Perioperative Outcomes and Cost Differences Between Open and Robotic Vesicovaginal Fistula Repair
Brittany D. Berk, MD, Vanessa A. Lukas, MD, Steven L. Chang, MD, Elodi J. Dielubanza, MD.
Brigham and Women's Hospital, Boston, MA, USA.
BACKGROUND: Vesicovaginal fistulae are the most commonly acquired fistula of the genitourinary tract globally, likely related to obstetrical complications in the developing world. Although less common in the US, VVF are most often associated with iatrogenic injury during gynecological procedures. Supra-trigonal fistulae have traditionally been managed with open abdominal repair. However, given the recent widespread adoption of robotics in urologic surgery, there has been a trend towards minimally-invasive surgery (MIS). In this study, we sought to evaluate intraoperative and postoperative outcomes and costs for the open and robotic approach to determine feasibility of widespread adoption of a MIS technique. METHODS: We performed a retrospective cohort study of adult women undergoing open and robotic VVF repair from 2011 to 2020. The data were abstracted from the Premier Hospital Database (PHD), a national hospital discharge dataset representing approximately 20% of non-federal hospital discharges in the United States, using relevant ICD and CPT codes. We assessed for an association between surgical approach (open vs robotic) and postoperative outcomes including 90-day surgical complications, operating room time, need for blood transfusion, length of stay, readmissions and 90-day overall costs. All multivariable logistic and quantile regression models were controlled for clinical, demographic and hospital factors. RESULTS: A total of 1,072 women in PHD underwent vesicovaginal repair during the 10-year period of the study. There were no differences between the surgical approaches for 90-day minor (Clavien grade 1-2), major (Clavien grade 3-5) complications, intraoperative and postoperative hemorrhage, or 90-day readmission. The robotic approach was associated with a longer median operating room time (+78 min, 95% CI: 42 to 113 min, p<0.0001), a minimally shorter hospitalization (-0.6 day, 95% CI: -1.2 to -0.05 days, p=0.034), and higher 90-day cost (+US$3,024, 95% CI: $1,254 to $4,793, p=0.001). CONCLUSIONS: Despite the national trend towards robotic surgeries, open VVF offers comparable outcomes compared to the robotic approach while keeping healthcare costs low. Therefore, optimal surgical approach should be guided by patient factors and surgeon preference.
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