Movement to outpatient hysterectomy for benign indications in the United States, 2008–2014

Abstract

IntroductionThe past decade has witnessed adoption of conservative gynecologic treatments, including minimally invasive surgery (MIS), alongside steady declines in inpatient hysterectomies. It remains unclear what factors have contributed to trends in outpatient benign hysterectomy (BH), as well as whether these trends exacerbate disparities.Materials and methodsRetrospective cohort of 527,964 women ≥18 years old who underwent BH from 2008 to 2014. BH surgical approaches included: open/abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and robotic-assisted hysterectomy (RH). Quarterly frequencies were calculated by care setting and surgical approach. We used multilevel logistic regression (MLR) using the most recent year of data (2014) to examine the influence of patient-, physician-, and hospital-level preoperative factors and surgical approaches on outpatient migration.ResultsFrom 2008–2014, surgical approaches for LH and RH increased, which coincided with decreases in VH and AH. Overall, a 44.2% shift was observed from inpatient to outpatient settings (P<0.0001). Among all outpatient visits MIS increased, particularly for RH (3.6% to 41.07%). We observed increases in the proportion of non-Hispanic Black and Medicaid patients who obtained MIS in 2014 vs. 2008 (P<0.001). Surgical approach (51.8%) and physician outpatient MIS experience (19.9%) had the greatest influence on predicting outpatient BH. Compared with LH, RH was associated with statistically significantly higher likelihood of outpatient BH overall (OR 1.23; 95% CI, 1.16–1.31), as well as in sub-analyses of more complex cases and hospitals that performed ≥1 RH (P<0.05).ConclusionFrom 2008–2014, rates of LH and RH significantly increased. A significant shift from inpatient to outpatient setting was observed. These findings suggest that RH may facilitate the shift to outpatient BH, particularly for patients with complexities. The adoption of MIS in outpatient settings may improve access to disadvantaged patient groups.

Outcomes of robotic, laparoscopic, and open hysterectomy for benign conditions in obese patients

“…For example, despite evidence that intraocular pressure goes up with the steep Trendelenburg position during minimally invasive gynecologic surgery ( 31 ), the magnitude of this effect has not been evaluated in obese patients. Also, although outpatient robotic hysterectomy was demonstrated to be safe and associated with financial savings ( 32 , 33 , 34 ), its safety and feasibility has not yet been evaluated in the obese patient subset. Similarly, costs of robotic gynecologic surgery in benign cases were analyzed with strategies for efficiency ( 35 , 36 ), but there is paucity of the effect of BMI on cost in benign robotic hysterectomy.…”

Surgical Care for Women with Endometrial Cancer in Florida

“…2,20 The dissemination of minimally invasive technologies, including laparoscopy-especially robotics-has resulted in a shift from inpatient hysterectomies toward outpatient hysterectomies. 21 MIS appears to lead to shorter lengths of stay and fewer complications even among high-risk populations, such as obese and morbidly obese women. [22][23][24][25] This supports MIS appropriateness for outpatient hysterectomies and likely explains its increasing use in outpatient settings, given that early ambulation and discharge is a desired goal in these settings.…”

“…It has also been suggested that the adoption of MIS in outpatient settings might improve access for disadvantaged patient groups. 21 Although all patient groups have benefited from the increased prevalence of MIS in Florida, significant disparities still persist. Racial minorities, such as African American patients and those of other non-white races were less likely to undergo minimally invasive hysterectomy than white patients.…”

Robotic surgery during the COVID pandemic: why now and why for the future

“…We must now consider the availability of the medical staff and hospital resources, the transmission risk of COVID-19 to health-care workers and non-infected patients, and perioperative outcomes when triaging surgeries [ 5 ]. Widespread adoption of outpatient major surgical procedures should be considered whenever safe and feasible, utilizing risk predictors whenever available [ 6 – 8 ]. Once we have utilized ethical and effective triaging systems, we must also contemplate the surgical route for the procedure, a consideration not yet addressed in the available literature.…”