Indication for Robotic-Assisted Surgery Influences Perioperative Outcomes and Hospital Readmissions among Women Undergoing Gynecologic Procedures for Benign and Malignant Pathologies

Abstract

Objective: Differences in complication rates and outcomes are expected when comparing surgery for benign and malignant indications, however there are limited data addressing this in robotic-assisted gynecologic surgery.As this distinction and its ramifications can influence patient counseling, surgical planning and reimbursement as we transition to value-based payment models, we sought to evaluate perioperative outcomes for women undergoing gynecologic robotic-assisted surgery for benign versus malignant indications. Methods:We reviewed the medical records of all patients undergoing robotic-assisted gynecologic surgery at a single institution by high-volume robotic surgeons from January 2013 -May 2016.Perioperative outcomes were evaluated using univariate and multiple regression analysis to compare complications for benign versus malignant surgical indications.Results: Two thousand seven hundred and fifty-seven patients were included (benign 2316, malignant 441).Malignant cases were significantly older (58 vs. 42y, P<0.001) with more medical comorbidities and higher BMI.Compared to benign cases, malignant cases included a higher percentage of hysterectomies (82.3% v. 34.7%, P<0.001) with a greater number of cases including lymph node dissection (54.2% v. 0.8%, P<0.001) or staging biopsies (3.4% v. 0.4%, P<0.001).Malignant cases also had longer surgical time (3.7 v. 2.8 hours, P<0.001), higher rates of intraoperative complications (7.5% v. 4.6%, P=0.01), conversion to laparotomy (3.4% v. 0.9%, P<0.001), length of hospital stay (10.5h vs. 7.0h, P<0.001), emergency department (ED) visits within six weeks (8.2% vs. 5.4%, P=0.02), and hospital readmission within six weeks (5.7% vs. 2.0%, P<0.001).There was no difference in estimated blood loss or postoperative complications.Post-operative complications in benign vs malignant cases, respectively included: fever [75 (5%) 21 (5%)]; urinary tract infection [59 (4%), 24 (6%)]; wound infection [38 (2%), 8 (2%)]; abscess [14 (1%), 4 (1%)]; other infection [13 (0.8%), 10 (2%)]; port-site hernia 11 (0.7%), 4 (0.9%)]; small bowel obstruction [7 (0.4%), 3 (1%)]; arrhythmia [19 (1%), 13 (3%)]; pulmonary embolism [4 (0.3%), 3 (0.7%)] and re-operation [12 (0.8%), 5 (1%)].On multiple regression analysis adjusting for age, BMI, medical comorbidities and perioperative complications, malignancy remained associated with longer operating time, lower rate of same-day hospital discharges, higher rate of conversion to laparotomy and more hospital readmissions within six weeks. Conclusion:Robotic surgery performed for gynecologic malignancy is associated with higher rates of conversion to laparotomy and hospital readmission compared to robotic surgery performed for benign disease.Malignant cases had longer operating time and fewer same-day discharges.This information is very important for physician and patient surgical expectations and anticipated healthcare costs and should be accounted for when determining models of value-based reimbursement.