Factors Associated With Unplanned Admission in Patients Intended for Same Day Discharge After Minimally Invasive Hysterectomy for Endometrial Cancer

Factors influencing same-day discharge after minimally invasive hysterectomy for malignant and non-malignant gynecological diseases: a systematic review and meta-analysis

Objective

To explore the factors influencing the successful implementation of same-day discharge in patients undergoing minimally invasive hysterectomy for malignant and non-malignant gynecological diseases.

Method

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, International Clinical Trials Registry Platform, and Clinical Trials.gov from inception to May 23, 2023. We included case-control and cohort studies published in English reporting same-day discharge factors in patients undergoing minimally invasive hysterectomy for malignant and non-malignant gynecological diseases. STATA 16.0 was used for the meta-analysis. Risk factors were assessed using odds ratios (OR) (relative risk (RR)/hazard ratios (HR)) with 95% confidence intervals (CI), and logistic regression determined the same-day discharge rate (%).

Results

We analyzed 29 studies with 218192 patients scheduled for or meeting same-day discharge criteria. The pooled rates were 50% (95% CI 0.46-0.55), and were similar for malignant and non-malignant gynecological diseases (48% and 47%, respectively). In terms of basic characteristics, an increase in age (OR: 1.03; 95% CI: 1.01-1.05), BMI (OR: 1.02; 95% CI: 1.01-1.03), and comorbidities including diabetes and lung disease were risk factors affecting SDD, while previous abdominal surgery history (OR: 1.54; 95% CI: 0.93-2.55) and hypertension (OR: 1.53; 95% CI: 0.80-2.93) appeared not to affect SDD. In terms of surgical characteristics, radical hysterectomy (OR: 3.46; 95% CI: 1.90-6.29), surgery starting after 14:00 (OR: 4.07; 95% CI: 1.36-12.17), longer surgical time (OR: 1.03; 95% CI: 1.01-1.06), intraoperative complications (OR: 4.68; 95% CI: 1.78-12.27), postoperative complications (OR: 3.97; 95% CI: 1.68-9.39), and surgeon preference (OR: 4.47; 95% CI: 2.08-9.60) were identified as risk factors. However, robotic surgery (OR: 0.44; 95% CI: 0.14-1.42) and intraoperative blood loss (OR: 1.16; 95% CI: 0.98-1.38) did not affect same-day discharge.

Conclusions

An increase in age, body mass index, and distance to home; certain comorbidities (e.g., diabetes, lung disease), radical hysterectomy, surgery starting after 14:00, longer surgical time, operative complications, and surgeon preference were risk factors preventing same-day discharge. Same-day discharge rates were similar between malignant and non-malignant gynecological diseases. The surgery start time and body mass index have a greater impact on same-day discharge for malignant diseases than non-malignant diseases.

Same-day dismissal for endometrial cancer robotic surgery: feasibility factors

The aim of this study was to investigate the factors in feasibility and safety of same-day dismissal (SDD) of endometrial cancer patients undergoing robotic hysterectomy and staging. A single-institution retrospective chart review of endometrial cancer patients who underwent robotic hysterectomy and staging between 2012 and 2021 was performed. Patient demographics, medical and surgical history, intra- and postoperative events were examined as possible factors related to non-SDD. These factors were analyzed using univariate (chi-square test) and multivariate logistic regression analysis. Of the 292 patients, 117 (40%) had SDD, and 175 (60%) had non-SDD. The SDD rate increased from 13.8% to 88% over the 10-year study period. The factors significantly associated with non-SDD (p < 0.05) were surgery in the first 5 years after the introduction of the SDD and ERAS protocols (2012-2016), age > 75 years, and comorbidities such as cardiovascular diseases, anemia (Hb < 11 g/dl), and anticoagulant therapy. Extensive adhesiolysis, the performance of complete pelvic and/or aortic lymphadenectomy, operating time > 180 min, and PACU discharge after 2:00 p.m. were significant factors for non-SDD. Sentinel lymph node sampling was significantly associated with SDD (OR 0.050; CI 0.273-0.934, p = 0.029). We reported no significant difference in the number, setting and timing of any unscheduled postoperative contacts, complications, and readmissions between SDD and non-SDD groups. SDD after robotic hysterectomy and staging for endometrial cancer is feasible and safe. There are patient and surgery factors for the failure of SDD. The sentinel lymph node sampling was significantly associated with achieving SDD. Trial registration: Institutional Review Board approved the study protocol (#: 1764-05).

Applications and Safety of Sentinel Lymph Node Biopsy in Endometrial Cancer

Lymph node status is important in predicting the prognosis and guiding adjuvant treatment in endometrial cancer. However, previous studies showed that systematic lymphadenectomy conferred no therapeutic values in clinically early-stage endometrial cancer but might lead to substantial morbidity and impact on the quality of life of the patients. The sentinel lymph node is the first lymph node that tumor cells drain to, and sentinel lymph node biopsy has emerged as an acceptable alternative to full lymphadenectomy in both low-risk and high-risk endometrial cancer. Evidence has demonstrated a high detection rate, sensitivity and negative predictive value of sentinel lymph node biopsy. It can also reduce surgical morbidity and improve the detection of lymph node metastases compared with systematic lymphadenectomy. This review summarizes the current techniques of sentinel lymph node mapping, the applications and oncological outcomes of sentinel lymph node biopsy in low-risk and high-risk endometrial cancer, and the management of isolated tumor cells in sentinel lymph nodes. We also illustrate a revised sentinel lymph node biopsy algorithm and advocate to repeat the tracer injection and explore the presacral and paraaortic areas if sentinel lymph nodes are not found in the hemipelvis.

Qualitative Interview Study of Gynecologic Oncologist Utilization of Recommended Same-Day Discharge Following Minimally Invasive Hysterectomy

Recent investigations have supported the safety and benefits of discharging women on the same day following a minimally invasive hysterectomy (MIH) for both benign and malignant indications. Not all eligible candidates for same-day discharge (SDD) are discharged the same day, and patients undergoing an MIH for malignant indications have decreased the odds of receiving SDD despite established safety. The objective of this study was to use qualitative interviews to explore physician decision making regarding SDD after an MIH for malignant indications. Six qualitative interviews of gynecologic oncologists were analyzed using recurrent theme analysis for distinct themes in physician decision making regarding SDD. Results suggest that physician-perceived barriers to SDD include patient health characteristics, patient social characteristics, and hospital-system factors. Cited factors influencing SDD include patient travel, social support, practice setting (urban vs. rural) and staff comfort with the recommendation. Obstructive sleep apnea and post-surgical oxygenation appear to be a recurring reason for unplanned admission. The utilization of SDD after an MIH in the gynecologic oncology patient population is influenced by patient, physician, and system factors. Addressing the physician’s perceived barriers to SDD and catering recommendations to the gynecologic oncology population may increase utilization.