David Eisenstein

Cost-effectiveness of single-dose methotrexate compared with laparoscopic treatment of ectopic pregnancy.

Objective To evaluate the cost-effectiveness of treatment with intramuscular (IM) methotrexate compared with fallo-pian tube–sparing laparoscopy for small unruptured ectopic pregnancy. Methods A decision-analytic model accounting for varying resolution rates, complication rates, and cost estimates was built to compare the use of methotrexate with laparoscopy. Meta-analysis results of studies identified by a MEDLINE search for IM methotrexate resolution rates and tube-sparing laparoscopy resolution rates were used in model estimation. A similar process was used to generate model complication rates. Data on associated resource use were derived from established clinical guidelines. Estimates of 1998 costs incurred by provider organizations were calculated using data from a large managed care organization. Results The average methotrexate resolution rate among the studies included was 87% (range 75–90%). The average laparoscopy resolution rate was 91% (range 72–100%). Complication rates for methotrexate ranged from 0% to 22%, with an average of 10% for minor complications, and from 0% to 11% for serious complications, with an average of 7%. Complication rates for laparoscopy ranged from 0% to 8% for intraoperative complications, with an average of 2%, and from 0% to 15% for postoperative complications, with an average of 9%. Baseline model estimates indicated an average cost saving of more than

Vaginal cuff closure during robotic-assisted total laparoscopic hysterectomy: Comparing vicryl to barbed sutures

3000 per resolved ectopic pregnancy with methotrexate treatment compared with laparoscopy. Results of extensive sensitivity analyses supported the finding of a cost saving with methotrexate treatment. Conclusion Single-dose methotrexate is a cost-saving, nonsurgical, fallopian tube–sparing treatment for ectopic pregnancy.

When treating the pain is not enough: a multidisciplinary approach for chronic pelvic pain

There were no differences in complications between O Vicryl™ figure-of-eight vaginal cuff closure and closure with V-Loc™ barbed sutures in this study.

Quality of Communication in Robotic Surgery and Surgical Outcomes.

Chronic pelvic pain (CPP) is related to psychological distress and interference in daily activities; however, CPP is not as extensively researched as other forms of chronic pain. Therefore, the purpose of this study was to investigate the relationships among pain, psychological distress, and functional impairment in patients with CPP. There were chart reviews conducted of 107 female patients who completed a psychiatric evaluation at a specialty, CPP clinic as a part of a multidisciplinary evaluation. Results suggest that psychological distress and impairment in daily activities are common in CPP patients. Most areas of functional impairment were not associated with pain variables. Rather, several forms of functional impairment were related to higher levels of depression and anxiety. Results from this study suggest the possibility that psychiatric symptoms are contributing to functional impairment in this population. These findings highlight the importance of a multidisciplinary approach in the evaluation and treatment of CPP patients to help decrease functional impairment in these patients.

How do I cope with pain? Let me count the ways: awareness of pain coping behaviors and relationships with depression and anxiety

Background and Objectives: Robotic surgery has introduced unique challenges to surgical workflow. The association between quality of communication in robotic-assisted laparoscopic surgery and surgical outcomes was evaluated. Methods: After each gynecologic robotic surgery, the team members involved in the surgery completed a survey regarding the quality of communication. A composite quality-of-communication score was developed using principal component analysis. A higher composite quality-of-communication score signified poor communication. Objective parameters, such as operative time and estimated blood loss (EBL), were gathered from the patients medical record and correlated with the composite quality-of-communication scores. Results: Forty robotic cases from March through May 2013 were included. Thirty-two participants including surgeons, circulating nurses, and surgical technicians participated in the study. A higher composite quality-of-communication score was associated with greater EBL (P = .010) and longer operative time (P = .045), after adjustment for body mass index, prior major abdominal surgery, and uterine weight. Specifically, for every 1-SD increase in the perceived lack of communication, there was an additional 51 mL EBL and a 31-min increase in operative time. The most common reasons reported for poor communication in the operating room were noise level (28/36, 78%) and console-to-bedside communication problems (23/36, 64%). Conclusion: Our study demonstrates a significant association between poor intraoperative team communication and worse surgical outcomes in robotic gynecologic surgery. Employing strategies to decrease extraneous room noise, improve console-to-bedside communication and team training may have a positive impact on communication and related surgical outcomes.

Minimally invasive surgery in pelvic floor repair

Abstract Patients with chronic pain are often undertreated with medications alone and need alternative ways of coping. Identifying pain coping skills patients use may be beneficial; however, no research has investigated whether patients are aware of their coping skills. The purpose of this study was to determine whether patients are aware of their pain coping skills, whether certain patient characteristics were related to using coping strategies, and whether coping strategies were related to psychiatric symptoms. Chart reviews were conducted on seventy-eight chronic pain patients who completed a semi-structured psychological interview. Patients endorsed using more coping strategies on the measure compared to the verbal self-report. Identifying with certain patient demographics was related to higher use of some coping strategies. Symptoms of anxiety and depression were also related to the use of some coping strategies. Anxiety was negatively related to ignoring the pain and using self-talk coping statements and positively related to catastrophizing. Depression was negatively related to the use of distraction, ignoring the pain, and using self-talk coping statements. Depression and pain severity were both positively related to catastrophizing and prayer. Results suggest that clinicians may need to help patients become aware of adaptive coping strategies they already use and that the use of certain coping strategies is related to lower levels of depression and anxiety.

Risk factors for trachelectomy following supracervical hysterectomy

Purpose of review To review the use and efficacy of minimally invasive surgery in pelvic organ prolapse (POP) repair. This review summarizes surgical options for management of POP with special emphasis on minimally invasive surgical approach and discusses the recent experience and feasibility of integrating robot-assisted technology. Recent findings Minimally invasive approaches have equal efficacy and less morbidity than laparotomy for POP repair, particularly apical prolapse. Robotics may facilitate the rate of minimally invasive surgery for POP repair with greater cost and as yet no proven superiority for conventional laparoscopy. Summary Minimally invasive surgery is the preferred approach to POP repair. Conventional laparoscopic or robotic sacral colpopexy is recommended for apical defect and procidentia.

Robotic Trachelectomy After Supracervical Hysterectomy for Benign Gynecologic Disease.

We identified risk factors for trachelectomy after supracervical hysterectomy (SCH) due to persistence of symptoms.

Vaginal Cuff Closure during Robotic Assisted Total Laparoscopic Hysterectomy: Comparing Vicryl to Barbed Sutures

Background and Objectives: A renewed interest in the supra cervical approach to hysterectomy has created a cohort of patients with a retained cervix at risk of persistent symptoms requiring a subsequent trachelectomy. The objective of this study was to evaluate the efficacy of robotic trachelectomy after a previous supracervical hysterectomy. Methods: This is a retrospective chart review of women who had robotic trachelectomy after supracervical hysterectomy for benign gynecologic disease from January 2009 through October 2014. Results: Eleven patients underwent robotic trachelectomy for benign conditions during the observed period. Prior supracervical hysterectomy had been performed for pelvic pain (8/11, 73%), abnormal uterine bleeding (7/11, 64%), and dysmenorrhea (5/11, 45%). In 10 of 11 patients, the symptoms leading to robotic trachelectomy were the same as those leading to supracervical hysterectomy. The time from hysterectomy to recurrence of symptoms ranged from 0.5 to 26 months (median, 6), whereas the time interval from previous surgery to robotic trachelectomy ranged from 1 to 57 months (median, 26). Mean age and body mass index at robotic trachelectomy were 42 ± 5.4 years and 32 ± 6.1 kg/m2. Mean length of surgery was 218 ± 88 minutes (range, 100–405). There was 1 major postoperative complication involving bladder perforation and subsequent vesicovaginal fistula (VVF). Endometriosis was seen in 27% of pathologic specimens and cervicitis in another 27%; 45% showed normal tissue histology. In 6 (55%) cases, symptoms leading to trachelectomy resolved completely after surgery, and the other 5 (45%) patients reported a significant improvement. Conclusions: Although trachelectomy can be a challenging surgery, our experience suggests that the robotic approach may be a valuable means of achieving safe and reproducible outcomes.