Detection of Urinary Tract Injuries by Routine Cystoscopy during Robotic Hysterectomy for Malignant and Complex Benign Pathology

Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201 Measurements and Main Results: Total 23 women underwent adenomyomectomy by robotics. The patient age was 35.91 ± 4.71 years old, and 91.3 percent of them were nulliparous. The Pre-op CA 125 was 128.46 ± 27.37 and VAS score of dysmenorrhea was 8.9 ± 1.0. The operation time was 328 ± 126.89 minutes. No case was converted into conventional laparoscopy or laparotomy and all the patients recovered without any major complication. As compared with open adenomyomectomy, Robotic surgery had less estimated blood loss during opertion (250 ± 249.6 mL vs 690.91 ± 776.47 mL)and shorter postoperative hospital das (2.57 vs 4.0 days).The dysmenorrhea and pelvic pain of the patients nearly disappeared after surgery. Conclusion: Robot-assisted laparoscopic adenomyomectomy would overcome the previous limitations of conventional laparoscopy, and could be an excellent treatment option as a minimally invasive surgery for women who wish to preserve their fertility. 143

Open Communications 11 – Robotics (11:00 AM–12:00 PM) 11:07 AM – GROUP A

Risk Factors for an Extended Length of Stay in Patients Undergoing Robot-Assisted Laparoscopic Myomectomy, a 10-Year Review Gaigbe-Togbe B, Roy-McMahon C, Rosen L, Huntly J, Ahron D, Ascher-Walsh CJ. Obstetrics and Gynecology, Icahn School of Medicine at Mt. Sinai, New York, New York Study Objective: To asses pre-operative and operative risk factors and associations for an extended hospital stay in patients undergoing a robotassisted laparoscopic myomectomy. Design: Retrospective chart review. Setting: University Hospital. Patients: 584 patients undergoing robotic-assisted laparoscopic myomectomy from 6/06–12/16 by on surgeon. Intervention: All patients were determined to be a can date for a roboticassisted laparoscopic myomectomy by MRI confirmation that all fibroids were accessible laparoscopically. All patients underwent a robot-assisted myomectomy with 4 total ports. All patients had vasopressin injected into the myoma before serosal incision. All patients were counseled that the surgery was scheduled as outpatient but that they would be evaluated in the recovery room and would be given the option to stay overnight if they were too uncomfortable to go home. Demographic, pre-operative and surgical data were evaluated in relation to hospital length of stay. Measurements and Main Results: Of the 584 patients, 450 (77.1%) patients went home the same day and 130 (22.3%) were discharged on postoperative day 1 and 4 on post-operative day 2 (0.7%) (Table 1). Age, duration of surgery, EBL, and weight of the myomas were found to be independently related to a greater likelihood of overnight admission. (all p < .001). Results

Number of patients Age BMI (SD) Parity Duration (min) (SD) EBL (cc) (SD) Fibroid Mass (gm) (SD) Fibroid number (SD) Clinical Size of uterus (weeks) (SD)

Same Day Discharge

At least one night stay

450 37.78 (8.12) 23.78 (4.47) 0.21 (0.55) 121.23 (40.23) 178.90 (229.4) 293.12 (230.33) 3.34 (2.55) 13.78 (2.87)

130 44.61 (14.72) 25.18 (6.01) 0.20 (0.53) 1.67.44 (55.55) 301.67 (364.3) 399.34 (387.41 3.71 (3.48) 13.97 (4.10)

p value

.000 .187 .701 .000 .000 .001 .066 .554

Conclusion: Age, greater blood loss, longer surgical duration and increased mass of the myomas removed increases the risk that the patient will be admitted overnight. Knowledge of this may help in guiding postoperative goals and expectations.

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Open Communications 11 – Robotics (11:00 AM–12:00 PM) 11:14 AM – GROUP A

Is Robotic Surgery for Endometrial Cancer Affected by Patient Physique? Investigation of Japanese Patients Moritake T, Ito H, Takamizawa S, Isaka K. Obstetrics and Gynecology, Tokyo Medical University, Tokyo, Tokyo, Japan Study Objective: This study targeted endometrial cancer patients to investigate whether robotic surgery is affected by obesity or physique. In particular, we investigated the usefulness of robotic surgery for Japanese patients, who often have small physiques, with short stature and low body weight. Design: Retrospective case-control study. Setting: Department of Obstetrics and Gynecology, Tokyo Medical University Hospital. Patients: 116 patients (70 cases and 46 controls) diagnosed as early endometrial cancer according to histopathological and imaging examinations. Intervention: 70 patients underwent robotic surgery between March 2010 and May 2016. The control group comprised 46 early endometrial cancer patients who underwent open surgery during the same period. Measurements and Main Results: Patient backgrounds and various perioperative factors between the robotic surgery group (RG) and the open surgery group (OG) were compared. All cases were divided into the five groups according to their BMI (W1 toW5) and their body height (H1 to H5) respectively to comparatively investigate patient backgrounds and various perioperative factors. RG led to markedly smaller blood loss (approximately 1/16), shorter hospital stays (approximately 1/3), and an increase in the number of lymph nodes resected and a significantly lower incidence of postoperative complications (approximately 1/10) than open surgery. No significant differences in patient data were noted between RG and OG. No significant differences were found between any BMI-based subgroups and height-based subgroups. Conclusion: In our study, which targeted Japanese women with small physiques, no significant differences were noted in perioperative factors in endometrial cancer patients of any weight, ranging from thin to extremely obese. This also suggests that robotic surgery for endometrial cancer offers higher utility than open surgery for patients with smaller physiques in the same manner as it does for patients with larger physiques. 145

Open Communications 11 – Robotics (11:00 AM–12:00 PM) 11:21 AM – GROUP A

Detection of Urinary Tract Injuries by Routine Cystoscopy during Robotic Hysterectomy for Malignant and Complex Benign Pathology El-Neemany D,1 Pursell N,1 Greenberg P,2 Curcio E,1 Giglio A,1 Chen Y,1 Elsahwi K1. 1Obstetrics & Gynecology, Jersey Shore University Medical Center, Neptune, New Jersey; 2Office of Research Administration, Jersey Shore University Medical Center, Neptune, New Jersey Study Objective: To evaluate the role of routine cystoscopy in the detection of urinary tract injuries in robotic total laparoscopic hysterectomies performed for malignant and complex benign pathology. Design: A retrospective chart review. Setting: Two academic affiliated hospitals. Patients: Patients undergoing robotic-assisted laparoscopic hysterectomy for malignant or complex benign indications by a single gynecologic oncologist between January 2012 and December 2015. Routine cystoscopy was performed for all cases. Intervention: N/A. Measurements and Main Results: A total of 212 cases were reviewed for inclusion and six cases of urinary tract injury were identified (3%). Patient ages ranged from 47–90 years old and the average BMI was 31.8 ± 7.7 across all six patients. Three patient injuries were detected intra-operatively and the other 3 were diagnosed postoperatively. Two of the 3 cases of urinary

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Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201

tract injury detected intra-operatively were all bladder injuries caused from dissection of the bladder from the lower uterine segment and detected prior to performing the cystoscopy. The third case was detected immediately after performing a mini-laparotomy to extract a large uterus. The 3 cases of urinary tract injury detected postoperatively were ureteral injuries. All three cases of intraoperative injury and 2 of the 3 cases of delayed injury were performed for Stage I endometrial cancer. Additionally, the urinary tract injury group had prolonged surgical time and increased estimated blood loss. Conclusion: In this study, the incidence of urinary tract injury in robotic hysterectomy performed for malignant and complex benign cases was 3%. Performing routine cystoscopy did not improve detection of urinary tract injuries.

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Open Communications 11 – Robotics (11:00 AM–12:00 PM) 11:32 AM – GROUP B

Perioperative Outcomes of Robotic Hysterectomy With Mini-Laparotomy (RHML) Versus Open Hysterectomy (OH) for Uterus Weighing More Than 250 Grams Gupta N, McKendrick R, Mohling S, Holcombe J, Boren T, Depasquale S. University of Tennessee College of Medicine, Chattanooga, Tennessee Study Objective: To compare perioperative outcomes in patients undergoing robotic hysterectomy and extraction of specimen via mini-laparotomy (RHML) versus open hysterectomy (OH) when uterus weighs more than 250 grams. To study the factors determining the length of hospital stay in the 2 groups. Design: Retrospective Study (Canadian Task Force Classification II-3). Setting: Academic Community Based Hospital. Patients: Patients undergoing hysterectomy with uterine size more than 250 grams between years 2012 to 2015. Intervention: A mini-laparotomy, connecting 2 lateral port sites was performed for removal of specimen after completing hysterectomy. Measurements and Main Results: A total of 140 patients were divided into 2 groups based on type of surgery performed; RHML (n = 82) and OH (n = 58). Patient factors and perioperative outcomes were compared using Student t-tests and Chi-square analysis. Mean length of stay (RHML=1.4 days; OH=5.4 days), patient age (RHML = 51.5; OH = 46.5), estimated blood loss (EBL) (RHML = 119.9 ml; OH = 547.5 ml) and operative time (RHML = 191.5 min; OH = 162.8 min) were significantly different. No significant differences were noted for patient BMI, comorbidities, intraoperative complications, pathology of uterus and uterus weight. Postoperative complications were significantly different between two groups (RHML = 11.0%; OH = 25.9%; p = .021). None of the patients stayed less than 24 hours in OH group compared to 59.8% patients in RHML group. Type of procedure (p = .004) and EBL (p = .002) significantly predicted length of stay, accounting for 28.5% of the variance. Age (p = .075), operative time (p = .354) and uterus weight (p = .205) were not predictive of increased length of stay. Conclusion: Patients undergoing RHML have significantly shorter length of stay, EBL and postoperative complications than OH. The operative time for RHML was longer than OH, but this disadvantage is overcome by the overall decreased length of stay. RHML approach retains all the benefits of using da Vinci, while simultaneously preserving the specimen. This is a safe and feasible technique for tissue extraction where contained morcellation is either not preferred or not available.

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Open Communications 11 – Robotics (11:00 AM–12:00 PM) 11:39 AM – GROUP B

Effect of Tumor Burden on Safety and Feasibility of Three-Port Robotic-Assisted Myomectomy

Tyan P, Abi Khalil E, Vargas MV, Marfori C, Moawad G. George Washington University Hospital, Washington, DC Study Objective: To assess optimal candidates for a three-port roboticassisted myomectomy. Design: Retrospective cohort analysis. Setting: Urban teaching university hospital. Patients: Patients undergoing robotic-assisted myomectomy by fellowship trained minimally invasive gynecologists. Intervention: Three-port robotic-assisted myomectomy-camera port and two robotic arms, with no assistant ports. Measurements and Main Results: A total of 213 consecutive patients undergoing robotic-assisted myomectomy between 2012 and 2016 were selected. Procedures requiring ≥4 ports were labeled as “multiport”; surgeries done through 3 ports were labeled as “reduced port.” The two populations were homogeneous for baseline demographics, surgical history, and concomitant procedures at the time of myomectomy. The multiport group had larger tumor burden evidenced by the mean number of fibroid removed (Multiport 6.1 vs. Reduced 3.7, p < .01) mean weight of fibroid removed (Multiport 401.7 g vs. Reduced 268.2 g, p = .01). The safety of the reduced port myomectomy for patients with a slightly reduced tumor burden was assessed through appropriate regression models for the five following outcomes: intraoperative and postoperative complications, estimated blood loss, operative time and length of hospital stay. Based on the regression analysis, the total surgery time for reduced port myomectomy is on average 38.86 (95% CI: 18.74–58.98) minutes shorter than the multiport approach and the estimated blood loss in the reduced port myomectomy is in average 135.85 (95% CI: 10.22–261.47) mL less than the multiport approach. Those findings reflect the increased surgical interventions needed for a larger tumor burden. However, no significant difference for intraoperative or postoperative complication between multiport versus reduced port myomectomy was detected. Furthermore, the length of hospital stay for reduced port myomectomy was on average only 39% as long as those who underwent a multiport myomectomy (p = .04), reinforcing the safety of this procedure. Conclusion: In appropriately selected patients based on tumor burden, the reduced port robotic myomectomy is an adequate substitute for the multiport approach with comparable safety profiles.

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Open Communications 11 – Robotics (11:00 AM–12:00 PM) 11:46 AM – GROUP B

Outpatient Morbidity Associated with Concomitant High-Uterosacral Ligament Plication at the Time of Robotic Total Hysterectomy Sanderson DJ,1 Malczewski S,2 Osman M,1 Eddib A2. 1Obstetrics and Gynecology, Millard Fillmore Suburban Hospital, Williamsville, New York; 2Western New York Urology Associates, Cheektowaga, New York Study Objective: To compare the associated outcomes of robotic total hysterectomy (RTLH) with high-uterosacral ligament plication (HUSLP) to RTLH during the outpatient post-operative period. Design: Retrospective cohort study. Setting: Academic affiliated community hospital. Patients: Women who had benign robotic hysterectomy with or without concomitant HUSLP performed between 2012 and 2017 were selected for inclusion if they had at least 12 weeks of outpatient follow-up data available. Intervention: Robotic total hysterectomy for benign indications with or without high-uterosacral ligament plication. Measurements and Main Results: Except for age (55.9 years vs 48.8 years, p = .02) patient demographics were similar between the HUSLP group (n = 30) and the RTLH group (n = 30). Performance of concomitant HUSLP was associated with a 10% difference in discharge by postoperative day 2 (83% vs 93%, p = .23). Patients in the HUSLP group were more likely to have 3 or more follow-up visits (12 vs 5, p = .04) compared