A comparison of costs for abdominal, laparoscopic, and robot-assisted sacral colpopexy

The aim of this study was to compare the short-term estimated hospital costs and charges for open, laparoscopic, and robot-assisted sacral colpopexy. The null hypothesis was that there would be no difference in costs and charges. Fifteen comparable cases were reviewed for demographics, surgical information, and estimated hospital charges and costs and then compared with analysis of variance. There were no differences in demographics and surgical variables among the three groups. For estimated hospital charges, minimally invasive sacral colpopexy was most expensive; open was the least expensive approach. The estimated direct costs were significantly higher for robot-assisted compared with open sacral colpopexy, but not different between robot-assisted and laparoscopic sacral colpopexy. Robot-assisted sacral colpopexy produces the highest estimated hospital charges and is more expensive than open sacral colpopexy. The least expensive surgical approach from the hospital costs perspective is open abdominal sacral colpopexy. Presented at the 34th American Urogynecologic Society Meeting, September 4–6, 2008, Chicago, Illinois     

De novo urinary stress incontinence after laparoscopic sacral colpopexy

OBJECTIVE

To analyse the incidence and the risk of developing de novo stress urinary incontinence (SUI) after laparoscopic sacral colpopexy (LSCP).

PATIENTS AND METHODS

In all, 53 women wit no concomitant or occult SUI before surgery had a LSCP with no anti‐incontinence procedure. All their medical charts were reviewed retrospectively and analysed statistically to assess the association between clinical data before LSCP (age, body mass index, maximum urethral closure pressure, medical history of UI and prolapse surgery, bladder neck hypermobility) and de novo SUI after LSCP.

RESULTS

With a mean (sd ) follow up of 20.4 (9.1) months, seven patients (13%) developed de novo SUI, within a median (range) of 2.1 (1–3) months after surgery. There was no statistical association between factors before LSCP and de novo SUI afterward on a univariate analysis (P > 0.05). The 5‐year SUI‐free survival rate after LSCP was 86%.

CONCLUSION

Despite the risk of de novo SUI remaining low after LSCP patients should always be informed before surgery, as it cannot be predicted. Moreover, it can directly affect the functional outcome and lead to a second procedure in a few cases.     

Pregnancy after laparoscopic sacral colpopexy: a case report

We report a case of a pregnancy and follow the delivery of a young woman who previously underwent a laparoscopic sacral colpopexy (LSC) for pelvic organ prolapse (POP). A 38-year-old woman with POP desires pregnancy who after unsuccessful medical treatment with pessary underwent a laparoscopic uterine ventrosuspension (LUV). However, this procedure also failed and there was an immediate relapse. Thus, LSC was then performed. After which, she became pregnant culminating in elective caesarean delivery. The LUV failure was documented by a POP-Q classification and dynamic pelvic magnetic resonance (PMR) which was carried out 1 month after the surgery. When the same assessment was conducted after the LSC, it showed an optimal POP correction. The short-term post-delivery follow-up exhibited a small prolapse relapse, which remained stable 48 months after surgery as confirmed by a new PMR. Surgical correction of POP is possible in women with pregnancy desires. The result is variable and links to the POP stage and other surgical interventions.     

Comparison of robot-assisted total laparoscopic hysterectomy and total abdominal hysterectomy for treatment of endometrial cancer in obese and morbidly obese patients

The objective of our study was to compare clinical and pathologic outcomes of robot-assisted and open abdominal techniques for treatment of uterine cancer in obese patients. Institutional review board approval was obtained. Patient demographic data, pathological data, and surgical data were collected by retrospective chart review. Data were analyzed using SAS statistical software. One-hundred and eighty-nine consecutive cases of suspected uterine cancer were identified from October 2003 until January 2009. Of these, 116 patients (61%) had a body mass index (BMI) over 30. There were 66 completed robot-assisted hysterectomies (RAHs), 43 total abdominal hysterectomies (TAHs), and seven patients that were converted from RAH to open abdominal hysterectomy. There were no significant differences in preoperative patient demographics, including body mass index (BMI), medical co-morbidities, or preoperative cytology, except for parity. There were no differences in postoperative grade, stage, lymph vascular space invasion, positive pelvic washings, mean number of pelvic lymph nodes, or proportion of patients undergoing pelvic lymphadenectomy. Length of stay and estimated blood loss were lower for the robotic technique; RAHs had a significantly longer operative time, however. Postoperative blood transfusions and wound infections were more frequent in the TAH group. Of the RAH group there were seven conversions to TAH (10%). Differences in surgical times with and without lymphadenectomy were least in patients in the largest BMI category of >50. Length of time required for RAH was significantly longer then TAH in obese and morbidly obese patients, however benefits to patients of a minimally invasive approach included reduced incidence of wound infections, reduced transfusion rates, reduced blood loss, and shortened length of stay. These data also suggest the greatest advantage of robotic technology over laparotomy in patients with BMI over 50.     

Single-incision total laparoscopic hysterectomy

Single-incision laparoscopic surgery is an alternative to conventional multiport laparoscopy. Single-access laparoscopy using a transumbilical port affords maximum cosmetic benefits because the surgical incision is hidden in the umbilicus. The advantages of single-access laparoscopic surgery may include less bleeding, infection, and hernia formation and better cosmetic outcome and less pain. The disadvantages and limitations include longer surgery time, difficulty in learning the technique, and the need for specialized instruments. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. We perform single-incision total laparoscopic hysterectomy using three ports in the single transumbilical incision.     

腹腔镜全子宫切除术后阴道残端的处理体会

目的:探讨腹腔镜全子宫切除术后阴道残端的处理方法。方法:随机将2009年5月至2012年2月267例腹腔镜全子宫切除术患者分为两组,对照组(n=132)经阴道行连续锁边缝合;研究组(n=135)经腹腔行连续锁边缝合,比较两组患者术中阴道流血量、阴道残端处理时间、术后阴道流血量及阴道流血时间、住院时间、术后并发症及随访情况。结果:两组术中、术后阴道流血量及流血时间、术后并发症、术后3个月内阴道排液量差异有统计学意义(P<0.01),而处理时间、住院时间差异无统计学意义(P>0.05)。结论:两种方法均适用于腹腔镜全子宫切除术,但经腹腔行连续锁边缝合具有术中、术后阴道流血量少、时间短、术后并发症少等优点,更利于妇科微创手术的临床推广。     

体质量指数对机器人辅助腹腔镜全子宫切除术的影响

目的:探讨体质量指数(Body mass index,BMI)对机器人辅助腹腔镜全子宫切除术的影响。方法:收集中国医科大学附属第一医院妇科行机器人辅助腹腔镜全子宫切除术的131例患者的临床资料,根据体质量指数的不同,将患者分为正常体重组(BMI<24kg/m²)、超重组(BMI为24~28kg/m²)和肥胖组(BMI≥28kg/m²),比较三组患者年龄、术前有内科合并症(高血压、冠心病或糖尿病)患者的占比、手术时间、中转开腹率,以及术后血红蛋白下降程度、排气时间、术后住院日等。结果:超重组和肥胖组术前有内科合并症(高血压、冠心病或糖尿病)患者的比例超过正常体重组。而在年龄、手术时间、术后血红蛋白下降程度、排气时间、术后住院日方面,体重正常组与超重组及肥胖组比较,差异无统计学意义(P>0.05),所有患者无1例中转开腹。结论:机器人辅助腹腔镜全子宫切除术对于超重及肥胖的患者是安全、可行的,在患者基础条件不佳的情况下,可以获得与正常体重患者相似的术中及术后结局,是一种可以选择的手术方式。     

A comparison of laparoscopic and abdominal sacral colpopexy: objective outcome and perioperative differences

The purpose of this study was to compare anatomic and perioperative outcomes following laparoscopic sacral colpopexy (LSC) and abdominal sacral colpopexy (ASC). The hypothesis is that the laparoscopic technique has similar anatomic outcomes as compared with the open technique. A retrospective comparative chart review was conducted consisting of 43 patients who underwent laparoscopic sacral colpopexy and 41 patients who underwent abdominal sacral colpopexy. Demographics were comparable between groups except mean follow-up time (LSC = 7.4 months, ASC = 10.6 months). Mean improvement at the apex was similar between the two groups. Hospital stay in hours was shorter for the LSC group (mean/median = 35.4/30.9) than the ASC group (mean/median = 63.3/54.1, p < 0.001). Mean operative time was similar (LSC = 183, ASC = 168 min, p = NS) and complication rates were comparable between the groups. Patients undergoing laparoscopic and abdominal sacral colpopexy have comparable anatomical outcomes and operative times. Laparoscopy affords a shorter hospital stay.     

Prolapsed epiploica of the sigmoid colon after total laparoscopic hysterectomy

Prolapsed epiploica of the sigmoid colon through the vaginal cuff is a rare finding that has never been reported after total laparoscopic hysterectomy. We encountered a case of prolapsed epiploica of the sigmoid colon in a 40-year-old female, 4 months status after total laparoscopic hysterectomy. Diagnostic laparoscopy demonstrated prolapsed epiploica of the sigmoid colon through a dehisced vaginal cuff.     

Small bowel volvulus following peritoneal closure using absorbable knotless device during laparoscopic sacral colpopexy

As laparoscopic sacral colpopexy is associated with long operation times, barbed suture can be used to reduce the time needed to accomplish peritoneal closure. However, little is known about the adverse events of this new technique. We report on the case of a small bowel volvulus following peritoneal closure using a barbed suture. The patient presented with acute abdominal pain and a bowel obstruction syndrome 1 month after laparoscopic sacral colpopexy.     

Lumbosacral spondylodiscitis due to rectal fistula following mesh penetration 7 years after colpopexy

IntroductionThe primary source of spondylodiscitis cannot always be identified. However, not treating the original focus might preclude successful healing due to further spread of the causative microorganisms.Case reportAn 80-year-old woman presented with lumbar spondylodiscitis. She received surgical debridement and stabilization with transforaminal lumbar interbody fusion and tailored antibiotic therapy after isolation of Enterococcus spp. Despite appropriate treatment, the patient’s condition continued to worsen. An extensive search for the primary infection source finally revealed a rectal fistula caused by a synthetic mesh that had been inserted 7 years before for abdominal sacrocolpopexy. Only after removal of the fistula and protective ileostomy did the patient’s condition improved, allowing successful healing of the spondylodiscitis. After a follow-up period of one year no infection relapse was observed.ConclusionIn cases of spondyodiscitis that are resistant to adequate treatment, a search for infection source must be continued until the focus is found and treated. The presence of uncommon enteric microorganisms causing spondylodiscitis, such as Enterococcus spp., is suggestive of contiguous spread and should therefore be further investigated.     

Outcomes after robot-assisted laparoscopic radical prostatectomy

Robot-assisted laparoscopic radical prostatectomy （RALRP） using the da Vinci surgical system is now in widespread use in many countries where economic conditions allow the installation of this expensive technology. Controversy has surrounded the procedure since it was first performed in 2000, with many critics highlighting the lack of evidence to support its use. However, despite the lack of level I evidence, many large studies of patients have confirmed that the procedure is feasible and safe, with low morbidity. Available longer-term oncological data seem to show that outcomes from the robotic approach at least match those of traditional open radical prostatectomy. Functional outcomes also seem satisfactory, although randomized controlled trials are lacking. This paper reviews the current status of RALRP with respect to perioperative data and complications and oncologic and functional outcomes.     

Abdominal sacral colpopexy: Surgical pearls and outcomes

Vaginal vault prolapse is a challenging form of pelvic organ prolapse that occurs in combination with cystocele, rectocele, or enterocele in nearly 75% of affected patients. Clinical presentation will vary depending on the associated defects. Any successful therapy for vaginal vault prolapse will depend on a thorough evaluation of the vaginal compartments and concomitant lower urinary tract function. Surgical correction of vaginal vault prolapse can be achieved through a variety of vaginal or abdominal approaches. This review focuses on the abdominal approach for vaginal vault prolapse surgery. We review outcomes of abdominal sacral colpopexy (ASC) and available comparisons to vaginal vault suspension. We address the role of laparoscopy and robotics in ASC and examine the outcomes of such procedures. We also discuss available literature on the management of the lower urinary tract in combination with ASC.     

257 incidental appendectomies during total laparoscopic hysterectomy

OBJECTIVE: This retrospective observational report analyzes the demographics, blood loss, length of surgical duration, number of days in the hospital, and complications for 821 consecutive patients undergoing total laparoscopic hysterectomy over a 11-year period stratified by incidental appendectomy. METHODS: A retrospective chart abstraction was performed. ANOVA and chi-square tests were performed with significance preset at P<0.05. RESULTS: Of 821 consecutive patients undergoing total laparoscopic hysterectomy, 257 underwent elective appendectomy with the ultrasonic scalpel, either as part of their staging, treatment for pelvic pain, or prophylaxis against appendicitis. Comparing the 2 groups, no difference existed in mean age of 50+/-10 years or mean BMI of 27.6+/-6.7. Both groups had a similar mean blood loss of 130 mL. Surgery took less time (137 vs 118 minutes, P<0.0012) and the hospital stay was shorter in the appendectomy group (1.5 vs 1.2, P<0.0001) possibly because it was performed incidentally in most cases. No complications were attributable to the appendectomy, and complication types and rates in both groups were similar. Though all appendicies appeared normal, pathology was documented in 9%, including 3 carcinoid tumors. CONCLUSIONS: Incidental appendectomy during total laparoscopic hysterectomy is not associated with significant risk and can be routinely offered to patients planning elective gynecologic laparoscopic procedures, as is standard for open procedures.