is the recommended approach for patients with benign pathology. When compared to hysterectomies performed via alternative routes, the vaginal approach is associated with decreased perioperative complications, length of hospitalization, and healthcare costs. Increase in uterine size is commonly cited as a relative contraindication to vaginal hysterectomy. The primary objective of this study was to determine the effect of uterine weight on perioperative outcomes among patients undergoing total vaginal hysterectomy. MATERIALS AND METHODS: Consecutive patients undergoing total vaginal hysterectomy between January 1, 2009 and August 31, 2014 were evaluated retrospectively. The primary outcomes were
Supplement to MARCH 2017 American Journal of Obstetrics & Gynecology
S583