Abstract

Study Objective:

Goal of this study is to present a cases series endorsing same-day discharge after minimally invasive robotic surgery for endometrial cancer and to determine factors that affect the length of hospital stay.

Design:

Retrospective study is comprised of all cases (N = 78) by a single gynecologic oncologist (July 2017 to July 2019) that involved a robotic-assisted total hysterectomy (RTH) with bilateral salpingo-oophorectomy (BSO) and total pelvic ± para-aortic lymphadenectomy for endometrial cancer. Categorical and continuous variables were analyzed using the Chi-square test and two-sided t-test respectively. Multivariate correlation analysis was utilized to determine risk factor influence on length of stay. Factors that may affect same-day discharge: surgery time, estimated blood loss, time of day (start of surgery after 15:00), cystoscopy, complexity of surgery, comorbidities, FIGO grade from endometrial biopsy pre-operatively, FIGO stage.

Setting:

Community hospital in El Paso, TX, a borderland city primarily comprised of a Hispanic population.

Patients:

78 patients who underwent robotic total hysterectomy with bilateral salpingo-oophorectomy and total pelvic ± para-aortic lymphadenectomy for surgical treatment of endometrial cancer.

Measurements and Main Results:

Total of 78 women with a median age of 61.8 years-old underwent RTH + BSO + surgical staging, and 56 (71.8%) of patients were successfully discharged the same day (< 24 h) despite no ERAS protocol. Number of comorbidities, body mass index (BMI), FIGO grade, surgery time of day, and surgery length did not have a statistically significant effect on length of stay. Of the same-day discharge cases, 20 (35.7%) were immediately discharged following post-op recovery (within 4 h). Patients were more likely to stayed longer than 24 hours if they were older (> 60 y), higher estimated blood loss (> 30 cc), higher surgical complexity (para-aortic lymphadenectomy and/or omentectomy performed), or higher FIGO stage (> IB).

Conclusion:

Same-day discharge is feasible following minimally invasive robotic surgery for endometrial cancer, despite multiple comorbidities, later surgery time of day, and higher FIGO grade.

Keywords: Same-day discharge; Minimally invasive gynecologic surgery; Endometrial cancer; Gynecologic oncology

Introduction

Endometrial cancer is the most common gynecologic cancer in women and 9

^th

most common cancer in women overall [1-2]. Moreover, incidence and mortality of endometrial cancer in the United States are increasing with an estimated 63,230 new cases and 11,350 deaths in 2018 [2-3]. Endometrial cancer is typically diagnosed in postmenopausal women who present with vaginal bleeding. First-line treatment for early–stage endometrial cancer is primary surgical resection via total hysterectomy with or without bilateral salpingo-oophorectomy and possible lymphadenectomy [4]. This surgery was traditionally performed via laparotomy, but now a minimally invasive approach has proven to be feasible and preferred with fewer surgical complications and shorter hospital stays [5-19].

To our knowledge, there are no consensus recommendations at a national level that endorse same-day discharge for minimally invasive surgery for patients with endometrial cancer. As the field of robotic surgery has grown significantly since its FDA approval in 2000, more and more physicians advocate for same-day discharge due to smaller incisions, better-controlled pain, and quicker recovery [7-8]. In gynecologic surgery, simple minimally invasive oophorectomies and ovarian cystectomies commonly have same-discharge. In comparison, many gynecologists admit their patients for overnight observation after more complex surgeries, like minimally invasive total hysterectomies [8]. The reasoning behind overnight observation is to detect potential perioperative complications, such as hemorrhage or unintentional injury to other pelvic structures, such as the ureters [5].

However, multiple studies have recently demonstrated feasibility and safety for same-day discharge status post minimally invasive hysterectomies without the need for reoperations or hospital admissions caused by perioperative complications [5, 8-17]. While some institutions have reported same-day discharge rates following minimally invasive hysterectomy as high as 93%, the national incidence is < 10% [5, 9]. Patients even report same or greater satisfaction with same-day discharge compared to 23-hour overnight observation in the hospital [8-9, 12]. Excluding high-risk patients with pre-planned hospital admission, some studies have found that longer operation time, later surgical end-time in the day, higher surgical complexity, increased age, and non-minimally invasive approach decrease the likelihood of same-day discharge [5, 8-9, 15-17].

The goal of this study is to present a cases series endorsing same-day discharge for minimally invasive surgery for endometrial cancer and to determine predictive factors. There is supporting data from multiple institutions that demonstrates feasibility and safety of same-day discharge for women undergoing minimally invasive hysterectomy.

Methods

Participants

All patients of single gynecologic oncologist who underwent a robotic-assisted total hysterectomy (RTH) with bilateral salpingo-oophorectomy (BSO) and pelvic ± para-aortic lymphadenectomy for endometrial cancer between July 2017 and July 2019 were retrospectively reviewed for potential inclusion (N=78). The initial cohort was evaluated for chronic pelvic pain as an exclusion characteristic, though none matched this criterion. By study design, patients who underwent a non-robotic-assisted approach were excluded.

Surgical Methods

The underlying indication for RTH was a positive endometrial biopsy (EMB), though 4 (5.1%) patients did not undergo EMB prior to surgery. The RTH and BSO was performed using four ports, one of which was utilized as an assistant-port. Local anesthesia was injected at the port sites prior to incision and after closure. All specimens were removed via the vagina.

Recovery Protocol

No strict Enhanced Recovery after (gynecologic) Surgery (ERAS) protocol was followed. Patients were encouraged to ambulate and advance diet as tolerated. Foley catheter was removed immediately following surgery in most cases. Patients had standard anesthesia care. Postoperative analgesia consisted of hydrocodone/acetaminophen 5/325 mg quantity 10-15, unless patient pain threshold necessitated further management in PACU.

Variables Recorded

Baseline demographic variables recorded were age and body mass index (BMI). Clinical characteristics noted were comorbidities, FIGO (International Federation of Gynecology and Obstetrics) grade, preoperative diagnosis, postoperative diagnosis, surgical procedures performed, surgery start time, and surgery length. Surgical outcomes documented were estimated blood loss (EBL), FIGO stage, surgical complications, reasons and length of hospital stay.

Statistical Analyses

Sample size was calculated using alpha set at 0.05, power set at 90%, and known population incidence set at 10% [5]. Minimum of 4 subjects were required for analysis to achieve statistical power. Continuous variables were calculated using two-sided t-tests and are expressed as

median (range).

Categorical variables were computed with the Chi-square test and are written as

number of cases (percentage of occurrence).

Multivariate analyses were executed using logistic and linear regression models. These regression models evaluated the correlation between the demographic and clinical variables compared to length of stay. Statistical significance was set at

p

<0.05 prior to data collection, and significant values are denoted with an asterisk. Statistical analyses were performed using GraphPad Prism version 8.0 for Windows (GraphPad Software, San Diego, CA) and JASP version 0.9.2 (University of Amsterdam, Department of Psychological Methods, Amsterdam, The Netherlands).

Results

A total of 78 patients underwent surgical management for endometrial cancer between July 2017 and July 2019. The demographic and clinical characteristics by length of stay were not significantly different between the groups of same-day discharge (≤ 24 h) and admitted (> 24 h); however, age becomes significant when dichotomized above and below age 60 (Table 1).

Table 1
Demographic and clinical characteristics by length of stay
Characteristic						≤ 24 h(N = 56)	> 24 h (N=22)		p value
Age, y						62.25 (28 – 91)	61.09 (40 – 88)		0.628
≤ 60, > 60						20 (36.0%), 36 (64.0%)	14 (64.0%), 8 (36.0%)		0.025*
BMI, kg/m 2						35.22 (21.79 – 55.78)	32.26 (18.44 – 50.07)		0.129
≤ 30, > 30						17 (30.4%), 39 (69.6%)	10 (45.5%), 12 (54.5%)		0.207
Comorbidities									0.788
≤ 1, > 1						17 (30.4%), 39 (69.6%)	6 (27.3%), 16 (72.7%)
Histologic grade									0.122
I, II – III						26 (46.4%), 30 (53.6%)	6 (27.3%). 16 (72.7%)

In this study, surgical complexity is distinguished by the performance of additional staging procedures.

Simple

indicates that only pelvic lymph nodes were dissected.

Complex

denotes that para-aortic lymphadenectomy and/or infracolic omentectomy occurred. No intraoperative complications occurred during any of the cases.  Length of stay was significantly associated with surgery time, EBL, surgical complexity, and FIGO stage (Table 2). There was no significant difference in surgery start time between the two groups.

Table 2
Surgical outcomes by length of stay
Characteristic						≤ 24 h(N = 56)	> 24 h (N=22)		p value
Surgery time, min						150.98 (68 – 256)	170.36 (103 – 233)		0.048*
≤ 120 > 120						10 (17.9%), 46 (82.1%)	4 (18.2%), 18 (81.8%)		0.048*
Surgery start time									0.789
Before 15:00, After 15:00						9 (16.1%), 47 (83.9%)	3 (13.6%), 19 (86.4%)
EBL, cc						32.68 (10 -100)	51.59 (10-200)		0.021*
≤ 30, > 30						44 (78.6%), 12 (21.4%)	12 (54.5%), 10 (45.5%)		0.34*
Surgical complexity									0.004*
Simple, Complex						14 (25.0%), 42 (75.0%)	13 (59.1%), 9 (40.9%)
FIGO stage									0.009*
IA, IB-IV						36 (64.3%), 20 (35.7%)	7 (31.8%), 15 (68.2%)

Multivariate models for predictors of same-day discharge demonstrated statistically significant relationships with age > 60 y, EBL ≤ 30, lower surgical complexity, and FIGO stage ≤ IA (Table 3).

Table 3
Multivariate analysis for predictors of same-day discharge (< 24 h) after RTH
		< 24 h (N=56)
Characteristic		Coefficient	95% Confidence interval	p value
Age >60		0.253	0.451, 0.033	0.025*
Comorbidities ≤ 1		0.030	0.251, -0.193	0.791
BMI ≤ 30		-0.143	0.082, -0.193	0.212
FIGO grade ≤ 1		0.175	0.383, -0.049	0.125
Surgery start time  before 15:00		0.030	0.251, -0.193	0.792
Surgery length ≤ 120		-0.004	0.219, -0.226	0.974
EBL ≤ 30		0.240	0.439, 0.019	0.034*
Surgery complexity- only pelvic lymphadenectomy		0.322	-0.108, -0.509	0.004*
FIGO stage ≤ IA		0.294	0.485, 0.076	0.009*

Of the 56 (71.8%) patients discharged home within 24 hours, 20 (35.7%) patients were immediately discharged within 4 hours. Multivariate analysis showed slightly different predictors in this subgroup. Discharge within 4 hours was associated with well-differentiated FIGO grade, surgery start time prior to 15:00, EBL ≤ 30, and FIGO stage ≤ IA (Table 4).

Table 4
Multivariate analysis for predictors of immediate discharge (< 4 h) after RTH
		< 4 h (N=20)
Characteristic		Coefficient	95% Confidence interval		p value
Age >60		-0.076	0.312, -0.129		0.509
Comorbidities ≤ 1		0.007	0.229, -0.216		0.954
BMI  ≤ 30		0.005	0.293, -0.149		0.967
FIGO grade ≤ 1		0.227	0.428, 0.004		0.046*
Surgery start time before 15:00		0.250	0.448, 0.030		0.027*
Surgery length ≤ 120		0.031	0.252, -0.192		0.785
EBL ≤ 30		0.238	0.437, 0.016		0.036*
Surgery complexity- only pelvic lymphadenectomy		0.180	0.387, -0.044		0.114
FIGO stage ≤ IA		0.294	0.485, 0.076		0.009*

Following RTH + BSO + staging, patients stayed at the hospital a median of 53.7 hours, ranging from 29 minutes to 168 hours or 7 days (Fig. 1). Of the 22 (28.2%) patients that were discharged after 24 hours, 7 (31.8%) patients were admitted secondary to comorbidities (Fig. 2).

Fig. 1
Distribution of length of stay. 56 (71.8%) patients were discharged within 24 h. Longest hospital stay was 168 h or 7 days.

Fig. 2
Reasons for prolonged hospital stay > 24 h. N = 22. SIRS = systemic inflammatory response syndrome; UTI = urinary tract infection.

Discussion

Our data support the feasibility and safety of same-day discharge after RTH + BSO + staging for endometrial cancer. This study suggests that younger (age ≤ 60) patients whose staging is limited to pelvic lymphadenectomy and with less invasive endometrial cancer (FIGO stage IA) are more likely to be successfully discharged within 24 hours. Of the 22 (28.2%) patients who stayed longer than 24 hours, 7 (31.8%) cases were associated with comorbidities, which included cardiovascular disease, pulmonary disease, renal disease, and seizure disorder. Of the same-day discharge cohort, only 1 (1.8%) patient had a reoperation for vaginal cuff dehiscence and 1 (1.8%) patient had a readmission for abdominal pain and leg edema.

Furthermore, our study demonstrated that immediate discharge within 4 hours is achievable for endometrial cancer patients after surgical management. Similar to same-day discharge, immediate discharge within 4 hours was associated with EBL ≤ 30 and FIGO stage IA. To our knowledge, one other study presents data for immediate discharge within five hours following total laparoscopic hysterectomy for benign indications [13]. In this study, patients received preoperative counseling by the surgeon and anesthesiologist on postoperative pain management and recovery. It also endorses early pain relief as necessary, quick mobilization, food within 2 hours, and no urinary catheter upon termination of surgery.

In our study, we also excluded chronic pelvic pain patients. Potentially, chronic pelvic pain patients undergoing surgical management for endometrial cancer may lead to longer hospital stay. One study found that patients undergoing hysterectomy indicated by chronic pelvic pain were admitted for an average of 2.5 days [20]. Perhaps it can be extrapolated that chronic pelvic pain patients undergoing more a complex hysterectomy for malignant reasons may have an even longer hospital stay.

Preoperatively, our patients were counseled on surgical procedure and recovery expectations, including discharge immediately after surgery. Multiple retrospective studies endorsing same-day discharge have encouraged these discussions, ensuring that the patient is mentally prepared and can also coordinate transportation and supportive care after surgery [8, 10, 15, 20]. These doctor-patient interactions act as a placebo, effectively manipulating the self-appraised symptoms, such as postoperative pain [21].

This study also presents some limitations. This is a retrospective study of a relatively small sample size treated by a single surgeon. Additionally, no formal ERAS protocol was implemented for this cohort. The ERAS guidelines encompass perioperative care elements to augment post-op recovery. These elements include thromboembolism prophylaxis, postoperative fluid control, postoperative serum glucose management, pain management, perioperative nutrition, early mobilization [22].

Despite these limitations, the robotic surgery was performed by a high-volume surgeon with relatively low rates of adverse outcomes [23]. Moreover, the majority of these cases were performed in less than 160 minutes. Less time in the OR may translate to less pain, fewer anesthesia effects, and quicker recovery and discharge.

Conclusion

This study demonstrates the feasibility of discharging patients directly from PACU after undergoing minimally invasive robotic surgery for endometrial cancer. In certain instances, patients required 23-hour observation postoperatively due to multiple comorbidities, some of which were anesthesia-related. Further clinical studies may show that ERAS protocol affects length of stay after RTH indicated for endometrial cancer. Although minimally invasive surgery is well documented for decreased length of stay and use of postoperative pain management [15], the use of consensus recommendations may be helpful in the management of this patient population postoperatively.

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