Minimally Invasive Hysterectomy Research Articles

Same-Day Discharge in Minimally Invasive Gynecologic Surgery: A Care Partner Perspective [ID 2683597

INTRODUCTION: Same-day hospital discharge after minimally invasive gynecologic surgery has gained popularity and become feasible with increased adherence to enhanced recovery after surgery protocols. Benefits include reduced hospital admissions, increased cost-effectiveness, and practicality of patient recovery at home—without any demonstrable increase in patient harm or readmissions. Although studies show patients perceive same-day discharge favorably, there are little data regarding care partner perception of this trend. METHODS: A REDCap survey was administered prospectively to care partners of patients undergoing minimally invasive hysterectomy (MIH) within a single tertiary-care department between November 2022 and September 2023. The 16-question survey included questions evaluating care-partner perspectives regarding same-day discharge and postoperative home care. Approximately 75 patients were targeted for recruitment. Responses were analyzed using descriptive statistics. RESULTS: Approximately 66.7% of care partners indicated they were “very comfortable” caring for the patient at home the night of surgery. When asked to rate the level of concern about the patient going home on the same day as surgery, 64% selected a 2 or below on a 5-point Likert scale, with 36.4% of these individuals indicating that they were “not concerned at all.” Moreover, 42.4% of the respondents reported that this was their experience with postoperative home care. CONCLUSION: This study demonstrates that despite having no prior experience, care partners are comfortable caring for MIH patients on postoperative day 0. This is additive to current literature on patient comfort in same-day discharge. Thus, not only is same-day discharge a reasonable option for many patients but also most care partners are comfortable supporting this plan.

Gynecologic Surgical Subspecialty Training Decreases Surgical Complications in Benign Minimally Invasive Hysterectomy

Study ObjectiveTo evaluate the impact of gynecologic subspecialty training on surgical outcomes in benign minimally invasive hysterectomies (MIH) while accounting for surgeon volume. DesignRetrospective cohort study of patients who underwent a MIH between 2014 and 2017. SettingSingle community hospital system. PatientsPatients were identified via CPT (Current Procedural Terminology) codes for MIH: vaginal, laparoscopic or robotic. Exclusion criteria included a gynecologic cancer diagnosis or concomitant major procedure at the time of hysterectomy. One thousand six hundred and thirty-one patients underwent a benign MIH performed by a gynecologic generalist or a subspecialist in Minimally-Invasive Gynecologic Surgery (MIGS), Urogynecology and Pelvic Reconstructive Surgery (URPS), or Gynecologic Oncology. 125 hysterectomies were vaginal, 539 were conventional laparoscopic, and 967 were robotic. InterventionsN/A Measurements and Main ResultsSurgical outcomes including intraoperative complications, operative outcomes, and postoperative readmissions and reoperations, were compared between generalists and subspecialists and stratified by surgeon volume status, with “high-volume” defined as performing 12 or more hysterectomies annually. Odds ratios for the primary outcome, Clavien-Dindo Grade III complications (which included visceral injuries, conversions, and reoperations within 90 days), were calculated to evaluate the impact of subspecialty training while accounting for surgeon volume status. 855/1631 (52.4%) MIH were performed by generalists and 776/1631 (47.6%) by subspecialists. High-volume generalists performed 618/1631 (37.9%) of MIH, 14.5% (237/1631) were performed by low-volume generalists. All subspecialists were high-volume surgeons; 38.1% of generalists were high-volume.The odds of a Clavien-Dindo Grade III complication was 0.39 (0.25-0.62) for hysterectomies performed by subspecialists compared to high-volume generalists after adjusting for potential confounding variables (p < .001). Subspecialists and high-volume surgeons had significantly lower incidence of visceral injuries, transfusions, blood loss over 500 mL, and conversions compared to generalists and low-volume surgeons, respectively. ConclusionBoth subspecialty training and high surgeon volume status are associated with a lower risk of surgical complications in benign MIH. Subspecialty training is associated with a reduction in surgical complications even after accounting for surgeon volume.

9520 Improving Disparities in Access to Minimally Invasive Hysterectomy (MIH)

9520 Improving Disparities in Access to Minimally Invasive Hysterectomy (MIH)

Assessment of the feasibility of same-day discharge following minimally invasive hysterectomy in the elderly population

ObjectiveTo determine the safety and feasibility of same-day discharge (SDD) following minimally invasive hysterectomy (MIH) for elderly patients and to evaluate associations between age, frailty, and postoperative outcomes. MethodsRetrospective review was conducted of patients aged ≥ 70 who underwent MIH within a single gynecologic oncology institution from 2018 to 2020. Demographics, peri-operative factors, postoperative complications, and 30-day readmission rates were collected. Frailty was determined by an 11-point modified frailty index ≥ 2. Outcomes were compared between SDD and observation groups using Fisher’s exact and Wilcoxon rank-sum tests. ResultsOf 169 patients included in the analysis, 8.9% (n = 15) underwent SDD, and 91.1% (n = 154) were admitted for OBS following MIH. Demographics, peri-operative factors, and frailty rates (33% SDD vs 43.5% observation; p = 0.59) were similar between groups. 86.7% (n = 13) of SDD cases were completed before 12PM, and none were completed after 6PM. No SDD patients had early post-operative complications or hospital readmissions. Early postoperative complications were diagnosed in 9 (5.8%) patients admitted for OBS, and the 30-day hospital readmission rate for patients who underwent OBS was 8.4% (n = 13). While elderly patients who met objective frailty criteria (n = 72) did not have a higher likelihood of early post-operative complications (44.4% vs 55.6%; p = 0.909), they did have a higher likelihood of ED visit within 30 days of discharge (15.3 vs 3.1%; p = 0.009), and a trend was noted toward a higher rate of 30-day hospital readmission (12.5% vs 4.1%; p = 0.080). ConclusionsElderly patients undergoing SDD following MIH did not have increased morbidity or mortality. Elderly patients who meet objective criteria for frailty, however, represent a more vulnerable population.

Comparing sentinel lymphadenectomy and complete lymphadenectomy among obese patients (BMI &gt;30) undergoing minimally invasive hysterectomy for early-stage endometrial cancer: An ACS-NSQIP database study.

e17618 Background: In patients with endometrial cancer, lymph node assessment is used for staging and adjuvant treatment planning. Sentinel lymphadenectomy (SLN) is an acceptable alternative to complete lymphadenectomy due to decreased risk of major complications. As obesity increases in the United States, so does the rate of endometrial cancer. Complete staging may be more challenging in obese patients. Our goal was to evaluate the relative use and complication rates of sentinel versus complete lymphadenectomy among obese patients undergoing minimally invasive hysterectomy (MIH) for early-stage endometrial cancer. Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried for patients diagnosed with stage I to III endometrial carcinoma between 2015 and 2020 who underwent MIH, identified by Current Procedural Terminology (CPT) code. Extent of lymphadenectomy was also identified using CPT codes. Relative utilization of sentinel versus complete lymphadenectomy was evaluated over the study period. Propensity scores were used to control for potential confounders, and complication rates were compared between propensity matched cohorts of sentinel versus complete lymphadenectomy. Major and minor complications were defined by the Clavien-Dindo scale. Results: From 2015 to 2020 a total of 11,844 obese (BMI &gt; 30) patients underwent MIH for stage I to III endometrial cancer. Of these 7,067 (59%) had a lymph node assessment. Sentinel lymphadenectomy was completed in 3,845 patients, and complete lymphadenectomy was completed in 3,222 patients. Over the five-year period, the utilization of SLN increased for obese and non-obese patients. Prior to 2018, complete lymphadenectomy was performed more often. After 2018, SNL was more common. After propensity matching, there was no increased risk of death (OR 0.67, 95% CI 0.06-5.8, p = 1.0), infection (OR 0.86, 95% CI 0.69-1.1, p = 0.20), thrombo-embolic events (OR 0.77, 95% CI 0.51-1.1, p = 0.21), major complications (OR 0.84, 95% CI 0.66-1.1, p 0.15), or minor complications (OR 0.87, 95% CI 0.69-1.1, P = 0.22) in obese patients who underwent SLN compared to complete lymphadenectomy. Conclusions: The average BMI of patients who underwent MIH over the study period was 35. After controlling for comorbidities and other baseline characteristics, there were no significant differences in complication rates between sentinel and complete lymphadenectomy in obese patients. With the adoption of SLN, more patients may be adequately staged, providing more prognostic information and targeted therapies. These results suggest that sentinel lymphadenectomy is a technically feasible and safe staging procedure in obese patients.

Evaluation of Perioperative Factors Contributing to Organ Space Surgical Site Infection After Minimally Invasive Hysterectomy [ID: 1374862

INTRODUCTION: Postoperative organ space surgical site infection (oSSI), commonly referred to as pelvic abscess, is a clinically impactful complication after hysterectomy. Although more common in open hysterectomies, oSSIs occur in minimally invasive hysterectomy (MIH), contributing to morbidity. In the current study, we evaluate perioperative factors contributing to development of oSSIs in patients undergoing MIH. METHODS: From 2016 to 2022, a multicenter retrospective analysis of patients undergoing MIH was conducted. Patient characteristics, preexisting conditions, surgical history, intraoperative factors, and type of MIH were evaluated to determine factors contributing to the development of oSSI. RESULTS: One thousand one hundred eighty-nine patients underwent MIH. 28 patient (2.4%) developed oSSI. There was no difference in age or body mass index between groups (P&gt;.05) and no difference in the incidence of oSSI based on type of MIH (P=.832). Patients with endometriosis were more likely to develop oSSI (4.9% versus 2.0%, P=.045, odds ratio [OR] 2.49, 95% CI 1.98–6.25). A diagnosis of cancer did not affect oSSI (3.9% versus 2.1%, P=.162, OR 1.90, 95% CI 0.76–4.78). History of diabetes, hypertension, cesarean delivery, prior laparoscopy, prior laparotomy, smoking, or obesity did not affect the incidence of oSSI (P&lt;.05). Patients developing oSSI had a greater mean intraoperative estimated blood loss (EBL) (233.55 cc versus 94.3 cc, P&lt;.001), greater mean length of stay (LOS) (2.4 versus 0.9 days, P&lt;.001), higher incidence of post-operative ileus (15.8% versus 0.7%, P&lt;.001) and blood transfusion (34.6% versus 1.0%, P&lt;.001). CONCLUSION: Development of oSSI is associated with preexisting endometriosis and greater intraoperative EBL. Development of oSSI was associated with greater LOS, postoperative ileus, and blood transfusions. Attention to hemostasis may reduce rates of oSSI.

Evaluation of Perioperative Factors Influencing Vaginal Cuff Dehiscence After Minimally Invasive Hysterectomy [ID: 1372339

INTRODUCTION: Vaginal cuff dehiscence (VCD) is one of the few surgical complications identified more commonly in minimally invasive hysterectomies (MIHs) versus open hysterectomies. The objective of this study is to determine perioperative risk factors that contribute to the development of VCD in patients undergoing MIH. METHODS: From 2016 to 2022, a multicenter retrospective analysis of patients undergoing MIH was conducted. Patient characteristics, preexisting conditions, surgical history, intraoperative factors, and type of MIH were evaluated to determine factors contributing to the development of VCD. RESULTS: One thousand one hundred eighty-nine patients underwent MIH. Only 10 (0.8%) patients developed VCD. There was no significant difference in mean body mass index, postoperative length of stay, or estimated blood loss between those with VCD versus those without. Incidence of VCD was highest in total laparoscopic hysterectomy versus all other MIH modalities (P=.002). There were no cases of VCD in laparoscopic-assisted vaginal hysterectomy. No patients with endometriosis experienced VCD, and there was no difference in the incidence in patients with cancer versus benign conditions (1.3% versus 0.8%, P=.488, odds ratio [OR] 1.29, 95% CI 0.68–8.23). Personal history of diabetes, hypertension, cesarean delivery, prior laparoscopy, prior laparotomy, or smoking did not affect the incidence of VCD (P&gt;.05) as well as insurance status and race (P=.728 and P=.775, respectively). Patients who developed deep surgical site infections (SSIs) had significant increase in VCD (10.0% versus 2.3%, P=.006, OR 4.79, 95% CI 0.587–33.22). CONCLUSION: We observed that mode of MIH and SSI were perioperative risk factors that contribute to the development of VCD. What is notable is that demographics and medical comorbidities did not affect the incidence of VCD.

Risk Assessment Model for Complications in Minimally Invasive Hysterectomy: A Pilot Study.

To estimate the rate of intra-operative and postoperative complications, and to define the risk of 30-day major postoperative complications (Clavien-Dindo &gt; 2) according to the presence of one of 10 different variables of minimally invasive (MI) hysterectomy; and then to create a risk assessment model easily applicable in clinical practice. A single center single arm retrolective study. Data of consecutive patients who have undergone MI hysterectomy for gynaecologic disorders between May 2018 and April 2021 were analyzed. Perioperative surgical outcomes, occurrence of intra- and postoperative complications, and readmissions within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major postoperative complications. Over the study period, 445 patients were included in the study. The majority of patients developed a minor event, while major complications (grade III) were required in 14 patients. None of the patients showed a grade IV or V complication. Univariate analysis was performed on patients who had developed intra- or postoperative complications from those who did not experience complications. Body mass index (BMI) (p-value 0.045) and surgeon's experience (p-value 0.015) were found to be associated with a different surgery time. Regarding major postoperative complications, a statistically significant association was found for the variables: BMI (p-value 0.006), previous abdominal surgery (p-value 0.015), and surgeon's experience (p-value 0.035) in the univariate analysis. Also in the multivariate analysis, the risk of major postoperative complications was higher in these three different variables. BMI, previous surgery, and surgeon's experience were inserted in a reproducible risk assessment model in order to stratify the risk of major postoperative complications. We proposed a risk assessment model including factors not previously considered in the literature: the standardization of the surgical technique, the surgeon's experience, the best MI approach (laparoscopy or robot-assisted), and previous abdominal surgery are crucial tools to consider. Further prospective studies with a larger population sample are needed to validate these preliminary evaluations for patients undergoing MI hysterectomy.

Uterine Weight as a Modifier of Black/White Racial Disparities in Minimally Invasive Hysterectomy Among Veterans with Fibroids in the Veterans Health Administration.

Uterine fibroids are the most common indication for hysterectomy. Minimally invasive hysterectomy (MIH) confers lower risk of complications and shorter recovery than open surgical procedures; however, it is more challenging to perform with larger fibroids. There are racialized differences in fibroid size and MIH rates. We examined the role of uterine size in black-white differences in MIH among Veterans in the Department of Veterans Affairs (VA). Using VA clinical and administrative data, we conducted a cross-sectional study among black and white Veterans with fibroids who underwent hysterectomy between 2012 and 2014. We abstracted postoperative uterine weight from pathology reports as a proxy for uterine size. We used a generalized linear model to estimate the association between race and MIH and tested an interaction between race and postoperative uterine weight (≤250 g vs. >250 g). We estimated adjusted marginal effects for racial differences in MIH by postoperative uterine weight. The sample included 732 Veterans (60% black, 40% white). Postoperative uterine weight modified the association of race and MIH (p for interaction=0.05). Black Veterans with postoperative uterine weight ≤250 g had a nearly 12-percentage point decrease in MIH compared to white Veterans (95% CI -23.1 to -0.5), with no difference by race among those with postoperative uterine weight >250 g. The racial disparity among Veterans with small fibroids who should be candidates for MIH underscores the role of other determinants beyond uterine size. To eliminate disparities in MIH, research focused on experiences of black Veterans, including pathways to treatment and provider-patient interactions, is needed.

Differences in Route of Benign Hysterectomy in Black Patients for Abnormal Uterine Bleeding with Exclusion of Fibroid Diagnosis

<h3>Study Objective</h3> To investigate whether racial disparities still exist in rates of minimally invasive hysterectomy (MIH) performed for abnormal uterine bleeding (AUB) when fibroid diagnosis is excluded. <h3>Design</h3> Cross-sectional survey with a target population of all ambulatory discharges in the United States. <h3>Setting</h3> 2019 Nationwide Ambulatory Surgery Sample (NASS) and National Inpatient Sample (NIS). <h3>Patients or Participants</h3> Female patients age ≥18 years undergoing hysterectomy for primary indication of abnormal uterine bleeding (AUB), excluding malignancy and uterine fibroids. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> A multivariate logistic regression model with appropriate weighting, primary sampling units and strata was utilized. Primary outcome was odds ratio (OR) of abdominal hysterectomy (AH) vs MIH (vaginal/endoscopic) in Black patients compared to white patients. Of 487,008 (SE=11,530) hysterectomies performed for benign indications, 64,681 (SE=1,483) were AH (13.3%), 422,327 (SE=10,047) were MIH (86.7%). After filtering the survey design dataset for hysterectomies performed primarily for AUB using the international classification of diseases 10^th edition, and further excluding those with an associated code for uterine fibroids, the sample size was 75,838 (SE=2,103). Of these, MIH: 68,206 (SE=1,812) (89.9%) and AH: 7,632 (SE=291) (10.1%). After controlling for comorbidities, demographic data, hospital, regional and payer factors, the OR for a Black patient to undergo AH vs MIH for all benign diagnoses was 2.7 (CI-2.44,2.98; p<0.001). For Black patients undergoing benign hysterectomy for AUB excluding fibroids, this trend persisted though was less extreme with OR=1.38 (CI-1.12,1.70; p<0.001). <h3>Conclusion</h3> For the primary indication of AUB excluding malignancy and fibroids, Black patients were still 38% more likely than white patients to undergo AH. It has previously been proposed that rates of MIH are lower in Black patients due to a larger prevalence of fibroids, and by extension, larger uterine sizes. Given that we excluded fibroids and still found a difference in MIH rates, our study suggests there may be other factors leading to disparity in surgical route.

Predictive Model for Complications in Minimally Invasive Hysterectomy: A Retrospective Single Cohort Analysis

<h3>Study Objective</h3> To create a predictive model score by estimating rate of intra-operative and post-operative complications and by defining the risk of 30-day major post-operative complications (Clavien-Dindo≥3) according to the presence of 10 different variables analyzed at the time of minimally invasive (MI) hysterectomy. <h3>Design</h3> A single center single-arm retrospective study. Data of consecutive patients who have undergone MI hysterectomy between May 2018 and April 2021 have been analyzed. Perioperative surgical outcomes, occurrence of intra- and post-operative complications, 30 days-readmissions were registered. Univariate and multivariable analyses were performed. <h3>Setting</h3> Miulli's Hospital surgery rooms (Bari). <h3>Patients or Participants</h3> 445 patients were included in the study. <h3>Interventions</h3> A standardized surgical approach of MI hysterectomy was adopted by laparoscopic or robotic-lps assisted approach. <h3>Measurements and Main Results</h3> The majority of patients developed a minor event. Major complications (grade III) were observed in 14 patients. The percentage of intraoperative and postoperative complications (Clavien-Dindo classification) was: 44 patients (9.88%) showed a related surgical complication. None showed a grade IV or V complication. Univariate analysis was performed on patients who had developed intra- or post-operative complications from those who did not experience complications. BMI (p-value 0.045) and surgeon's experience (p-value 0.015) were found to be associated with a different surgery time. No one clinic-pathological characteristics were found to be correlated with complications. About major postoperative complications, it was found a statistically significant association for the variables BMI (p-value 0,006), previous surgery (p-value 0,015), and surgeon experience (<i>p</i>-value 0,035). The three significant variables were inserted in a reproducible predictive model in order to stratify the risk of post-operative complications: the score of our predictive model was directly proportional to the severity of complications. <h3>Conclusion</h3> MI hysterectomy should be considered as a safe approach, and it's associated with a low risk of intra- and post-operative complications. Overall, we developed a risk assessment tool including factors not previously considered in the Literature.

8258 Does Uterine Size Matter? the Relationship between Surgeon Volume, Surgical Approach, and Uterine Weight for Benign Hysterectomy.

<h3>Study Objective</h3> To assess the relationship between surgeon volume and surgical approach for benign hysterectomies across increasing uterine weights. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Hospitals in the Michigan Surgical Quality Collaborative (MSQC) registry between July 2012 and April 2021. <h3>Patients or Participants</h3> Patients undergoing benign hysterectomy. <h3>Interventions</h3> Hysterectomy. <h3>Measurements and Main Results</h3> For each hysterectomy, surgeon volume was determined by the number of hysterectomies contributed to the MSQC registry by the surgeon in the calendar year. Cases were classified into tertiles by surgeon volume. Multivariable logistic regression with interaction analysis was used to determine the likelihood of undergoing a minimally-invasive hysterectomy (MIH) by surgeon volume and uterine weight. Of the 59,356 patients, 47,149 (79.4%) patients underwent MIH and 12,207 (20.6%) underwent abdominal hysterectomy. The proportion of minimally-invasive hysterectomy (MIH) decreased with increasing uterine weight. Hysterectomies performed by high- and intermediate-volume surgeons were more likely to be minimally-invasive versus those performed by low-volume surgeons (high-volume: aOR 2.13 [95% CI 1.86-2.44]; intermediate-volume: aOR 1.74 [95% CI 1.52-2.00]). For hysterectomies performed by high-volume surgeons, the propensity for a minimally-invasive approach was amplified for uterine weights between 250-2000g, with the maximum interaction effect between 1000-2000g (aOR 4.23 [95% CI 2.57-6.96]). There was no interaction effect among weights below 250g or above 2000g. <h3>Conclusion</h3> Hysterectomies performed by high-volume surgeons are more likely to be associated with a minimally-invasive approach compared to those performed by low-volume surgeons among all uterine weights, but especially among uteri weighing between 250-1999g.

7879 Complication Rates Following Total Laparoscopic Vs. Vaginal Hysterectomy in Patients with BMI ≥ 50 Kg/m2

<h3>Study Objective</h3> To determine which minimally invasive hysterectomy (MIH) route is associated with the lowest risk of complication in women with BMI ≥ 50 kg/m². <h3>Design</h3> Retrospective cohort study utilizing the National Surgical Quality Improvement Program (NSQIP) database. <h3>Setting</h3> NSQIP participating institutions. <h3>Patients or Participants</h3> 5570 women with BMI ≥ 50 kg/m² undergoing MIH from 2014 through 2020. <h3>Interventions</h3> Total laparoscopic (TLH) or vaginal hysterectomy (TVH) for uterus ≤ 250 g. <h3>Measurements and Main Results</h3> 481 patients underwent TVH, and 5089 women underwent TLH. Women who underwent TLH were significantly older (median age 51 vs. 46 years, p<0.01), and were more likely to identify as White race (77% vs. 67%, p<0.01), have hypertension (58% vs. 47%, p<0.01), and have an ASA class ≥ III (87% vs. 73%, p<0.001). Of patients who underwent TLH, 459/5089 (9%) experienced one or more complication within 30 days of surgery compared to 44/481 (9%) of women who underwent TVH (p=0.93). Median operative time was significantly longer for patients undergoing TLH (137 vs. 105 minutes, p<0.01), and median length of hospital stay (LOS) was identical (1 day, p=0.09). Patients undergoing TLH were more likely to develop superficial surgical site infections (SSI) (2% vs. 0%, p<0.01) but less likely to require transfusion (1% vs. 3%, p<0.01). The rates of all other individual complications were similar between the two groups. In multivariable regression modeling adjusted for potential confounding covariates, we did not observe significant evidence that vaginal as compared to laparoscopic hysterectomy was associated with increased odds of complication (aOR 1.1, 95% CI 0.8-1.5, p=0.7). <h3>Conclusion</h3> Patients with BMI ≥ 50 kg/m² experienced hysterectomy-related complications at a higher rate than published in the general population, but the overall complications rates were similar between those undergoing TVH and TLH. In the carefully selected patient and with the appropriate surgeon skill set, both approaches are feasible for hysterectomy of the very obese patient.

8532 Patient Satisfaction with Postoperative Follow up after Benign Minimally Invasive Hysterectomy: A Randomized, Controlled Trial

<h3>Study Objective</h3> To assess whether patient satisfaction varies with a single six week versus a two- and six-week postoperative visit after minimally invasive hysterectomy (MIH). Secondary aim was to determine the rate of postoperative complications between randomized groups. <h3>Design</h3> Prospective, randomized controlled trial of English-speaking women aged 18 to 70 undergoing MIH at an academic institution from August 2018 to December 2019. Patient satisfaction was determined by The Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS) global satisfaction response and compared between groups using a non-inferiority test with 12% non-inferiority limit. Comparison of postoperative outcomes were performed utilizing the Clavien-Dindo Classification System. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> 174 patients were randomized for postoperative follow up; 140 included in overall analysis. <h3>Interventions</h3> Randomization to either a two and six week or a single six-week postoperative appointment. <h3>Measurements and Main Results</h3> For the primary outcome of an S-CAHPS satisfaction score of 8 or higher, the six weeks only group was non-inferior to the two- and six-week group (93% satisfaction in both groups; non-inferiority p=0.003). There was no difference in satisfaction with number of postoperative appointments between groups: 94% for two and six week and 90% for six weeks only (p=0.694). When asked if more or fewer appointments were desired, there was no difference between groups (p=0.465). Patients with abnormal uterine bleeding were more likely to be satisfied (p=0.030). Between the two and six weeks versus six weeks only groups, there was no significant increase in emergency room visits (18% versus 20%, respectively, p=0.863) or hospital readmissions (3% versus 6%, respectively, p=0.682). <h3>Conclusion</h3> Patient satisfaction with postoperative visits are similar among women randomized to a two and six week and a single six week visit. Postoperative complications were rare and comparable between groups. A single six-week appointment showed non-inferior patient satisfaction relative to a two- and six-week schedule.

8519 Effects of Prior Cesarean Section on Outcomes of Laparoscopic Hysterectomies Performed by Minimally Invasive Gynecology Trained Surgeons

<h3>Study Objective</h3> To evaluate the effect of a history of cesarean section (CS) on complications and operative time of minimally invasive hysterectomies (MIH) performed by surgeons trained in minimally invasive gynecologic surgery (MIGS). <h3>Design</h3> Retrospective cross-sectional study. <h3>Setting</h3> Single institution, tertiary care center in Southeastern USA from 2016-2019 <h3>Patients or Participants</h3> Patients who underwent MIH for benign conditions, performed by a MIGS trained surgeon, and did not have a history of laparotomy other than CS. <h3>Interventions</h3> Minimally invasive hysterectomy. <h3>Measurements and Main Results</h3> A total of 484 hysterectomies met inclusion criteria. Of these, 152 patients had a history of CS and 332 did not have a history of CS. No significant demographic differences were noted between groups. In patients with a history of CS, 69 (45.4%) had one, 52 (34.2%) had two, 24 (15.8%) had three, and 7 (5.2%) had four or more prior CS. Generalized linear models controlling for body mass index (BMI) did not show a relationship between history of CS as a binary variable (CS vs no CS) and estimated blood loss (EBL) (mean 62 mL vs 57 mL, p=0.44) or operative time (mean 152 minutes vs 148 minutes, p=0.70). Similarly, there was no relationship between the number of prior CS and EBL (p=0.421) or operative time (p=0.411). The adjusted odds ratios were not significant between CS vs no CS for intraoperative complication (aOR = 0.920, CI 0.282 – 3.00) or 30-day postoperative complication (aOR = 0.946, CI 0.573 – 1.563). <h3>Conclusion</h3> While previous studies have found a relationship between history of CS and hysterectomy complications, this has not been evaluated in patients undergoing MIH with a MIGS trained surgeon. In our study, neither a history of any CS nor the number CS had an effect on EBL, operative time, or intraoperative or post-operative complications of MIH performed by MIGS trained surgeons.

Laparoscopic Uterosacral Bupivacaine Injection during Minimally-Invasive Hysterectomy: A Single-Blinded Randomized Controlled Trial

<h3>Study Objective</h3> To determine the effect of laparoscopic uterosacral bupivacaine injection on post-operative pain and opioid usage in patients undergoing minimally invasive hysterectomy. <h3>Design</h3> Single-Blinded, Triple-Arm, Randomized Controlled Trial. <h3>Setting</h3> Academic Hospital Center. <h3>Patients or Participants</h3> Patients undergoing benign MIGS hysterectomy between 3/15/2021 and 4/8/2022. Exclusion criteria: conversion to laparotomy, bupivacaine allergy, concurrent procedures, supracervical hysterectomy, TAP block, preoperative opioid usage, non-English speaking. <h3>Interventions</h3> Patients were randomized in a 1:1:1 fashion to the following before colpotomy: no injection, 20cc normal saline, or 20cc of 0.25% bupivacaine. All patients received incisional infiltration with 10cc 0.25% bupivacaine. Post-operative pain scores, total opioid consumption and return of bowel function were recorded via Qualtrics surveys. <h3>Measurements and Main Results</h3> Of 360 hysterectomies screened, 298 were eligible (83%), 161 (45%) agreed to participate, and 125 were ultimately included in interim analysis. The majority of hysterectomies were performed laparoscopically (91, 73%) and the remainder robotically. Most hysterectomies were discharged home POD#0 (116, 93%). Patients randomized to placebo had a lower proportion of public insurance and higher proportion of mood disorders. There was a statistical difference in the proportion of cases that required morcellation between bupivacaine and no injection (43% vs 18%, p=0.038; no difference between bupivacaine and saline, 43% and 32%, p=0.87). In regression controlling for surgical approach, administration of Toradol, and time from injection to discharge, mean pain scores on VAS at time of discharge were statistically lower in the bupivacaine group compared to placebo (-1.09, p=0.033) or no injection (-1.15, p=0.023). There was no difference between groups in PACU OME administration or post-operative OME usage, day of last use, or return of bowel function. <h3>Conclusion</h3> Laparoscopic uterosacral injection of bupivacaine at the time of MIS hysterectomy results in decreased post-operative VAS pain scores, although without a difference in post-operative opioid consumption. Complete trial data to be available at the time of AAGL.

Comparative Effectiveness of Minimally Invasive Hysterectomy Type in the Treatment of Endometrial Cancer

<h3>Study Objective</h3> Determine the comparative effectiveness of robotic-assisted versus traditional laparoscopic hysterectomy for the treatment of endometrial cancer. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Hospitals performing a minimum of 20 minimally-invasive surgeries for endometrial cancer per year recorded in the National Cancer Database between 2010 and 2018. <h3>Patients or Participants</h3> Women who underwent hysterectomy for endometrial cancer and had an epithelial histology, a Charlson comorbidity score of 0 or 1, and stage I to III disease. <h3>Interventions</h3> Route of minimally invasive hysterectomy, either robotic-assisted (RAH) or traditional laparoscopic hysterectomy (TLH) by intention-to-treat analysis. Cox proportional hazard regression was used to evaluate overall survival. <h3>Measurements and Main Results</h3> A total of 201,039 women underwent hysterectomy for endometrial cancer; 121,770 (60.6%) RAH, 37,701 (18.8%) TLH and 41,568 (20.7%) via laparotomy. From 2010 to 2018, RAH increased (40.7% to 69.9%, 3.7% per year), laparotomy decreased (43.0% to 11.0%, 4% per year), and TLH increased (16.4% to 19.1%, 0.3% per year, all p<0.001). RAH was associated with a higher likelihood of any nodal evaluation (77.5% versus 66.4%; OR 1.74 95%CI 1.70-1.79); whereas, TLH was associated with higher rates of conversion to laparotomy (7.6% versus 1.7%; OR 4.08 95%CI 4.03-4.12), increased 30-day mortality (0.29% versus 0.18%; OR 1.55 95%CI 1.21-1.99) and increased 90-day mortality (0.69% versus 0.42%; OR 1.65 95%CI 1.41-1.94). Overall survival was not different for patients who underwent minimally-invasive hysterectomy after adjustment for age, stage, histology, and Charlson comorbidity score (HR 0.98 95%CI 0.94-1.01). <h3>Conclusion</h3> RAH for endometrial cancer increased dramatically between 2010 and 2018 compared to TLH. Additionally, RAH was associated with a 4-fold lower risk of conversion to laparotomy, increased likelihood of nodal assessment, and decreased short-term mortality compared to TLH.

Shared decision-making in opioid prescribing for minimally invasive hysterectomy: A prospective randomized controlled trial.

To determine the impact of shared decision-making in postsurgical opioid prescribing in women who underwent minimally invasive (MIS) hysterectomy. A randomized controlled trial. A single, tertiary care, academic center. From January 2019 through April 2020, 73 women aged 18 years and older who had a planned MIS hysterectomy with the Department of Gynecology were enrolled into the study (36 in the standard arm and 37 in the patient-directed arm). Participants were assigned either to the standard arm (30 tablets) or patient-directed arm (0-30 tablets) of oxycodone 5 mg. The primary outcome was the percentage of excess opioid tablets, calculated by the number of unused tablets divided by the number of tablets prescribed. Secondary outcomes included total opioid tablets used, frequency of obtaining additional opioid tablets after discharge, frequency of unscheduled post-operative visits, and patient satisfaction with number of opioid tablets prescribed. Age, race, and body mass index did not differ between groups. Hysterectomies were performed via laparoscopy (16.9 percent), robotic-assisted laparoscopy (38.5 percent), and vaginal routes (44.6 percent). The median (IQR) number of oxycodone prescribed in the patient-directed arm was 15.0 (12.0 and 24.0) tablets. The standard arm had a greater percentage of excess oxycodone tablets 73.6 percent (0.03) than the patient-directed arm 56.3 percent (0.03, p < .01). However, there was no difference in the total number of oxycodone used by patients in the standard (mean 7.9 [0.5] tablets) and patient-directed arms (mean 8.4 [0.5] tablets, p = .50). The mean number of oxycodone used for the entire cohort was 8.1 (0.4) tablets. Shared decision-making significantly decreased the percent of excess oxycodone tablets but did not decrease the total number of oxycodone tablets used in patients undergoing MIS hysterectomy. Patients used about 22 tablets less than the standard 30 tablets prescribed.

Effect of insurance type on outcomes after minimally invasive hysterectomy by gynecologic oncologists (569)

<b>Objectives:</b> Insurance status can be a proxy for social determinants of health and has been shown to correlate with poorer postoperative and oncologic outcomes. We sought to evaluate the relationship between insurance status and clinical outcomes among patients undergoing minimally invasive hysterectomy (MIS-H) by gynecologic oncologists at a single institution. <b>Methods:</b> We conducted an IRB-approved retrospective chart review of patients who underwent MIS-H by a gynecologic oncologist for benign or malignant pathology from January 2015 to December 2017. Insurance status (private or public), demographics, comorbidity information, surgical outcomes, and 3-year overall survival (OS) were collected and analyzed. Non-parametric tests and multivariate logistic regression were used to evaluate associations. <b>Results:</b> MIS-H was performed in 202 women, with 125 (61.9%) having private insurance and 77 (38.1%) having only public insurance (Medicare, Medicaid, or self-pay). Demographic characteristics are summarized in Table 1. Publicly insured patients were older (median 67 vs 52, p=<0.001), predominantly menopausal (79.2% vs 45.6%, p=<0.001), multiparous (3.9% nulliparous vs 17.7%, p=0.004), less likely to be White (85.7% vs 93.6%, p=0.009), and less likely to be married (46.8% vs 71.0%, p<0.001). Publicly insured patients also had significantly more comorbid conditions. They were more likely to have diabetes (32.5% vs 14.4%, p=0.004), COPD or asthma (19.5% vs 8.8%, p=0.032), hypertension (72.7% vs 38.2%, p=<0.001), hyperlipidemia (64.9% vs 25.0%, p=<0.001), and coronary artery disease (11.7% vs 2.4%, p=0.011). Surgical pathology was more likely to be benign in privately insured patients (57.3% vs 36.4%, p=0.006). Perioperative outcomes were evaluated with no significant difference in intraoperative complications (p=0.19), re-admissions (p=0.81), or subsequent surgeries related to the initial operation (including hernia surgeries or other elective procedures) (private 14.4%, public 5.2%, p=0.061). On univariate analysis of oncologic patients, only 104 privately insured patients had significantly more future operations (22% private vs 6% public, p=0.027). Further, among those with an oncologic diagnosis, there was no difference in OS (p=0.30). A multivariate analysis of future operations among the entire cohort controlled for potential confounders, such as age, adhesive disease, and intraabdominal disease. Insurance status was shown to be an independent risk factor for subsequent operation among the publicly insured (p=0.023). <b>Conclusions:</b> Publicly insured patients, as expected, were older and had increased comorbid conditions. Despite this, re-admission rates, operative times, and complications were not significantly different between populations. After controlling for confounders, insurance status was noted to be independently associated with subsequent surgical intervention, more frequent among the publicly insured. Further research may explore the possible differences that lead to increased reoperations among these patients.

Racial and ethnic disparities in readmission risk following the surgical management of endometrial cancer

ObjectiveMost women diagnosed with endometrial cancer undergo primary surgical management with hysterectomy. Although racial disparities in readmission risk following hysterectomy for non-cancerous conditions have been reported, data among women with endometrial cancer are absent. This study evaluates racial differences in readmission risk among women undergoing endometrial cancer-related hysterectomy. MethodsIn the National Cancer Database, women who underwent surgical management for endometrial cancer from 2004 to 2018 were identified. Readmission and minimally invasive hysterectomy (MIH) proportions were plotted according to year of diagnosis and race/ethnicity. Multivariable logistic regression models were used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for associations between readmission risk and epidemiological, facility, tumor, and surgical characteristics. A base model was sequentially adjusted to incorporate significant covariates. ResultsThere were 350,631 patients included in the study. The proportion of MIH increased among all race/ethnicities over the study period; however, MIH rates were lower among Black women. Readmission proportions were 2.7% among White, 4.2% among Black, 2.9% among Hispanic, 2.4% among Asian, 2.1% among American Indian/Alaska Native, and 3.1% among Native Hawaiian/Pacific Islander women. In the fully adjusted model incorporating surgical approach, Black women (OR: 1.20, 95% CI = 1.13, 1.28) and Native Hawaiian/Pacific Islander women (OR: 1.54, 95% CI = 1.09, 2.18) were more commonly readmitted compared to White women. ConclusionsIn this study, Black and Native Hawaiian/Pacific Islander women with endometrial cancer had significantly higher readmission risk than White women. Optimizing perioperative care for minority women is an essential component of overcoming racially disparate endometrial cancer outcomes.