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Female Pelvic Medicine and Reconstructive Surgery ; 28(6):S61, 2022.
Article in English | EMBASE | ID: covidwho-2008713


Introduction: The COVID-19 pandemic has had a considerable and evolving impact on delivery of surgical care to patients. During the early stages of the pandemic, resource scarcity was experienced by many healthcare systems. This led to the implementation of a surgical moratorium on elective surgeries in New York State between the months of March through June 2020. Certain specialties, specifically those performing elective surgeries, experienced significant strain and transformation. Objective: This study aims to describe perioperative and intraoperative characteristics of patients undergoing hysterectomy for pelvic organ prolapse (POP) with and without concomitant urogynecology procedures between 2019-2021 at a multi-hospital healthcare system that experienced significantly strain and a subsequent moratorium on elective surgery during the first peak of the pandemic. Methods: This is a retrospective cohort analysis of all patients in a multi-hospital healthcare system in New York City who underwent hysterectomy for POP from August 19th, 2019 through August 11th, 2021. Cases were identified using procedural and diagnostic codes for hysterectomy and POP, respectively. Patients were separated into three cohorts based on dates corresponding to phases of the COVID-19 pandemic. The 'early peak' was defined from March through June 2020, coinciding with the New York State moratorium. The primary outcome was the stage of POP for patients undergoing surgery. Secondary outcomes included concomitant urogynecologic procedures, route of surgery, time from indication to procedure, length of inpatient stay, and utilization of pre-operative medical assessment/clearance (POMA). Results: A total of 253 cases were included: 106 (41.90%), 15 (5.93%), and 132 (52.17%) patients in the 'pre-pandemic','early peak pandemic', and 'stable pandemic' groups, respectively. Although not statistically significant, vaginal hysterectomy approach was performed less frequently during the 'early peak pandemic' and 'stable pandemic' cohorts (P = 0.0544). The 'early peak pandemic' cohort had significantly more stage IV POP compared to other cohorts (P = 0.0021). Rates of concomitant urogynecology procedures including slings, anterior or posterior repair, or apical repair did not differ between the cohorts. Further, cystoscopy was utilized intraoperatively more frequently in the 'stable pandemic' cohort (P = 0.0272). Time from surgical indication to operation was also significantly different with patients most frequently waiting at least 3 months in the 'early peak pandemic' group (P = 0.0132). Length of inpatient stay did not demonstrate a significant difference (P = 0.3982). The most frequent postoperative complication was transient voiding dysfunction, and this was observed more commonly in the 'stable pandemic' cohort (P = 0.0236), though overall no cases were complicated by persistent voiding dysfunction or urinary retention requiring surgical intervention in any group. Conclusions: In late spring 2020, when the moratorium was lifted, surgical volume returned to pre-peak numbers. However, time from booking to day of surgery remained significantly longer during and after the 'peak'. There was a statistically significant increase in patients with stage IV POP during the 'early peak' and 'stable' pandemic periods. There was a statistically significant increase in use of precautionary measures peri and intra-operatively during the 'peak' and 'stable pandemic' periods with significant increases in use of POMA performed outpatient by anesthesia and an increased utilization of intraoperative cystoscopy.

Female Pelvic Medicine and Reconstructive Surgery ; 28(6):S20-S21, 2022.
Article in English | EMBASE | ID: covidwho-2008705


Introduction: In terms of the lifetime risk of pelvic organ prolapse surgery, based on data obtained from the USA covering the years 2007 - 2011 relating to a large population of adult women (over 10 million), the cumulative risk for POP surgery was 12.6% and for SUI 13.6% [1]. In the Czech Republic all inhabitants have the same mandatory health insurance. All health insurance companies have to report all data about outpatient and inpatient procedures to the National Register of Covered Health Services from the year 2010. Objective: The aim of the study was to estimate the lifetime risk of pelvic organ prolapse surgery and stress urinary incontinence in the whole population of the Czech Republic, and to assess the overall number and type of surgery provided. Methods: The analysis is based on data provided by the Institute of Health Information and Statistics of the Czech Republic (IHIS CR);these data are collected in the context of The National Health Information System (NHIS) and national health registers;the relevant data from 2010 to 2020 are available. The methodology used to establish the lifetime risk of surgery for prolapse (or incontinence) was based on data from the Czech Statistical Office estimating the probability of the woman surviving to a particular age. Results: 60,996 women underwent surgery for pelvic organ prolapse and 44,403 for SUI between 2010-2020 (at 1 January 2020 5,421,943 women were living in the Czech Republic);the average age of women undergoing surgery for POP was 64, and for SUI the mean age was 57. The most common prolapse procedure was hysterectomy (40,082), generally in combination with traditional vaginal wall repair (20,188 procedures). Similarly, the provision of traditional vaginal wall repair remained steady (overall 25,723 procedures). In the period monitored an increase in laparoscopical procedures was evident, rising by 100% from 1180 procedures in 2010 to 2009 surgeries in 2019 (in total 18727 from 2010 to 2020). The most common procedure is laparoscopically assisted vaginal hysterectomy (15268). And increase in laparoscopical sacrocolpopexis is also apparent (total 2298). The risk of reoperation for POP in women undergoing surgery between 2010 and 2015 varied between 3.3 and 4.2%. Mean lifetime risk for POP surgery for women having surgery between the years 2015 and 2020 is 14.12% (min 13.58, max 14.37%). The Covid pandemic significantly decreased the number of procedures for POP (on average on 29%). The most common anti-incontinent procedure is tension-free vaginal tape (total 44389). In terms of risk, the risk of reoperation for SUI for women having surgery between 2010 and 2015 varied between 0.2 and 0.7%. The mean lifetime risk for SUI surgery for women undergoing surgery between the years 2015 and 2020 is 6.44 (min 5.82, max 6.71) with a declining trend of anti-incontinence surgery. Conclusions: We have unique data available which covers the whole female population of the Czech Republic, indicating trends in surgical treatment of POP and SUI and making it possible to estimate lifetime risk of such surgery and also the risk of recurrent surgery.

Female Pelvic Medicine and Reconstructive Surgery ; 28(6):S152, 2022.
Article in English | EMBASE | ID: covidwho-2008700


Introduction: Minimally invasive sacrocolpopexy (SCP) is the gold-standard treatment for patients with apical prolapse and is increasingly used as a primary intervention in women with uterovaginal prolapse. There is a lack of comparative data evaluating costs between SCP versus native tissue vaginal repair in the post-ERAS implementation era. Objective: The primary aim was to determine the cost difference between performing hysterectomy and minimally-invasive sacrocolpopexy as compared to vaginal hysterectomy with native tissue vaginal repair for uterovaginal prolapse. We hypothesized that minimally-invasive sacral colpopexy has a higher cost when compared to native tissue repair but when failure rates of native tissue repair approach 15%, costs equilibrate. Methods: This was a retrospective cohort study at a tertiary care center. The electronic medical record system was queried for women who underwent native tissue vaginal repair or minimally invasive SCP with concomitant hysterectomy for uterovaginal prolapse in calendar year 2021 (post-COVID enhanced recovery after surgery implementation). We excluded all patients who had concomitant colorectal procedures and where billing was not complete or re-imbursement was not received. Hospital charges, direct and indirect costs and operating margin (net revenue minus all costs) were obtained from Strata Jazz and were compared using R statistical program. Net revenue (reimbursement) was directly obtained from the record as the total payment received by the hospital from the payor. Results: A total of 81 women were included, (33 SCP (25 robotic and 8 laparoscopic) versus 48 native tissue). Payor mix included 27% Medicare, 5% medicaid, 61% employer-based and 7% private insurance. Demographic and surgical data is presented in Table 1. The mean total charge per case for services was higher in the SCP group compared to the vaginal repair group ($119,863 vs. $82,205, P < 0.01). Cost of supplies was more in the SCP group ($4429 vs. $2108, P < 0.01), but the cost of operating room time and staff was similar ($7926 vs. $7216, P = 0.06). Controlling for surgeon, age and BMI, the direct and indirect costs were also higher in the SCP group ($13,649 vs. $10,168, P < 0.01 and $5068 vs. $3685, P < 0.01, respectively). Net revenue was lower for the vaginal repair group compared to the SCP group ($14,614 vs. $31,618, P < 0.01). The operating margin was significantly higher in the SCP group ($11,770 vs. $ 517, P < 0.01). Additionally, there were no significant differences in the net revenue between different payors (P = 0.8997). Same-day discharge and EBL were similar among both groups with operative time being higher in the SCP group (204 vs. 161, P < 0.01). Using the means of the direct costs between groups, a re-operation rate of 25.5% would be needed for the native tissue repair costs to equilibrate to the SCP group. From a hospital perspective, due to the low operating margins experienced with native tissue vaginal repair, 227 native tissue vaginal repairs would need to be performed for the same net return as 10 minimally-invasive SCP's. Conclusions: Vaginal hysterectomy with native tissue repair had lower direct and indirect costs compared to minimally-invasive SCP. However, operating margins are significantly higher for SC P due to net revenue received. (Table Presented).