Koji Matsuo1, Rachel S Mandelbaum2, David J Nusbaum3, Erica J Chang2, Renee H Zhang3, Shinya Matsuzaki2, Maximilian Klar4, Lynda D Roman5. 1. Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA. Electronic address: koji.matsuo@med.usc.ed. 2. Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA. 3. Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. 4. Department of Obstetrics and Gynecology, University of Freiburg, Freiburg, Germany. 5. Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
Abstract
STUDY OBJECTIVE: Recent studies suggest that prolonged Trendelenburg positioning during robotic-assisted total laparoscopic hysterectomy (RA-TLH) may lead to fluid shifts and pulmonary, airway, head and neck, and cranial complications in the upper-body. This study examined upper-body complications during RA-TLH for benign gynecologic disease. DESIGN: Population-based retrospective study SETTING: The National Inpatient Sample PATIENTS: A total of 771,412 women who had total hysterectomy for benign gynecologic disease from 10/2008-9/2015, including 661,284 women who had total abdominal hysterectomy (TAH), 51,544 women who had traditional TLH, and 58,584 women who had RA-TLH. INTERVENTIONS: A multiple-group generalized boosted model to balance the measured baseline covariates across the three hysterectomy groups, and a generalized estimating equation model to assess the effect size of complication risk (overall and upper-body complications). MEASUREMENTS AND MAIN RESULTS: Women in the RA-TLH group were more likely to be older, white, and have a higher comorbidity index (all, P<0.001). The overall rate of upper-body complications was 4.6% across the three groups. RA-TLH was not associated with increased risk of upper-body complications compared to traditional TLH (odds ratio [OR] 1.06, 95% confidence interval [CI] 0.90-1.26) or TAH (OR 0.98, 95%CI 0.87-1.11). In contrast, RA-TLH was associated with decreased risk of overall perioperative complications compared to TAH (12.0% versus 18.6%, OR 0.64, 95%CI 0.59-0.70, P<0.001). RA-TLH and traditional TLH had similar risk of overall perioperative complications (12.0% versus 13.1%, OR 0.91, 95%CI 0.82-1.02, P=0.099). Women who developed upper-body complications had a higher perioperative mortality rate (0.4% versus <0.01%, OR 79.1, 95%CI 36.0-174). The highest rates of complications (62.5%) were observed in morbidly-obese women aged 70-79 with a comorbidity index of ≥4. CONCLUSION: In hysterectomy for benign gynecological disease, RA-TLH was not associated with an increased risk of upper-body complications compared to TAH or traditional TLH. However, older age and higher comorbidity are key risk factors that increase the risk of upper-body complications which carry a disproportionally high mortality rate.
STUDY OBJECTIVE: Recent studies suggest that prolonged Trendelenburg positioning during robotic-assisted total laparoscopic hysterectomy (RA-TLH) may lead to fluid shifts and pulmonary, airway, head and neck, and cranial complications in the upper-body. This study examined upper-body complications during RA-TLH for benign gynecologic disease. DESIGN: Population-based retrospective study SETTING: The National Inpatient Sample PATIENTS: A total of 771,412 women who had total hysterectomy for benign gynecologic disease from 10/2008-9/2015, including 661,284 women who had total abdominal hysterectomy (TAH), 51,544 women who had traditional TLH, and 58,584 women who had RA-TLH. INTERVENTIONS: A multiple-group generalized boosted model to balance the measured baseline covariates across the three hysterectomy groups, and a generalized estimating equation model to assess the effect size of complication risk (overall and upper-body complications). MEASUREMENTS AND MAIN RESULTS:Women in the RA-TLH group were more likely to be older, white, and have a higher comorbidity index (all, P<0.001). The overall rate of upper-body complications was 4.6% across the three groups. RA-TLH was not associated with increased risk of upper-body complications compared to traditional TLH (odds ratio [OR] 1.06, 95% confidence interval [CI] 0.90-1.26) or TAH (OR 0.98, 95%CI 0.87-1.11). In contrast, RA-TLH was associated with decreased risk of overall perioperative complications compared to TAH (12.0% versus 18.6%, OR 0.64, 95%CI 0.59-0.70, P<0.001). RA-TLH and traditional TLH had similar risk of overall perioperative complications (12.0% versus 13.1%, OR 0.91, 95%CI 0.82-1.02, P=0.099). Women who developed upper-body complications had a higher perioperative mortality rate (0.4% versus <0.01%, OR 79.1, 95%CI 36.0-174). The highest rates of complications (62.5%) were observed in morbidly-obesewomen aged 70-79 with a comorbidity index of ≥4. CONCLUSION: In hysterectomy for benign gynecological disease, RA-TLH was not associated with an increased risk of upper-body complications compared to TAH or traditional TLH. However, older age and higher comorbidity are key risk factors that increase the risk of upper-body complications which carry a disproportionally high mortality rate.