Joshua L. Woelk

The learning curve of robotic hysterectomy

OBJECTIVE: To evaluate the learning curve of robotic hysterectomy using objective, patient-centered outcomes and analytic methods proposed in the literature. METHODS: All cases of robotic hysterectomy performed at Mayo Clinic, Rochester, Minnesota, from January 1, 2007, through December 31, 2009, were collected. Experience was analyzed in 6-month periods. Operative time, complications, and length of stay longer than 1 day were compared between periods for significant change. For learning curve analysis, standard and risk-adjusted cumulative summation charting was used for the two most experienced robotic surgeons (A and B). Outcomes of interest were intraoperative complications and intraoperative or postoperative complications within 6 weeks. Proficiency was defined as the point at which each surgeons curve crossed H0 based on complication rates of abdominal hysterectomy. Cumulative summation parameters were p0=5.7% and p1=11.4% for outcome 1 and p0=36.0% and p1=50% for outcome 2. RESULTS: In 325 cases, operative time decreased significantly from 3.5 to 2.7 hours during the 3-year period. The proportion of patients with length of stay longer than 1 day decreased significantly from 49.2% to 14.7%. Complications did not decrease significantly. The average number of procedures to cross H0 was 91 for outcome 1 and 44 for outcome 2. Observed cumulative summation curves of surgeons A and B differed from the average number of attempts calculated from p0 and p1. CONCLUSIONS: Operative time and length of stay decrease with 36 months of experience with robotic hysterectomy, whereas complications may not. Cumulative summation analysis provides an objective, individualized tool to evaluate surgical proficiency and suggests this occurs after performing approximately 91 procedures. LEVEL OF EVIDENCE: III

Cost Differences Among Robotic, Vaginal, and Abdominal Hysterectomy

OBJECTIVE: To compare the costs of vaginal and abdominal hysterectomy with robotically assisted hysterectomy. METHODS: We identified all cases of robotically assisted hysterectomy, with or without bilateral salpingo-oophorectomy, treated at the Mayo Clinic (Rochester, Minnesota) from January 1, 2007, through December 31, 2009. Cases were propensity score-matched (one-to-one) to cases of vaginal and abdominal hysterectomy, selected randomly from January 1, 2004, through December 31, 2006 (before acquisition of the robotic surgical system). All billed costs were abstracted through the sixth postoperative week from the Olmsted County Healthcare Expenditure and Utilization Database and compared between cohorts with a generalized linear modeling framework. Predicted costs were estimated with the recycled predictions method. Costs of operative complications also were estimated. RESULTS: The total number of abdominal hysterectomies collected for comparison was 234 and the total number of vaginal hysterectomies was 212. Predicted mean cost of robotically assisted hysterectomy was

Cost differences among robotic, vaginal, and abdominal hysterectomy

2,253 more than that of vaginal hysterectomy (

Patient Satisfaction After Sling Revision for Voiding Dysfunction After Sling Placement.

13,619 compared with

Perioperative complications of robotic sacrocolpopexy for post-hysterectomy vaginal vault prolapse

11,366; P<.001), although costs of complications were not significantly different. The predicted mean costs of robotically assisted compared with abdominal hysterectomy were similar (

Assessing the learning curve of robotic sacrocolpopexy

14,679 compared with

A cohort study comparing a single-incision sling with a retropubic midurethral sling

15,588; P=.35). The costs of complications were not significantly different. CONCLUSIONS: Overall, vaginal hysterectomy was less costly than robotically assisted hysterectomy. Abdominal hysterectomy and robotically assisted hysterectomy had similar costs. LEVEL OF EVIDENCE: II

PD50-10 ASSESSING THE LEARNING CURVE OF ROBOTIC SACROCOLPOPEXY

RESULTS: The total number of abdominal hysterectomies collected for comparison was 234 and the total number of vaginal hysterectomies was 212. Predicted mean cost of robotically assisted hysterectomy was

Assessing the Learning Curve of Robotic Sacrocolpopexy

2,253 more than that of vaginal hysterectomy (

Predictors of Successful Urethrolysis in Women with Obstructive Voiding after Sling Surgery: Follow-Up Mailed Survey Study

13,619 compared with