Rose Calixte

Establishing the Learning Curve of Robotic Sacral Colpopexy in a Start-up Robotics Program

STUDY OBJECTIVE To determine the learning curve of the following segments of a robotic sacral colpopexy: preoperative setup, operative time, postoperative transition, and room turnover. DESIGN A retrospective cohort study to determine the number of cases needed to reach points of efficiency in the various segments of a robotic sacral colpopexy (Canadian Task Force II-2). SETTING A university-affiliated community hospital. PATIENTS Women who underwent robotic sacral colpopexy at our institution from 2009 to 2013 comprise the study population. INTERVENTIONS Patient characteristics and operative reports were extracted from a patient database that has been maintained since the inception of the robotics program at Winthrop University Hospital and electronic medical records. Based on additional procedures performed, 4 groups of patients were created (A-D). MEASUREMENTS AND MAIN RESULTS Learning curves for each of the segment times of interest were created using penalized basis spline (B-spline) regression. Operative time was further analyzed using an inverse curve and sequential grouping. A total of 176 patients were eligible. Nonparametric tests detected no difference in procedure times between the 4 groups (A-D) of patients. The preoperative and postoperative points of efficiency were 108 and 118 cases, respectively. The operative points of proficiency and efficiency were 25 and 36 cases, respectively. Operative time was further analyzed using an inverse curve that revealed that after 11 cases the surgeon had reached 90% of the learning plateau. Sequential grouping revealed no significant improvement in operative time after 60 cases. Turnover time could not be assessed because of incomplete data. CONCLUSIONS There is a difference in the operative time learning curve for robotic sacral colpopexy depending on the statistical analysis used. The learning curve of the operative segment showed an improvement in operative time between 25 and 36 cases when using B-spline regression. When the data for operative time was fit to an inverse curve, a learning rate of 11 cases was appreciated. Using sequential grouping to describe the data, no improvement in operative time was seen after 60 cases. Ultimately, we believe that efficiency in operative time is attained after 30 to 60 cases when performing robotic sacral colpopexy. The learning curve for preoperative setup and postoperative transition, which is reflective of anesthesia and nursing staff, was approximately 110 cases.

A comparison of obstetrical outcomes and costs between misoprostol and dinoprostone for induction of labor

Abstract Objective: The objective of this study is to compare resource utilization (efficiency) and obstetrical/cost outcomes of single dose misoprostol versus dinoprostone for induction of labor (IOL) at term. Methods: Retrospective cohort of induced deliveries 37–41 weeks gestation presenting with a Bishop score ≤4 using single-dose-50 mcg vaginal misoprostol or 10 mg-dinoprostone vaginal-inserts. Dinoprostone patients were compared (5:1) with misoprostol patients. The primary outcome variable was length of L&D stay (proxy for resource utilization). Baseline characteristics, clinical outcomes, and costs were compared. Results: Three-hundred thirty-one patients were included, 276 received dinoprostone and 55 received misoprostol. The misoprostol group had statistically significant decreased time to active labor [median 8 h (1.6,24) versus 12(0.8,52)], time-to-delivery [median 11 h (4,31) versus 17(2.8,56)] and L&D stay [median 16 h (13,28) versus 24(18,30)]. Differences remained significant after adjustment for race, method of delivery, birth weight, gravidity/parity, gestational age, and BMI (adjusted p values <0.001,  <0.01, and < 0.05, respectively). There were no statistical differences in Apgar scores, tachysystole rate, cesarean section rate, and composite maternal/neonatal morbidity. A policy of using misoprostol would result in annual cost savings of approximately

Does cervical cerclage decrease preterm birth in twin pregnancies with a short cervix

242 500 at our institution as compared with dinoprostone. Conclusion: Single-dose misoprostol is more efficient in IOL at term with respect to L&D utilization and cost and its use is not associated with increased adverse obstetrical outcomes.

Prevalence and Overtesting of True Heparin-Induced Thrombocytopenia in a 591-Bed Tertiary Care, Teaching Hospital:

Abstract Purpose: To determine if use of cerclage in twin gestations with mid-trimester short cervix is associated with decreased preterm birth rate. Study design: This is a retrospective cohort of twin gestations identified with cervical length of ≤2.5 cm before 24 weeks of gestation through the perinatal ultrasound database of two institutions from 2008 to 2014. Patients with and without cerclage were compared for a primary outcome of preterm birth at <35 weeks. A pre-planned sub-group analysis of patients with cervical length ≤1.5 cm was also performed. Results: Eighty-two patients were included; 43 received cerclage, 39 did not. Mean gestational age at cerclage placement was 20.8 weeks. There was no significant difference in rate of preterm birth <35 weeks between the groups (34.9% versus 48.7%, respectively). In the sub-group analysis of patients with cervical length ≤1.5 cm, there was a significant decreased risk of preterm birth <35 weeks [37% versus 71.4%; adjusted RR 0.49 (0.26–0.93)]. Conclusion: Cerclage placement for cervical length ≤2.5 cm in twin gestations did not decrease the rate of preterm birth at <35 weeks; however, cerclage placement for cervical length ≤1.5 cm was associated with a significantly decreased rate of preterm birth <35 weeks when compared to patients managed without cerclage.

Reoperation After Robotic and Vaginal Mesh Reconstructive Surgery: A Retrospective Cohort Study.

Heparin-induced thrombocytopenia type II (HIT) is a rare but potentially fatal antibody-mediated reaction to all forms of heparin (unfractionated heparin, low-molecular weight heparin, heparin flushes, and heparin-coated catheters), which can lead to HIT with thrombosis. Two tests commonly used to screen for HIT include the enzyme-linked immunosorbent assay (ELISA) and serotonin release assay (SRA). This is a retrospective chart review study conducted from January 1, 2013, through December 31, 2014, to estimate the rate of true HIT in critical care patients at Winthrop-University Hospital, located in Mineola, New York. Patients are classified as positive for HIT if both ELISA and SRA immunoassays are positive. We reviewed 507 heparin immunoassays, excluding 64 who had an inappropriate ELISA test sent due to no administration of heparin, enoxaparin, or heparin lock flush at this or previous hospital stays at Winthrop. Of the 443 heparin immunoassays, ELISA results were positive for 66 patients (15.1%), and only 11 (2.5%) patients had true cases of HIT with a 95% confidence interval of 1.3% to 4.4%. The 4T score for those with true HIT (median: 5.0) was statistically higher compared to those without true HIT (median: 2.0; P < .001). Despite guidelines in place, overtesting for HIT is still a prevalent issue.

Factors Influencing Adhesion Formation After Primary Cesarean Delivery [26C]

Objectives Our primary objective was to compare reoperations after robotic-assisted sacrocolpopexy and transvaginal mesh for apical prolapse repair. Our secondary aim was to record perioperative complications after robotic and vaginal surgeries. Methods We reviewed medical records of women who underwent vaginal apical mesh support procedures or robotic sacrocolpopexy at Winthrop University Hospital between August 2009 and August 2013. We compared reoperations and perioperative complications between the 2 groups. Results There were 245 eligible cases during the 4-year study period. One hundred eighty-one women underwent robotic-assisted sacrocolpopexy and 64 women underwent transvaginal mesh. Women who underwent robotic surgery were younger and had decreased blood loss. Patients were followed up for a median of 3 months after robotic surgery and 11.5 months after transvaginal mesh. We found no difference in overall rate of reoperation between robotic and transvaginal mesh repair for apical prolapse. Specifically, there was no difference in the rate of reoperation for mesh exposure. Conclusions Despite recent controversies, transvaginal mesh offers the benefit of an effective minimally invasive procedure with shorter operative times, and may not pose additional risk for reoperation when compared to robotic-assisted sacrocolpopexy.

Do Obese Women Need Higher Dosages of Misoprostol for Labor Induction? [6A]

INTRODUCTION: To determine the association, if any, between obstetrical and surgical factors and adhesion formation after a primary cesarean delivery (CD). METHODS: This is retrospective cohort of patients at a single institution who underwent a primary CD between 2008 and 2010, with a repeat CD by 12/2013. At the time of each CD, an adhesion assessment form was completed, as per the standard of care. The form evaluates the character of adhesions (none [score 0], filmy [score 1], dense [score 2]) in five locations (bowel, fascia to uterus, omentum to uterus, omentum to fascia, bladder to uterus). Patients with an adhesion score greater than or equal to 4 were compared to those patients with fewer adhesions. 38 possible obstetrical and surgical predictors of adhesions were entered into a univariable analysis; then, all significant variables were entered into an adjusted model to determine independent predictors of adhesion formation. RESULTS: 851 patients met inclusion criteria for the study. After multivariable analyses, patients with peritoneal closure (OR 0.25, 95% CI 0.14–0.43, P<.001) or rectus muscle closure (OR 0.57, 95% CI 0.37–0.89, P<.01) at primary CD are less likely to have an adhesion score greater than or equal to 4. No difference was seen with adhesion barrier use (OR 1.19, 95% CI 0.76–1.89, P<.45). CONCLUSION: Our study suggests that peritoneal and/or rectus muscle closure at the time of CD should be routinely performed, as these are safe, cost-effective surgical techniques that reduce adhesion formation and may decrease long term risks of operative morbidity.

Comparing Length of Stay Between Patients Taking Rivaroxaban and Conventional Anticoagulants for Treatment of Venous Thromboembolism

INTRODUCTION: To determine the association between maternal BMI and time to delivery in women receiving misoprostol for labor induction (IOL). METHODS: This is a retrospective cohort study of women undergoing IOL with intravaginal misoprostol from 1/2013–2/2015. Women admitted for IOL with singleton, term, cephalic gestations were identified through a database. Maternal demographics, obstetrical variables, and admission BMIs were collected. Time to delivery (vaginal and cesarean) from the initial misoprostol dose was primary outcome. Groups were made based on maternal BMI and misoprostol dose (25 mcg vs 50 mcg). Time to delivery was compared among BMI categories stratified for misoprostol dose using two-sample t test, Wilcoxon rank sum test, and exact chi-square test. A P value less than 0.05 was considered significant. Kaplan Meyer survival and time to event curves were created. RESULTS: 483 patients were included. Mean gestational age was 39.2±1.6 wks, median parity was 0 (range 0–1), and maternal age was 30.5±6.1. Misoprostol 25 mcg was most commonly used (n=290, 60%). Vaginal delivery was achieved in 79% (n=382). More than 90% (n=435) of the women had BMIs greater than 30. Time to delivery was significantly longer with BMIs greater than 30 when misoprostol 25 mcg was used compared with 50 mcg. For BMIs greater than or equal to 40, time to delivery was six hours longer regardless of dose. CONCLUSION: There is an association between maternal BMI and initial misoprostol dosage on time to delivery. Admission BMI should be taken into consideration when dosing misoprostol for IOL.