Longer Operative Time During Benign Laparoscopic and Robotic Hysterectomy Is Associated With Increased 30-Day Perioperative Complications.

STUDY OBJECTIVE: The relationship between operative time and perioperative morbidity has not been fully characterized in gynecology. We aimed to determine the impact of operative time on 30-day perioperative complications after laparoscopic and robotic hysterectomy. DESIGN: Patients undergoing laparoscopic and robotic hysterectomy for benign disease from 2006 to 2011 within the National Surgical Quality Improvement Program (NSQIP) database were identified by Current Procedural Terminology code. Operative times were stratified into 60-minute intervals and complication rates analyzed. Primary outcomes included 30-day overall, medical, and surgical complications. Bivariate analyses using χ(2), Fisher's exact, and one-way analysis of variance tests were performed to compare clinical and procedural characteristics associated with longer operative time and complications. Multivariable logistic regression analyses were then performed to determine the independent association between operative time and perioperative complications. DESIGN CLASSIFICATION: Canadian Task Force classification II-2 (Evidence obtained from well-designed cohort or case-control studies preferably from more than 1 center or research group). SETTING: American College of Surgeons NSQIP. PATIENTS: Patients who underwent laparoscopic or robotic hysterectomy for benign disease from 2006 to 2011 at any institution participating in NSQIP. INTERVENTIONS: None, retrospective database study. MEASUREMENTS AND MAIN RESULTS: Of the 7630 laparoscopic and robotic hysterectomies identified, 399 patients (5.2%) experienced complications, most commonly urinary tract infection (UTI; 2.1%), superficial surgical site infection (1.0%), and blood transfusion (1.0%). Return to the operating room was required in 97 patients (1.3%), and there were 4 deaths, for a mortality rate of .05%. Complications increased steadily with longer operative time. Operative time ≥ 240 minutes was associated with increased overall complications (13.8% vs 4.6%, p < .001), surgical complications (5.4% vs 1.5%, p < .001), medical complications (10.4% vs 3.2%, p < .001), return to the operating room (2.7% vs 1.2%, p = .002), deep venous thrombosis (.5% vs .06%, p = .011), pulmonary embolism (.7% vs .1%, p = .012), and blood transfusion (3.4% vs .8%, p < .001). These associations remained statistically significant after multivariable regression analysis. Based on continuous regression modeling, each additional hour of operative time would be expected to increase odds of overall complications (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.28-1.54; p < .001), medical complications (OR, 1.42; 95% CI, 1.28-1.57; p < .001), surgical complications (OR, 1.32; 95% CI, 1.17-1.49; p < .001), venous thromboembolism (OR, 1.47; 95% CI, 1.12-1.92; p = .005), UTI (OR, 1.20; 95% CI, 1.05-1.36; p = .006), blood transfusion (OR, 1.42; 95% CI, 1.18-1.71; p < .001), and return to the operating room (OR, 1.25; 95% CI, 1.08-1.45; p = .003). CONCLUSION: We demonstrated a direct, independent association between operative time and 30-day complications after laparoscopic and robotic hysterectomy. Future research should aim to further delineate risk factors for prolonged operative time and morbidity in laparoscopic hysterectomy to allow surgeons to maximize preoperative planning and optimize patient selection for minimally invasive hysterectomy.

Contemporary national surgical outcomes in the treatment of ureteropelvic junction obstruction.

OBJECTIVE: To evaluate contemporary national trends and outcomes of open pyeloplasty (OP) vs minimally invasive pyeloplasty (MIP) in the treatment of ureteropelvic junction obstruction using the National Surgical Quality Improvement Program database. METHODS: Patients treated by OP or MIP between 2006 and 2011 were identified by The International Classification of Diseases, Ninth Revision, Clinical Modification codes corresponding to pyeloplasty as their primary operative procedure. Perioperative variables were analyzed using the chi-square and the Student t test. Multiple logistic regressions were used to identify morbidities and readmission risk factors. RESULTS: Three hundred fifty-five patients were identified. Of them, 20.2% of cases were OP and 79.8% were MIP. There was a significant increase in MIP from 33% in 2006 to 83% in 2011 (P <.001). A total of 11.7% of patients in the MIP group underwent outpatient surgery (P = .002). Patients treated at a teaching hospital were over 3 times more likely to undergo MIP (odds ratio = 3.17; P = .001). There was significantly longer hospitalization in OP vs MIP (3.9 vs. 2.2 days; P = .001). OP was associated with significantly increased risk of reoperation or postoperative morbidity compared with MIP (11.1% vs. 4.2%; P = .02). Multivariate analysis confirmed a higher rate of overall morbidity in the OP cohort (P = .03). Male patients had significantly higher postoperative morbidity or reoperation rates (odds ratio = 4.38; P = .002). There was no significant difference in operative time between groups (P = .2). CONCLUSION: Within the American College of Surgeons National Surgical Quality Improvement Program hospitals, MIP is associated with decreased reoperation and postoperative morbidity compared with OP.

Venous thromboembolism in reconstructive pelvic surgery.

OBJECTIVE: We sought to determine the incidence and risk factors for venous thromboembolism (VTE) in women undergoing reconstructive pelvic surgery (RPS). STUDY DESIGN: Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified patients who underwent RPS from 2006 through 2010 based on Current Procedural Terminology codes. We defined 2 cohorts: women with any RPS performed, with concomitant surgery from other specialties allowed (RPS + other), and women whose only procedure was RPS. VTE was defined as deep vein thrombosis or pulmonary embolism diagnosed within 30 days of surgery. Demographic characteristics, comorbidities, and operative characteristics were extracted from the database. Variables were analyzed using χ(2) tests and Student t tests for categorical and continuous variables. We performed a multiple logistic regression to control for confounding variables. RESULTS: In all, 20,687 women underwent RPS + other, with 69 cases of VTE for a rate of 0.3%. Multivariate analysis demonstrated predictors for postoperative VTE including inpatient hospital status (odds ratio [OR], 7.69; P < .001), higher American Society of Anesthesiology Physical Status classification (OR, 2.70; P < .001), and emergency intervention (OR, 3.65; P = .008). When women undergoing only RPS were analyzed, there were 14 cases of VTE, with an incidence of 0.1% and the only specific predictor for postoperative VTE was length of stay (P < .037). CONCLUSION: The incidence of VTE following RPS is very low, but it is increased in women undergoing concomitant surgeries. Patients undergoing inpatient surgery with higher American Society of Anesthesiology Physical Status classifications and requiring emergency intervention were at highest risk for VTE.

Impact of resident involvement on urological surgery outcomes: an analysis of 40,000 patients from the ACS NSQIP database.

PURPOSE: In addition to excellent patient care, the focus of academic medicine has traditionally been resident training. The changing landscape of health care has placed increased focus on objective outcomes. As a result, the surgical training process has come under scrutiny for its influence on patient care. We elucidated the effect of resident involvement on patient outcomes. MATERIALS AND METHODS: We retrospectively analyzed data from the 2005 to 2011 NSQIP® participant use database. Patients were separated into 2 cohorts by resident participation vs no participation. The cohorts were compared based on preoperative comorbidities, demographic characteristics and intraoperative factors. Confounders were adjusted for by propensity score modification and complications were analyzed using perioperative variables as predictors. RESULTS: A total of 40,001 patients met study inclusion criteria. Raw data analysis revealed that cases with resident participation had a higher rate of overall complications. However, after propensity score modification there was no significant difference in overall, medical or surgical complications in cases with resident participation. Resident participation was associated with decreased odds of overall complications (0.85). Operative time was significantly longer in cases with resident participation (159 vs 98 minutes). CONCLUSIONS: Urology resident involvement is not associated with increased overall and surgical complications. It may even be protective when adjusted for appropriate factors such as case mix, complexity and operative time.

Risk factors for 30-day perioperative complications after Le Fort colpocleisis.

PURPOSE: We identified rates of and risk factors for complications after colpocleisis using the American College of Surgeons NSQIP® database. MATERIALS AND METHODS: Women treated with Le Fort colpocleisis from 2005 to 2011 were identified in the database. Primary outcomes were 30-day complication rates. Secondary outcomes were risk factors for complications and the impact of age and a concomitant sling on morbidity. Clinical and procedural characteristics were compared using the chi-square test and 1-way ANOVA. RESULTS: We identified 283 women, of whom 23 (8.1%) experienced complications. The most common complication was urinary tract infection in 18 women (6.4%). There was 1 death for a 0.4% mortality rate. Increased complications were associated with age less than 75 years (p = 0.03), chronic obstructive pulmonary disease (p = 0.03), hemiplegia (p = 0.03), disseminated cancer (p = 0.03) and open wound infection (p = 0.02). Six patients (2.1%) required return to the operating room within 30 days. Complication rates did not differ based on operative time (p = 0.78), inpatient status (p = 0.24), resident involvement (p = 0.35), concomitant sling placement (p = 0.81) or anesthesia type (p = 0.27). Women undergoing colpocleisis without (191) and with (92) a sling had similar baseline characteristics. Colpocleisis without and with a sling had similar rates of complications (7.9% vs 8.7%, p = 0.81), urinary tract infection (5.8% vs 7.6%, p = 0.55), return to the operating room (2.1% vs 2.2%, p = 0.97) and mortality (0% vs 1.1%, p = 0.15). CONCLUSIONS: Mortality and complication rates after colpocleisis are low with urinary tract infection being the most common postoperative complication. Concomitant sling placement does not increase 30-day complication rates.

Predictors of readmission following outpatient urological surgery.

PURPOSE: The Patient Protection and Affordable Care Act increases oversight of surgical outcomes and ties hospital readmissions to Medicare reimbursement. Given the increasing volume of outpatient urological procedures, to our knowledge this study provides the first multi-institutional multivariate analysis of patient factors that contribute to readmission. MATERIALS AND METHODS: Using the 2011 National Surgical Quality Improvement Program database we identified 7,795 patients. Multiple logistic regression was used to predict 30-day unplanned hospital readmissions controlling for demographics, clinical characteristics and comorbidities. Readmission rates of the 5 most common procedures were calculated along with the rate of postoperative complications associated with readmission. RESULTS: Outpatient urological surgery had an overall 3.7% readmission rate. The 5 most common procedures were cystourethroscopy and resection of bladder tumor (readmission rate 4.97%), laser prostatectomy (4.27%), transurethral resection of prostate (4.24%), hydrocele excision (1.92%) and sling surgery for urinary incontinence (0.85%). The most common comorbidities in readmitted patients were hypertension, diabetes and smoking. Risk adjusted multiple regression indicated that cancer history (OR 3.48), bleeding disorder (OR 2.03), male gender (OR 1.38), ASA(®) level 3 or 4 (OR 1.34) and age (OR 1.01) were significant predictors of readmission. Readmitted patients also had a higher 30-day complication rate. CONCLUSIONS: Readmission after outpatient urological surgery occurs at a rate of 3.7%. A history of cancer, bleeding disorder, male gender, ASA level 3 or 4 and age were associated with readmission along with greater rates of medical and surgical complications. Our results may help guide risk reduction initiatives and prevent costly readmissions.

National multi-institutional comparison of 30-day postoperative complication and readmission rates between open retropubic radical prostatectomy and robot-assisted laparoscopic prostatectomy using NSQIP.

BACKGROUND: Many American hospitals will soon face readmission penalties deducted from Medicare reimbursements, which will place further scrutiny on techniques that may offer reduced postoperative morbidity. We aimed to perform the first multi-institutional study using the National Surgical Quality Improvement Program (NSQIP) database, to compare predictors of readmission within cohorts of open radical retropubic prostatectomy (RRP) and robot-assisted laparoscopic radical prostatectomy (RALRP) in a contemporary nationwide series of radical prostatectomy. METHODS: All patients who underwent radical prostatectomy in 2011 were identified in the NSQIP database using procedural codes. As no patients in the analysis underwent LRP, patients were grouped as RRP or RALRP for analysis. Perioperative variables were analyzed using chi-squared and Student's t-tests as appropriate. Multiple logistic regression was used to identify readmission risk factors. RESULTS: Of 5471 patient cases analyzed, 4374 (79.9%) and 1097 (20.1%) underwent RALRP and RRP, respectively. RRP and RALRP cohorts experienced different readmission rates (5.47% vs 3.48%, respectively; p=0.002). In addition, RRP experienced a higher rate of overall complications than RALRP (23.25% vs 5.62%, respectively; p<0.001), but not higher rates of reoperation (1.09% vs 0.96%, respectively; p=0.689). Overall predictors of readmission included operative time, dyspnea, and RRP or RALRP procedure type. Current smoking and patient age were predictive of readmission for RRP only, while dyspnea was predictive of readmission following RALRP only. CONCLUSION: This is the first multi-institutional retrospective study that examines readmission rates and procedural intracohort predictors of readmission for RRP in the contemporary United States. We report a significant difference in postoperative complication and readmission rates in RRP compared with RALRP. Further prospective analysis is warranted.

Predictors of readmission after outpatient otolaryngologic surgery.

OBJECTIVES/HYPOTHESIS: Hospital readmissions increase costs to hospitals and patients. There is a paucity of data on benchmark rates of readmission for otolaryngological surgery. Understanding the risk factors that increase readmission rates may help enhance patient education and set system-wide expectations. We aimed to provide benchmark data on causes and predictors of readmission following outpatient otolaryngological surgery. STUDY DESIGN: This study is a retrospective analysis of the 2011 National Surgical Quality Improvement Program (NSQIP) dataset. METHODS: NSQIP was reviewed for outpatients with "Otolaryngology (ENT)" as their recorded surgical specialty. Readmission was tracked through the "Unplanned Readmission" variable. Patient characteristics and outcomes were compared using chi-square analysis and student t tests for categorical and continuous variables, respectively. Multivariate regression analysis investigated predictors of readmission. RESULTS: A total of 6,788 outpatient otolaryngological surgery patients were isolated. The unplanned readmission rate was 2.01%. Multivariate regression analysis revealed superficial surgical site infection (odds ratio [OR] 2.672, confidence interval [CI] 1.133-6.304, P = .025) and work relative value units (RVU) (OR .972, CI .944-1, P = .049) to be significant predictors of readmission. CONCLUSION: Outpatient otolaryngological surgery has an associated 2.01% unplanned readmission rate. Superficial surgical site infection and work RVUs proved to be significant positive and negative risk factors, respectively, for readmission. These findings will help to benchmark outpatient readmission rates and manage patient and hospital system expectations.