Clinical Utility and Cost of Postoperative Hemoglobin Level Testing Following Robotic-assisted Hysterectomy for Endometrial Cancer.

AIM: Our aim was to assess the clinical utility of postoperative hemoglobin testing following hysterectomy. PATIENTS AND METHODS: We carried out a retrospective cohort study of patients who underwent robotic surgery at an academic center during a 44-month study period. Data included demographics and perioperative outcomes. The mean postoperative decrease in hemoglobin level was evaluated using numerical and categorical variables. RESULTS: A total of 201 women were included. A total of 45 (22.4%) developed symptoms suggestive of hemodynamic compromise. When compared to asymptomatic patients, these patients were no different in operative time, estimated blood loss, pre- or post-operative hemoglobin levels, or the change in hemoglobin levels. Symptomatic patients did receive less fluid intraoperatively (1.2 vs. 1.5 l; p<0.0001). Perioperative outcomes were not associated with a greater postoperative decrease in hemoglobin (Hb). Postoperative anemia was associated with preoperative anemia (0% vs. 45%; p<0.0001). Patients with postoperative anemia were also more likely to be re-admitted within 30 days after surgery (7% vs. 23%; p=0.025). Of the three patients who received blood transfusions postoperatively, all three had preoperative Hb<9.5 g/dl, compared to 2.5% of those who were not transfused (p<0.0001). Using Institutional charges and Medicare reimbursement rates for blood hemoglobin testing, savings were estimated to be $3,629 and $1,236, respectively, during the study period. CONCLUSION: Postoperative Hb testing may be safely avoided unless starting Hb is less <10 g/dl. Clinical practice change can reduce healthcare costs without hindering patient care.

Oncologic outcomes in older women with endometrial carcinoma (≥70 years).

Data are limited in the management of elderly women with endometrial cancer as they are under-represented in clinical trials. The aim of this study was to evaluate the outcomes of women ≥70 years who underwent hysterectomy. One hundred and twenty-one patients met the inclusion criteria. The median age among the cohort was 75 years (range: 70-91), and 52% underwent robotic surgery. The five-year overall survival (OS) rate was 67%. The five-year cumulative incidence of recurrence was 19%. Based on univariate analysis, white race, lower ASA score, higher pre-operative and post-operative haematocrit, lower estimated blood loss, stage I and robotic surgery were associated with improved OS. On multivariable analysis, ASA score, preoperative haematocrit, estimated blood loss and stage were associated with survival.Survival rates among older women were low and disease recurrence was high. Robotic surgery was safe and appeared to improve perioperative outcomes in older women with endometrial cancer.Impact StatementWhat is already known on this subject? Endometrial cancer is the most common gynaecologic cancer with an overall survival above 90%. Surgery is the cornerstone of treatment. With an ageing population, an increased incidence of endometrial cancer is also expected. Increased frailty and comorbid conditions may prevent this population from undergoing surgery; consequently, these patients are often undertreated for a potentially curable disease.What do the results of this study add? Older women with endometrial cancer have low survival rates and high disease recurrence rates. Elderly women can tolerate robotic surgery to reduce the risk of adverse events.What are the implications of these findings for clinical practice and/or further research? It is important to develop best practices to optimise patients for minimally invasive surgery. The benefits of robotic surgery may encourage patients and surgeons to partake in this approach. A multidisciplinary approach with geriatric evaluation may improve post-operative care and survival. Future clinical trials should include elderly women.

Incidence of venous thromboembolism after robotic-assisted hysterectomy in obese patients with endometrial cancer: do we need extended prophylaxis?

Robotic surgery for gynecologic malignancy is associated with a lower rate of venous thromboembolism (VTE) than laparotomy. Obese patients represent a particularly high-risk group for VTE, but prior studies tend to focus on patients with a much lower BMI and without extended VTE prophylaxis. Our objective was to examine the role of extended thromboprophylaxis in obese patients who underwent robotic-assisted surgery for endometrial cancer. We conducted a retrospective cohort study of obese patients (BMI ≥ 35 kg/m2) who underwent robotic surgery for newly diagnosed endometrial cancer. The primary outcome measured was the occurrence of a VTE event within the 30-day postoperative period. The Farrington-Manning score test was used for equivalence analysis with a 5% margin. Secondary outcomes were perioperative complications. One hundred thirty-two robotic cases for endometrial cancer met our criteria. One hundred twenty-one (92%) received preoperative pharmacologic thromboprophylaxis, and 100% used pneumatic compression devices. Ninety-three percent and 90% received preoperative pharmacologic prophylaxis in the extended and no extended group, respectively (p-value = 0.7). Seventy patients (54%) received 4-week extended prophylaxis. Estimated blood loss was similar in both groups (75 mL vs 60 mL, p-value = 0.6). Perioperative complications and readmissions were similar between the two groups. There were no VTE events during hospital stay. One patient in the group that did not receive extended prophylaxis developed a VTE in the 30-day postoperative period (1.6%), versus 0% in the group that did receive extended prophylaxis (p-value = 0.1). The risk of VTE was low. The absence of extended VTE prophylaxis did not significantly increase the risk for VTE in obese patients with newly diagnosed endometrial cancer who underwent robotic-assisted surgery.