The Role of Robotics in Meeting Institutional Goals: A Unified Strategy to Facilitate Program Excellence.

PURPOSE: The rapid expansion of robotic surgical equipment necessitates a review of the needs and challenges faced by hospitals introducing robots for the first time to compete with experienced institutions. The aim of this study was to analyze the impact of robotic surgery on our hospital compared to open and laparoscopic surgery, examine internal transformations, and assess regional, domestic, and international implications. METHODS: A retrospective review was conducted of electronic medical records (EMRs) from 2019 to 2022 at Inha University Hospital, including patients who underwent common robotic procedures and equivalent open and laparoscopic operations. The study investigated clinical and operational performance changes in the hospital after the introduction of robotic technology. It also evaluated the operational effectiveness of robot implementation in local, national, and international contexts. To facilitate comparison with other hospitals, the data were transmitted to Intuitive Surgical, Inc. for analysis. The study was conducted in compliance with domestic personal information regulations and received approval from our Institutional Review Board. RESULTS: We analyzed EMR data from 3,147 patients who underwent surgical treatment. Over a period of 3.5 years, the adoption of robotic technology in a hospital setting significantly enhanced the technical skills of all professors involved. The introduction of robotic systems led to increased patient utilization of conventional surgical techniques, as well as a rise in the number of patients choosing robotic surgery. This collective trend contributed to an overall increase in patient numbers. This favorable evaluation of the operational effectiveness of our hospital's robot implementation in the context of local, national, and global factors is expected to positively influence policy changes. CONCLUSION: Stakeholders should embrace data science and evidence-based techniques to generate valuable insights from objective data, assess the health of robot-assisted surgery programs, and identify opportunities for improvement and excellence.

Formononetin Inhibits Progression of Endometriosis via Regulation of p27, pSTAT3, and Progesterone Receptor: In Vitro and In Vivo Studies.

OBJECTIVES: Formononetin is one of the phytoestrogens that functions like a selective estrogen receptor modulator (SERM). In this study, we evaluated the effects of formononetin on endometriosis progression in vitro and in vivo. MATERIALS AND METHODS: After pathological confirmation, 10 eutopic and ectopic endometria were collected from patients with endometriosis. Ten eutopic endometria samples were collected from patients who did not have endometriosis. To determine the cytotoxic dose and therapeutic dose of formononetin, the concentration of 70% of the cells that survived after formononetin administration was estimated using a Cell counting kit-8 (CCK 8) assay. Western blot analysis was used to determine the relative expression levels of BAX, p53, pAKT, ERK, pERK, p27, and pSTAT3 in the eutopic endometria without endometriosis, eutopic endometria with endometriosis, and ectopic endometria with endometriosis as the formononetin concentration was increased. We confirmed the effect of formononetin on apoptosis and migration in endometriosis using fluorescence-activated cell sorting (FACS) and wound healing assays, respectively. A mouse model of endometriosis was prepared using a non-surgical method, as previously described. The mice were intraperitoneally administered formononetin for four weeks after dividing them into control, low-dose formononetin (40 mg/kg/day) treatment, and high-dose (80 mg/kg/day) formononetin treatment groups. All the mice were euthanized after formononetin treatment. Endometriotic lesions were retrieved and confirmed using hematoxylin and eosin (H&E) staining. Immunohistochemical (IHC) staining of p27 was performed. RESULTS: We set the maximum concentration of formononetin administration to 80 µM through the CCK8 assay. Based on formononetin concentration, the expression levels of BAX, p53, pAKT, ERK, pERK, p27, and pSTAT3 proteins were measured using Western blot analysis (N = 4 per group). The expression level of pERK, p27, and pSTAT3 in eutopic endometrium with endometriosis tended to decrease with increasing formononetin concentration, and a significant decrease was noted at 80 µM. The expression of p27 in ectopic endometrium with endometriosis was also significantly decreased at 80 µM of formononetin. FACS analysis revealed that formononetin did not significantly affect apoptosis. In the wound healing assay, formononetin treatment revealed a more significant decrease in the proliferation of the eutopic endometrium in patients with endometriosis than in the eutopic endometrium without endometriosis. Relative expression of sex hormone receptors decreased with increasing formononetin doses. Although no significant differences were observed in the ER, PR-A, ERß/ERα, and PR-B/PR-A, significant down-regulation of PR-B expression was noted after formononetin treatment at 80 µM. In the in vivo study, endometriotic lesions in the formononetin-treated group significantly decreased compared to those in the control group. The relative expression of p27 using IHC was highest in the control group and lowest in the high-dose formononetin treatment group. CONCLUSIONS: Formononetin treatment was shown to inhibit the proliferation of eutopic and ectopic endometria in patients with endometriosis through the regulation of p27, pSTAT3, and PR-B. In an endometriosis mouse model, formononetin treatment significantly reduced the number of endometriotic lesions with decreased p27 expression. The results of this study suggest that formononetin may be used as a non-hormonal treatment option for endometriosis.

Transcriptomic patterns in early-secretory and mid-secretory endometrium in a natural menstrual cycle immediately before in vitro fertilization and embryo transfer.

OBJECTIVE: This study aimed to evaluate the endometrial transcriptomic patterns in the early secretory phase (ESP) and mid-secretory phase (MSP) of the natural menstrual cycle before in vitro fertilization and embryo transfer (IVF-ET). METHODS: Thirty patients whose endometrial tissues were obtained from the ESP or MSP of a natural menstrual cycle immediately before IVF-ET were included. Endometrial dating was histologically confirmed as ESP (cycle days 16-18) or MSP (cycle days 19-21), according to the noyes criteria. The patients were divided into two groups depending on the IVF-ET outcome: pregnant (n=14; 7 in ESP and 7 in MSP) or non-pregnant (n=16; 8 in ESP and 8 in MSP). Differentially expressed genes (DEGs) in the MSP, compared to the ESP, were identified using NanoString nCounter (NanoString Technologies, Seattle, WA, USA) data for both the pregnant and non-pregnant groups. RESULTS: Thirteen DEGs in the pregnant group and 11 DEGs in the non-pregnant group were identified in the MSP compared to those in the ESP. In both groups, adrenoceptor alpha 2A, interleukin 1 receptor-associated kinase 2, a disintegrin and metalloproteinase with thrombospondin repeats 15 (ADAMTS15), serpin family E member 1, integrin subunit beta 3, transmembrane protein 252 (TMEM252), huntingtin associated protein 1, C2 calcium-dependent domain containing 4A, and integrin subunit alpha 2 were upregulated in the MSP, compared to the ESP. TMEM37, galactosidase beta 1 like 2, Rho family GTPase 3, and cytochrome P450 family 24 subfamily A member 1 were upregulated in the MSP only in the pregnant group. ADAMTS8 was downregulated and monoamine oxidase A was upregulated in the MSP only in the non-pregnant group. CONCLUSION: Transcriptomic patterns in the endometrium immediately before IVF-ET appear to differ according to the IVF-ET outcome. These novel DEGs, which have not been previously studied, may have functional significance during the window of implantation and serve as potential biomarkers of endometrial receptivity.

Effect of maternal age on maternal and perinatal outcomes including cesarean delivery following induction of labor in uncomplicated elderly primigravidae.

ABSTRACT: Age above 35 years at the time of birth is generally referred to as advanced maternal age (AMA), and it could be a risk factor for various complications besides genetic changes in the fetus. The primary outcome of this study was to determine if AMA is associated with emergent cesarean delivery (CD) following induction of labor (IOL). The secondary outcomes were a composite of adverse maternal and perinatal outcomes following IOL.This retrospective observational study included women with singleton, live-born, cephalic, non-anomalous pregnancies undergoing IOL from 38 0/7 to 41 6/7 weeks of gestation. Mode of delivery and other maternal and neonatal outcomes were compared between women aged ≥35 (AMA) and <35 years. Multivariate logistic regression analyses were performed.A total of 307 nulliparous women underwent IOL (≥35 years n = 73, 23.8%; <35 years n = 234, 76.2%) and among them, 252 (82.1%) delivered vaginally. The rate of CD was significantly higher in women of AMA (31.5% vs 13.7%, P = .001). Multivariable analysis showed that AMA was independently associated with CD (odds ratio 3.04, 95% confidence interval 1.55-5.96, P = .001). The rate of instrumental deliveries was higher in the AMA group (19.6% vs 8.2%, P = .043) and hemoglobin decrease during delivery was similar between the 2 groups (1.90 ±â€Š1.25 vs 2.02 ±â€Š1.27 mg/dL, all P > .05). Regarding neonatal outcomes, there was no difference between the 2 groups in the neonatal intensive care unit admission rate and Apgar score <7 at 5 minutes (30.3% vs 30.1% and 6.0% vs 8.2%, respectively, all P > .05). Neonatal intubation rate and severe respiratory problems were non-significantly higher in AMA (3.8% vs 2.7% and 3.4% vs 1.4%, respectively, all P > .05).AMA was associated with an approximately three-fold increased likelihood of birth by CD and operative vaginal delivery in uncomplicated nulliparous women following IOL. However, we found no evidence that IOL in primigravid women of AMA increases adverse maternal and perinatal outcomes as compared with women aged <35 years except the high prevalence of CD and operative vaginal delivery.

The effect of diagnosis-related group payment system on the quality of medical care for pelvic organ prolapse in Korean tertiary hospitals.

PURPOSE: To assess changes in clinical practice patterns after implementing diagnosis-related group (DRG) payment system in July 2013 and its effect on the quality of care for pelvic organ prolapse (POP). MATERIALS AND METHODS: Using the 2011-2016 administrative database from National Health Insurance claim data, we reviewed medical information of 7362 patients who underwent hysterectomies for POP in Korean tertiary hospitals. We compared changes in several variables including length of stay, concomitant procedures, outpatient visits and readmission within 30 days after discharge, and retreatment for POP or stress urinary incontinence within postoperative 1 year before and after DRG system. RESULTS: After the introduction of DRG system, the average length of stay decreased (7.74 ± 2.88 to 6.63 ± 2.18 days, p<0.001) without increasing readmission rates. However, the number of outpatient visits increased (2.78±2.33 to 2.98±2.47, p<0.001). Regarding concomitant procedures, the rates of colpopexy and midurethral slings significantly decreased (7.87% and 9.84% to 4.93% and 2.93%, respectively, all p<0.001). Even though there was no difference in the reoperation rates, pessary insertion for recurrent POP significantly increased after the introduction of DRG system (0.10% to 0.38%, p = 0.015). CONCLUSION: The implementation of DRG in Korean tertiary hospitals has led to increase of outpatient visits and reduced surgical management for POP, which indicates that the uniform application of DRG influences the quality of care for POP patients.

Benefits and risks of induction of labor at 39 or more weeks in uncomplicated nulliparous women: a retrospective, observational study.

OBJECTIVE: To critically compare the benefits and risks of labor induction versus spontaneous labor in uncomplicated nulliparous women at 39 or more weeks of gestation. METHODS: We conducted a retrospective, observational study of 237 nulliparous women who were at 39 or more weeks of a singleton pregnancy with vertex presentation and intact membranes. We compared maternal outcomes including the Cesarean section rate and neonatal outcomes in the induced labor and spontaneous labor groups. RESULTS: Among the 237 women, 199 delivered vaginally (84.0%). The spontaneous labor group and induced labor group had a similar incidence of Cesarean delivery (17.7% vs. 12.3%, P=0.300). The length of stay and blood loss during delivery were also similar between the groups (4.3±1.5 vs. 3.9±1.5 days and 1.9±1.3 vs. 1.8±1.0 mg/sL, respectively; all P>0.05). Regarding neonatal outcomes, the rate of meconium-stained amniotic fluid, Apgar score <7 at 5 minutes, and intubation rate were similar between the groups (18.9% vs. 24.7%, 7.9% vs. 4.1%, and 6.1% vs. 4.4%, respectively, all P>0.05). Only the neonatal intensive care unit admission rate was significantly lower in the induction group than in the spontaneous labor group (28.0% vs. 13.2%, P=0.001). CONCLUSION: Maternal adverse outcomes of labor induction at 39 weeks of gestation were similar to those in a spontaneous labor group in uncomplicated nulliparous women. Neonatal adverse events were also similar between the groups. It may be acceptable to schedule labor induction as long as 7 days before the estimated date, even when the indication is only relative.