Determining Optimal Route of Hysterectomy for Benign Indications: Clinical Decision Tree Algorithm

To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy. A retrospective postrobot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined...

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Vydané v:Obstetrics and gynecology (New York. 1953) Ročník 129; číslo 1; s. 130
Hlavní autori: Schmitt, Jennifer J, Carranza Leon, Daniel A, Occhino, John A, Weaver, Amy L, Dowdy, Sean C, Bakkum-Gamez, Jamie N, Pasupathy, Kalyan S, Gebhart, John B
Médium: Journal Article
Jazyk:English
Vydavateľské údaje: United States 01.01.2017
Predmet:
Adult
Algorithms
Clinical Decision-Making - methods
Decision Trees
Female
Genital Diseases, Female - surgery
Hospital Costs
Humans
Hysterectomy - adverse effects
Hysterectomy - economics
Hysterectomy - methods
Hysterectomy - statistics & numerical data
Hysterectomy, Vaginal - adverse effects
Hysterectomy, Vaginal - economics
Hysterectomy, Vaginal - statistics & numerical data
Middle Aged
Operative Time
Organ Size
Patient Readmission - statistics & numerical data
Retrospective Studies
Robotic Surgical Procedures - adverse effects
Robotic Surgical Procedures - economics
Robotic Surgical Procedures - statistics & numerical data
Surgical Wound Infection - etiology
Urinary Tract Infections - etiology
Uterus - pathology
ISSN:1873-233X, 1873-233X
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Shrnutí:To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy. 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. 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. 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.
Bibliografia:ObjectType-Article-1
SourceType-Scholarly Journals-1
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content type line 23
ISSN:1873-233X
1873-233X
DOI:10.1097/AOG.0000000000001756