Determining Optimal Route of Hysterectomy for Benign Indications

Jennifer J. Schmitt, Daniel A. Carranza Leon, John A. Occhino, Amy L. Weaver, Sean Christopher Dowdy, Jamie N Bakkum-Gamez, Kalyan S Pasupathy, John B. Gebhart

Research output: Contribution to journalArticle

13 Citations (Scopus)

Abstract

OBJECTIVE: To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy. METHODS: A retrospective postrobot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded the laparoscopic hysterectomy route. A prerobot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated. RESULTS: Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the prerobot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the postrobot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%) robot-assisted; and 136 (11.4%) abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when a vaginal approach was expected. Robotic hysterectomies had longer operations (141 compared with 59 minutes, P<.001) and higher rates of surgical site infection (4.7% compared with 0.2%, P<.001) and urinary tract infection (8.1% compared with 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years. CONCLUSION: When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.

Original languageEnglish (US)
Pages (from-to)130-138
Number of pages9
JournalObstetrics and Gynecology
Volume129
Issue number1
DOIs
StatePublished - Jan 1 2017

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Vaginal Hysterectomy
Hysterectomy
Robotics
Laparotomy
Decision Trees
Surgical Wound Infection
Costs and Cost Analysis
Hospital Costs
Operative Time
Parity
Urinary Tract Infections
History
Technology
Infection

ASJC Scopus subject areas

  • Obstetrics and Gynecology

Cite this

Schmitt, J. J., Carranza Leon, D. A., Occhino, J. A., Weaver, A. L., Dowdy, S. C., Bakkum-Gamez, J. N., ... Gebhart, J. B. (2017). Determining Optimal Route of Hysterectomy for Benign Indications. Obstetrics and Gynecology, 129(1), 130-138. https://doi.org/10.1097/AOG.0000000000001756

Determining Optimal Route of Hysterectomy for Benign Indications. / Schmitt, Jennifer J.; Carranza Leon, Daniel A.; Occhino, John A.; Weaver, Amy L.; Dowdy, Sean Christopher; Bakkum-Gamez, Jamie N; Pasupathy, Kalyan S; Gebhart, John B.

In: Obstetrics and Gynecology, Vol. 129, No. 1, 01.01.2017, p. 130-138.

Research output: Contribution to journalArticle

Schmitt, Jennifer J. ; Carranza Leon, Daniel A. ; Occhino, John A. ; Weaver, Amy L. ; Dowdy, Sean Christopher ; Bakkum-Gamez, Jamie N ; Pasupathy, Kalyan S ; Gebhart, John B. / Determining Optimal Route of Hysterectomy for Benign Indications. In: Obstetrics and Gynecology. 2017 ; Vol. 129, No. 1. pp. 130-138.
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AU - Dowdy, Sean Christopher

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N2 - OBJECTIVE: To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy. METHODS: A retrospective postrobot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded the laparoscopic hysterectomy route. A prerobot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated. RESULTS: Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the prerobot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the postrobot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%) robot-assisted; and 136 (11.4%) abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when a vaginal approach was expected. Robotic hysterectomies had longer operations (141 compared with 59 minutes, P<.001) and higher rates of surgical site infection (4.7% compared with 0.2%, P<.001) and urinary tract infection (8.1% compared with 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years. CONCLUSION: When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.

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