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Hospital Outcomes of Robotic Versus Laparoscopic Hysterectomy: A Texas Statewide Analysis
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253 177 Robot-Assisted Laparoscopic Myomectomy, an Alternative to Laparotomy for Numerous Myomas (Over 10) Kim HK, Kang SY, Chung YJ, Cho HH, Kim JH, Kim MR. Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea Study Objective: To evaluate the feasibility of robot-assisted laparoscopic myomectomy in multiple myomas over 10 in number Design: A retrospective chart review. Setting: An academic medical center. Patients: Women who underwent removal of 10 or more uterine myomas by robotics. Intervention: This study is a retrospective chart review of 216 patients who underwent robot-assisted laparoscopic myomectomy by a single operator at St. Mary’s Fibroid Center in Seoul between October 1, 2010 and January 31, 2014; in the selected patients, 10 or more uterine myomas were removed. We reported the characteristics of the removed myomas including the with maximum diameter of the myomas, the sum of the diameter of each myoma, and the types of the combined surgeries with robot-assisted laparoscopic myomectomy that were used on 10 or more myomas; we the organized surgical outcomes that were measured including the operative time, length of hospital stay, and perioperative complications. Measurements and Main Results: A total of 14 women underwent the removal of 10 or more uterine myomas by robotics. The patient age was 38.03.8 years and all of the patients were nulliparous. The operation time was 434.1100.6 min. The number of removed myomas for each case was 13.33.6. The myoma with the maximum diameter was 6.60.8 centimeters. The sum of the diameters was 34.89.6 centimeters (range 20.0-54.5 centimeters). No case was converted into conventional laparoscopy or laparotomy. The postoperative hospital stay was 2.60.6 days. One patient had post-operative neck pain, which regressed spontaneously. Conclusion: This report is the first to describe the feasibility of robotassisted laparoscopic myomectomy in multiple myomas over 10 in number. In robot-assisted laparoscopic myomectomies, supplementary techniques including preoperative MRI assessment, intraoperative sonographic navigation, and palpation by an assistant to localize the myomas are helpful in overcoming the absence of haptic perception. This technique is considered to be an alternative to laparotomy for more than 10 myomas.
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excluding the outliers necessitated by a few extreme values. There was no difference in the mean operating time, blood loss and need for transfusion. Patients in RALM group had significantly lesser requirement of intravenous analgesic (61 hours versus 33 hours) and a shorter hospital stay (1.8 days versus 2.8 days). Conclusion: RALM offers comparable surgical outcomes while reducing intravenous analgesic requirements and hospital stay. The number of fibroids removed at RALM is higher although the overall weight removed is the same, suggesting that this approach might be more useful in patients with multiple fibroids. The operating time is similar (time needed for docking and morcellation was excluded in RALM group). Docking and morcellation time can be reduced as the experience of the surgical team increases. Patients with dysmenorrhea chose RALM more often suggesting that presentation and possibly patient-bother might influence choices. The major limitations are that this study is retrospective, nonrandom and open label. 179 Hospital Outcomes of Robotic Versus Laparoscopic Hysterectomy: A Texas Statewide Analysis Lopez S, Saldivar JS, Hernandez LL, Mulla ZD. Ob/Gyn, Texas Tech Health Science Center El Paso, El Paso, Texas Study Objective: To compare women who underwent robotic-assisted laparoscopic hysterectomy(RALH) with women who underwent laparoscopic hysterectomy(LH) and were found in a statewide hospital database, the Texas Research Data File(RDF). Design: The 2011 RDF was analyzed. Women who underwent RALH and LH were identified using ICD-9-CM procedure codes. The outcomes were urinary retention, a prolonged length of stay, and elevated total charges in dollars. Prolonged length of stay was defined as any stay longer than the median length of stay of the sub-sample of patients in question. Elevated total charges was defined as any total charge greater than the median value of the subgroup in question. The final analysis focused on women
178 A Comparison of Robot-Assisted Laparoscopic Myomectomy (RALM) With Laparoscopic-Assisted Myomectomy (LAM) Sinha R, Sanjay M, Bana R. Gynecology, Apollo Hospital, Hyderabad, Telangana, India Study Objective: To assess whether RALM provides clinical outcomes comparable to LAM in terms of operative time, post operative recovery and complications. Design: Retrospective cohort study. Setting: Tertiary care private teaching Hospital. Patients: All patients who underwent myomectomy between June 2012 to December 2014. Intervention: Patients underwent myomectomy by either RALM or LAM. Large fibroids were morcellated and removed. Measurements and Main Results: 76 patients underwent myomectomy in the study period. 40 and 36 women chose RALM and LAM respectively. There were no open myomectomies or conversions. The mean age (33.9y, 32.2y), BMI (24.6, 25.0) and co-morbidities were similar in both groups. Number of women presenting with dysmenorrhea were more in RALM group (9/40 versus 1/36, p=0.03). The average number of fibroids removed at RALM was higher (2.3 versus 1.3, p=0.01) but the average weight of fibroids removed was similar in the two groups (399679g versus 6881115g). These differences persisted despite re-analysis after
Figure 1. Identifying the Sample of 10,229 Women who Underwent Robotic-Assisted Laporoscopic Hysterectomy (RALH) or Laparoscopic Hysterectomy (LH) Throughout Texas and were Discharged in 2011.
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Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
who underwent RALH for a benign indication with the patient’s county of residence serving as the exposure variable: women who resided in Texas counties along the Mexican border were compared to women who resided in non-border Texas counties. Adjusted relative risks (RR) were calculated. Setting: Hospital. Patients: Female patients undergoing a hysterectomy for benign indications. Measurements and Main Results: 10,229 women had either an RALH or LH. Among women with benign conditions, RALH vs LH was associated with a 48% increase in the risk of elevated total charges (adjusted RR=1.48, P\0.0001) and a 24% decrease in the risk of a prolonged length of stay (adjusted RR=0.76, P\0.0001). After controlling for several factors, border residents were 81% more likely than non-border
Table 1 Unadjusted and Adjusted* Risk Ratios (RR), 95% Confidence Intervals (CI), and P Values for Three Hospital Outcomes Among 9412 Women who Underwent Robotic-Assisted Laparoscopic Hysterectomy (RALH) or Laparoscopic Hysterectomy (LH) for a Benign Indicationy and were Discharged in 2011 from Reporting Hospitals Throughout Texas. RRs Compare the RALH Group with the LH Group. Unadjusted Outcome
RR
Elevated 1.50 total charges Prolonged 0.78 length of stay Urinary 0.83 retention
95% CI
P value
Adjusted RR
95% CI
P value
1.44-1.56 \0.0001 1.48
1.42-1.54 \0.0001
0.73-0.83 \0.0001 0.76
0.72-0.81 \0.0001
0.57-1.21 0.33
0.72-0.81 0.31
0.82
* Adjusted for age, health insurance, race/ethnicity, diabetes, obesity, and tobacco use. y This group of women did not have a principal or secondary discharge diagnosis of an in situ or invasive neoplasm of any reproductive organ.
Table 2 Unadjusted and Adjusted* Risk Ratios (RR), 95% Confidence Intervals (CI), and P Values for Three Hospital Outcomes Among 3169 Women who Underwent Robotic-Assisted Laparoscopic Hysterectomy for a Benign Indicationy and were Discharged in 2011 from Reporting Hospitals Throughout Texas. RRs Compare Women who Lived on the Texas-Mexico Border with Those who Lived in Non-Border Texas Counties at the Time of their Hysterectomy. Unadjusted Outcome
RR
Elevated 1.88 total charges Prolonged 0.94 length of stay Urinary 1.05 retention
95% CI
P value
Adjusted RR
95% CI
P value
1.77-1.99 \0.0001 1.81z
1.67-1.96 \0.0001
0.79-1.13 0.51
0.91
0.75-1.12 0.38
0.37-2.94 0.93
1.20
0.37-3.94 0.76
* Adjusted for age, health insurance, race/ethnicity, diabetes, obesity, and tobacco use. y This group of women did not have a principal or secondary discharge diagnosis of an in situ or invasive neoplasm of any reproductive organ. z The log-binomial model did not converge. This adjusted RR is from a Poisson regression model.
residents to have total charges that were higher than the median value for this cohort of 3169 patients (P\0.0001). Conclusion: RALH (compared with LH) was associated with a higher risk of elevated total charges but a lower risk of having a prolonged length of stay. Among women who underwent RALH for benign indications, those who lived along the Texas-Mexico border were more likely to experience the outcome of elevated total charges.
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Open Communications 13 - Reproductive Issues (11:00 AM - 12:00 PM)
Fertility and Pregnancy Outcomes Following Robotic Myomectomy Rosen L, Sekhon L, Alicia R, Mandelberger A, Ascher-Walsh C. Obstetrics and Gynecology, Icahn School of Medicine at Mt. Sinai, New York, New York Study Objective: To assess post-operative fertility rates and pregnancy outcomes of patients who had a robotic myomectomy with a single surgeon at Mount Sinai Hospital from June 2006 to May 2013. Design: Retrospective case series. Setting: University Hospital. Patients: 337 patients that underwent robotic myomectomy with a single surgeon. Intervention: We reviewed the medical records of 337 patients that underwent robotic myomectomy with a single surgeon at a large university hospital program. Routine postoperative care involved obtaining follow up on their fertility and pregnancy outcomes. Measurements and Main Results: 337 women with mean age of 40.55 +/12.24 years (range 24-55) and mean BMI of 24.53+/-4.9 kg/m2. Patients had a mean of 3.34 +/- 2.9 fibroids removed (range 1-21), with the average mass of the fibroids being 331.23 +/- 310.36 grams. 254 of 337 patients (75.4%) provided fertility and pregnancy outcome data. Follow-up from time of surgery to most recent charted data ranged from 10 months to 7.9 years. Of the 254 women, 112 (44.1%) actively tried for pregnancy after surgery. 73.2% of the 112 achieved a total of 82 pregnancies – 50 full term, 12 preterm, 19 spontaneous abortions and 1 termination. 90.4% of these patients underwent cesarean section. A subset of 50 women had pre-existing infertility. 17 of these patients underwent intrauterine insemination (IUI), while 16 underwent in vitro fertilization (IVF). After surgery, 60% of these patients achieved 30 total pregnancies. Of the 254 cases, there was one placenta accreta and no uterine ruptures. Conclusion: The fertility rate after robotic myomectomy for all women attempting to conceive (73.2%) and for those with known infertility who continued to try for pregnancy (60%) were similar. There was a low incidence of major complications associated with the presence of uterine scarring in pregnancies conceived after robotic myomectomy in both women with and without a diagnosis of fertility.
181 The Association Between Surgically-Diagnosed Endometriosis and Adverse Pregnancy Outcomes Chen I,1 Shen M,2 Singh SS,1 Lalani S,1 Wen S-W.2 1Department of Obstetrics and Gynaecology, University of Ottawa, Ottawa, Ontario, Canada; 2The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada Study Objective: To determine the relationship between surgicallydiagnosed endometriosis and maternal, fetal, and neonatal outcomes in pregnancy. Design: A retrospective cohort study of women with deliveries from 2003 to 2013 was conducted using The Ottawa Hospital (TOH) Data Warehouse Discharge Abstract Database. Setting: A tertiary level academic centre (The Ottawa Hospital) in Ottawa, Ontario, Canada. Patients: Women with surgically-diagnosed endometriosis were identified using ICD-10 codes from previous hospital admissions and were compared
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excluding the outliers necessitated by a few extreme values. There was no difference in the mean operating time, blood loss and need for transfusion. Patients in RALM group had significantly lesser requirement of intravenous analgesic (61 hours versus 33 hours) and a shorter hospital stay (1.8 days versus 2.8 days). Conclusion: RALM offers comparable surgical outcomes while reducing intravenous analgesic requirements and hospital stay. The number of fibroids removed at RALM is higher although the overall weight removed is the same, suggesting that this approach might be more useful in patients with multiple fibroids. The operating time is similar (time needed for docking and morcellation was excluded in RALM group). Docking and morcellation time can be reduced as the experience of the surgical team increases. Patients with dysmenorrhea chose RALM more often suggesting that presentation and possibly patient-bother might influence choices. The major limitations are that this study is retrospective, nonrandom and open label. 179 Hospital Outcomes of Robotic Versus Laparoscopic Hysterectomy: A Texas Statewide Analysis Lopez S, Saldivar JS, Hernandez LL, Mulla ZD. Ob/Gyn, Texas Tech Health Science Center El Paso, El Paso, Texas Study Objective: To compare women who underwent robotic-assisted laparoscopic hysterectomy(RALH) with women who underwent laparoscopic hysterectomy(LH) and were found in a statewide hospital database, the Texas Research Data File(RDF). Design: The 2011 RDF was analyzed. Women who underwent RALH and LH were identified using ICD-9-CM procedure codes. The outcomes were urinary retention, a prolonged length of stay, and elevated total charges in dollars. Prolonged length of stay was defined as any stay longer than the median length of stay of the sub-sample of patients in question. Elevated total charges was defined as any total charge greater than the median value of the subgroup in question. The final analysis focused on women
178 A Comparison of Robot-Assisted Laparoscopic Myomectomy (RALM) With Laparoscopic-Assisted Myomectomy (LAM) Sinha R, Sanjay M, Bana R. Gynecology, Apollo Hospital, Hyderabad, Telangana, India Study Objective: To assess whether RALM provides clinical outcomes comparable to LAM in terms of operative time, post operative recovery and complications. Design: Retrospective cohort study. Setting: Tertiary care private teaching Hospital. Patients: All patients who underwent myomectomy between June 2012 to December 2014. Intervention: Patients underwent myomectomy by either RALM or LAM. Large fibroids were morcellated and removed. Measurements and Main Results: 76 patients underwent myomectomy in the study period. 40 and 36 women chose RALM and LAM respectively. There were no open myomectomies or conversions. The mean age (33.9y, 32.2y), BMI (24.6, 25.0) and co-morbidities were similar in both groups. Number of women presenting with dysmenorrhea were more in RALM group (9/40 versus 1/36, p=0.03). The average number of fibroids removed at RALM was higher (2.3 versus 1.3, p=0.01) but the average weight of fibroids removed was similar in the two groups (399679g versus 6881115g). These differences persisted despite re-analysis after
Figure 1. Identifying the Sample of 10,229 Women who Underwent Robotic-Assisted Laporoscopic Hysterectomy (RALH) or Laparoscopic Hysterectomy (LH) Throughout Texas and were Discharged in 2011.
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Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
who underwent RALH for a benign indication with the patient’s county of residence serving as the exposure variable: women who resided in Texas counties along the Mexican border were compared to women who resided in non-border Texas counties. Adjusted relative risks (RR) were calculated. Setting: Hospital. Patients: Female patients undergoing a hysterectomy for benign indications. Measurements and Main Results: 10,229 women had either an RALH or LH. Among women with benign conditions, RALH vs LH was associated with a 48% increase in the risk of elevated total charges (adjusted RR=1.48, P\0.0001) and a 24% decrease in the risk of a prolonged length of stay (adjusted RR=0.76, P\0.0001). After controlling for several factors, border residents were 81% more likely than non-border
Table 1 Unadjusted and Adjusted* Risk Ratios (RR), 95% Confidence Intervals (CI), and P Values for Three Hospital Outcomes Among 9412 Women who Underwent Robotic-Assisted Laparoscopic Hysterectomy (RALH) or Laparoscopic Hysterectomy (LH) for a Benign Indicationy and were Discharged in 2011 from Reporting Hospitals Throughout Texas. RRs Compare the RALH Group with the LH Group. Unadjusted Outcome
RR
Elevated 1.50 total charges Prolonged 0.78 length of stay Urinary 0.83 retention
95% CI
P value
Adjusted RR
95% CI
P value
1.44-1.56 \0.0001 1.48
1.42-1.54 \0.0001
0.73-0.83 \0.0001 0.76
0.72-0.81 \0.0001
0.57-1.21 0.33
0.72-0.81 0.31
0.82
* Adjusted for age, health insurance, race/ethnicity, diabetes, obesity, and tobacco use. y This group of women did not have a principal or secondary discharge diagnosis of an in situ or invasive neoplasm of any reproductive organ.
Table 2 Unadjusted and Adjusted* Risk Ratios (RR), 95% Confidence Intervals (CI), and P Values for Three Hospital Outcomes Among 3169 Women who Underwent Robotic-Assisted Laparoscopic Hysterectomy for a Benign Indicationy and were Discharged in 2011 from Reporting Hospitals Throughout Texas. RRs Compare Women who Lived on the Texas-Mexico Border with Those who Lived in Non-Border Texas Counties at the Time of their Hysterectomy. Unadjusted Outcome
RR
Elevated 1.88 total charges Prolonged 0.94 length of stay Urinary 1.05 retention
95% CI
P value
Adjusted RR
95% CI
P value
1.77-1.99 \0.0001 1.81z
1.67-1.96 \0.0001
0.79-1.13 0.51
0.91
0.75-1.12 0.38
0.37-2.94 0.93
1.20
0.37-3.94 0.76
* Adjusted for age, health insurance, race/ethnicity, diabetes, obesity, and tobacco use. y This group of women did not have a principal or secondary discharge diagnosis of an in situ or invasive neoplasm of any reproductive organ. z The log-binomial model did not converge. This adjusted RR is from a Poisson regression model.
residents to have total charges that were higher than the median value for this cohort of 3169 patients (P\0.0001). Conclusion: RALH (compared with LH) was associated with a higher risk of elevated total charges but a lower risk of having a prolonged length of stay. Among women who underwent RALH for benign indications, those who lived along the Texas-Mexico border were more likely to experience the outcome of elevated total charges.
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Open Communications 13 - Reproductive Issues (11:00 AM - 12:00 PM)
Fertility and Pregnancy Outcomes Following Robotic Myomectomy Rosen L, Sekhon L, Alicia R, Mandelberger A, Ascher-Walsh C. Obstetrics and Gynecology, Icahn School of Medicine at Mt. Sinai, New York, New York Study Objective: To assess post-operative fertility rates and pregnancy outcomes of patients who had a robotic myomectomy with a single surgeon at Mount Sinai Hospital from June 2006 to May 2013. Design: Retrospective case series. Setting: University Hospital. Patients: 337 patients that underwent robotic myomectomy with a single surgeon. Intervention: We reviewed the medical records of 337 patients that underwent robotic myomectomy with a single surgeon at a large university hospital program. Routine postoperative care involved obtaining follow up on their fertility and pregnancy outcomes. Measurements and Main Results: 337 women with mean age of 40.55 +/12.24 years (range 24-55) and mean BMI of 24.53+/-4.9 kg/m2. Patients had a mean of 3.34 +/- 2.9 fibroids removed (range 1-21), with the average mass of the fibroids being 331.23 +/- 310.36 grams. 254 of 337 patients (75.4%) provided fertility and pregnancy outcome data. Follow-up from time of surgery to most recent charted data ranged from 10 months to 7.9 years. Of the 254 women, 112 (44.1%) actively tried for pregnancy after surgery. 73.2% of the 112 achieved a total of 82 pregnancies – 50 full term, 12 preterm, 19 spontaneous abortions and 1 termination. 90.4% of these patients underwent cesarean section. A subset of 50 women had pre-existing infertility. 17 of these patients underwent intrauterine insemination (IUI), while 16 underwent in vitro fertilization (IVF). After surgery, 60% of these patients achieved 30 total pregnancies. Of the 254 cases, there was one placenta accreta and no uterine ruptures. Conclusion: The fertility rate after robotic myomectomy for all women attempting to conceive (73.2%) and for those with known infertility who continued to try for pregnancy (60%) were similar. There was a low incidence of major complications associated with the presence of uterine scarring in pregnancies conceived after robotic myomectomy in both women with and without a diagnosis of fertility.
181 The Association Between Surgically-Diagnosed Endometriosis and Adverse Pregnancy Outcomes Chen I,1 Shen M,2 Singh SS,1 Lalani S,1 Wen S-W.2 1Department of Obstetrics and Gynaecology, University of Ottawa, Ottawa, Ontario, Canada; 2The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada Study Objective: To determine the relationship between surgicallydiagnosed endometriosis and maternal, fetal, and neonatal outcomes in pregnancy. Design: A retrospective cohort study of women with deliveries from 2003 to 2013 was conducted using The Ottawa Hospital (TOH) Data Warehouse Discharge Abstract Database. Setting: A tertiary level academic centre (The Ottawa Hospital) in Ottawa, Ontario, Canada. Patients: Women with surgically-diagnosed endometriosis were identified using ICD-10 codes from previous hospital admissions and were compared