Robotic hysterectomy compared with laparoscopic hysterectomy: is it still more costly to perform?

To establish the economic value of simple robotic hysterectomy vs laparoscopic hysterectomy and assess the impact of surgeon's experience. Retrospective cohort study. University-affiliated US regional healthcare system. Reproductive and post-menopausal women undergoing hysterectomy for benign indications. Robotic or laparoscopic hysterectomy. Between January 2018 and December 2019, a total of 985 simple laparoscopic and robotic hysterectomies were performed by 47 different gynecologists. Overall, the mean payment, direct cost, and profit were comparable (p value > 0.05) among simple robotic and laparoscopic hysterectomy. However, the mean operative time was significantly shorter for robotic hysterectomy compared to laparoscopic hysterectomy (106 min vs 127 min, respectively, p < 0.05). Operative time decreased as a surgeon's annual robotic case volume increased. Per-minute profitability of robotic hysterectomy increased significantly when a surgeon performed greater than 45 cases annually (p = 0.04). This effect became most pronounced when a surgeon performed 60 or more cases per year (p = 0.01). Simple robotic hysterectomy has shorter operative time compared to laparoscopic hysterectomy, with direct costs being similar. Robotic hysterectomy has higher per-minute profit compared to laparoscopic hysterectomy when a surgeon performs > 45 cases per year.

Risk Factors for Polypropylene Midurethral Sling Extrusion: A Case-Control Study.

OBJECTIVE: To identify risk factors associated with surgical revision of midurethral sling (MUS) due to mesh extrusion. MATERIALD AND METHODS: This is a case-control study identifying women who underwent primary surgical revision of polypropylene MUS for vaginal mesh extrusion from 2001 to 2016. Cases of surgical revision were compared to a randomly selected control group in a 1:5 ratio. Patient demographics and clinical characteristics were compared and multivariate logistic regression modeling was performed to analyze the relationships between risk factors and vaginal mesh extrusion. RESULTS: In total, 64 cases were identified and compared to 400 controls. The average subject was 51.7 years old (range, 30-78) with a body mass index (BMI) of 27.9 kg/m2 (range, 23.6-30.2) at the time of surgical revision. The median time to MUS revision was 318 days (interquartile range, 144-1355 days). Surgical revision was associated with current smokers (odds ratio [OR] = 5.43 [95% confidence interval [CI] 2.86, 10.31]), a BMI under 30 kg/m2 (OR = 4.37 [95% CI = 2.05, 9.36]), age under 55 years (OR = 2.02, [95% CI = 1.13, 3.61]), a retropubic sling (OR = 2.10 [95% CI = 1.14, 3.88]), and fibromyalgia (OR = 3.33 [95% CI 1.12, 9.95]). CONCLUSION: Smoking status, age under 55 years, BMI below 30 kg/m2, fibromyalgia, and retropubic approach were factors associated with surgical revision of MUS due to vaginal mesh extrusion. These findings may improve counseling and patient selection.

Manual morcellation compared to power morcellation during robotic myomectomy.

Clinical practice has drastically changed following the 2014 U.S. Food and Drug Administration (FDA) warning statement regarding power morcellation during laparoscopic hysterectomy and myomectomy. Despite investigation into alternative tissue extraction techniques, there remain a paucity of data associated with contained manual morcellation techniques. The goal of this study was to investigate the associated perioperative outcomes of contained manual morcellation compared to power morcellation in women undergoing robotic myomectomy. Performing manual morcellation (n = 38) resulted in a 21-min decrease in mean operative time (105.4 ± 42.2 vs 126.1 ± 44.1 min, p = 0.02) compared to power morcellation (n = 62). Women were younger (33 vs 36 years, p = 0.03) in the manual morcellation group, with all other patient demographics being similar. Median specimen weight (82 vs 104 g, p = 0.13), number of fibroids removed (2 vs 1, p = 0.16), estimated blood loss (10 vs 50 mL, p = 0.25), and post-operative morphine equivalents administered (5.57 ± 4.57 vs 5.29 ± 4.39, p = 0.76) were similar. The same-day discharge rate was not significantly different between the groups (86 vs 90%, p = 0.74). Linear regression modeling identified specimen weight, number of fibroids removed, and use of power morcellation as significant contributors to surgical time. Contained manual morcellation during robotic myomectomy is associated with a significant decrease in surgical time when compared to power morcellation, with similar post-operative narcotic administration and length of stay.