Systematic review of same‐day discharge after minimally invasive hysterectomy

Same‐day discharge has been suggested to safe and acceptable following minimally invasive hysterectomy.


| INTRODUCTION
Hysterectomy is one of the commonest gynecologic surgical procedures and an increasing number of hysterectomies are being completed minimally invasively. [1][2][3] Laparoscopic supra-cervical hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, and robotic-assisted laparoscopic hysterectomy are common minimally invasive techniques in gynecologic surgery. [4][5][6] Minimally invasive surgery has been adopted widely within gynecologic oncology and is increasingly used in advanced surgical staging procedures for both endometrial and cervical cancer. [7][8][9] Compared with open surgery, minimally invasive surgery offers fewer complications, faster recovery, a reduction in the duration of hospital stay, earlier return to activities, reduced pain and estimated blood loss, smaller incisions, and improved cosmetic outcomes. 4,[10][11][12][13] Previously, hysterectomies have been performed as in-patient operative procedures to manage post-operative pain and monitor post-operative complications such as symptomatic anemia or delayed return of bowel function. 14 Studies have described same-day discharge after laparoscopic hysterectomy to be safe and acceptable, [15][16][17][18][19] and same-day discharge can reduce hospital costs and decrease iatrogenic complications associated with hospitalization such as venous thromboembolic complications due to delayed mobilization or infections. 20 The aim of the present systematic review was to evaluate if sameday discharge is feasible after minimally invasive hysterectomy and to identify factors associated with same-day discharge.

| MATERIALS AND METHODS
The present systematic review protocol was registered in the international prospective register of systematic reviews (PROSPERO/ID CRD42014013453) on September 8, 2014. The review was conducted in accordance with the PRISMA statement and checklist, 21 which are relevant when reporting systematic reviews of non-randomized studies to assess the benefit and harms of interventions. and was screened manually for relevant studies on October 16, 2015 by an investigator (M.K.). The reference lists from relevant articles were also searched. The database searches used medical subject headings (MeSH) terms and a keyword search with Boolean operators ("OR" and "AND"). The combined search terms included "Patient Discharge OR same day discharge", "Surgical Procedures OR minimally invasive surgery", and "Hysterectomy OR gynecologic cancer". Non-full-text manuscripts were excluded and all articles were identified by title. All titles and abstracts were downloaded and managed using EndNote X7 (Thomson Reuters, New York, NY, USA), and duplicates were removed.
Studies were included if the populations included patients who underwent minimally invasive hysterectomy for benign or malignant indications. The minimally invasive techniques included in the review were total laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy, sentinel-node mapping, pelvic and/or paraaortic nodal dissection, appendectomy, and omentectomy. The review included peer-reviewed studies where hysterectomies were performed minimally invasively and patients were discharged on the day of surgery before midnight. Studies not including discharge details and studies including only vaginal hysterectomies were excluded (Fig. 1).
Only studies performed within gynecology departments were included because the aim of the study was to compare institutions that were experienced in performing minimally invasive hysterectomies.
In the absence of a suitable checklist for recording bias in observational studies, a checklist was designed that was inspired by evidence-based clinical practice guidelines developed by the Scottish Intercollegiate Guidelines Network for use in the National Health Service in Scotland. 22 In the checklist, the intervention was minimally invasive surgery, and the outcome was categorized as hospitalization or same-day discharge (Fig. 2). To determine the risk of bias, two authors (M.K. and M.M.J.) made an overall assessment of studies, as well as independently assessing the validity of patient selection, and the descriptions of the study populations, surgical circumstances, outcome variables, confounding variables, and statistical analyses. Any disagreements were resolved by consensus.
The primary outcome of the present study was the possibility of same-day discharge before midnight and the secondary outcome was the factors associated with same-day discharge. The highest available level of evidence was included 23 and descriptive statistics were used to describe the studies.

| RESULTS
The initial search returned 3985 citations, with 3058 remaining following the elimination of duplicates (Fig. 1 (Table 3).

| DISCUSSION
The available observational studies that examined same-day discharge after minimally invasive hysterectomy suggested that same-day T A B L E 2 Pre-operative inclusion criteria among prospective studies (n=6).

Inclusion criteria Exclusion criteria Conclusions
Donnez et al. 25 Excessive bleeding due to uterine fibroids Previously undergone surgery for type 3 deep nodular endometriosis or pelvic abscesses, frozen pelvis.

Outpatient TLH was feasible and safe, and associated with low levels of pain
Uterine size equivalent to <14 wk of pregnancy

Uterine volume equivalent to >14 wk of pregnancy
Uterine adenomyosis unresponsive to medical therapy Endometrial/cervical cancer at biopsy or suspect adnexal masses Diagnosis of endometriosis, recurrence of cervical dysplasia after more than two conizations, or recurrence of endometrial hyperplasia

Vaginal bleeding of unknown origin
Minig et al. 24 At least one family or friend available to provide care following discharge Surgery converted to laparotomy Peri-operative multimodal recovery program was safe and feasible in a selected group of women following elective laparoscopic hysterectomy.

Age >70 y Patient and physician information is important for successful same-day discharge
Limited independent mobility at pre-operative assessment Beginning surgery before 1:00 pm was associated with a two-fold increase in same-day discharge Charlson comorbidity index <5 Patients with endometrial cancer undergoing pelvic lymph node dissection were more likely to be admitted after surgery Penner et al. 8 Lower EBL was associated with increased odds of same-day discharge (range 10-400 mL vs 10-950 mL) Same-day discharge was associated with lower pain score in the postanesthesia care unit Beginning surgery before 2:00 pm was associated with increased odds of same-day discharge Same-day discharge was associated with a shorter time before resuming oral intake Robotic-assisted laparoscopy was associated with same-discharge in comparison with traditional laparoscopic surgery Same-day discharge was associated with a reduced time before being able to void following Foley catheter removal Rivard et al. 14 For every 10-y increase in age a 50% increase in the risk of hospitalization was observed Intra-operative adverse events were associated with an eight-fold increase in the odds of hospitalization Age >70 y was associated with a three-fold increase in the risk of hospitalization For every 30-min increase in surgical duration the risk of hospitalization increased Comorbidities and lung disease were associated with decreased odds of same-day discharge Borahay et al. 10 Length of operation 217.43 vs 293.8 min (mean) Lee et al. 30 Lower EBL was associated with increased odds of same-day discharge (range 5-300 mL vs 10-800 mL) Shorter operating time was associated with increased odds of same-day discharge A shorter time from patients entering the operating room to leaving was associated with increased odds of same-day discharge Surgery finishing before 6:00 pm was associated with increased odds of same-day discharge Intraoperative use of ketorolac was associated with increased odds of same-day discharge Abbreviation: EBL, estimated blood loss.
as a lack of transportation from the hospital, requiring placement in a rehabilitation facility, or arranging further healthcare services.
Home support from family or friends to provide care after discharge was observed in the pre-operative selection criteria among prospective studies with a very high percentage of patients discharged on the day of surgery. 26,28,30 In the study of Melamed et al., 32 patients were routinely offered same-day discharge; however, very clear and specific inclusion and discharge criteria were included. Therefore, careful pre-operative planning, including clear pre-operative patient-selection criteria, and reassurances regarding family support at home on the first post-operative night, could be very beneficial in attempting same-day discharge following minimally invasive hysterectomy.
In the present review, having a malignant indication for mini- and several studies have confirmed their safety in terms of adverse events and oncologic outcomes. [38][39][40][41][42] Consequently, it is likely that future studies will focus on further decreasing the duration of hospital stay for patients undergoing more advanced surgical procedures.
In the present study, the findings from patients with malignant diagnoses should be interpreted with caution owing to the small number of patients; the available literature do not preclude patients with cancer from undergoing same-day discharge. 10,26,43 Therefore, it is suggested that patients undergoing minimally invasive surgery for early-stage endometrial, cervical, or ovarian cancer could be considered candidates for same-day discharge, in particular, with sufficient pre-planning and careful patient selection (e.g. prioritizing younger patients without co-morbidities as the first operations performed each day).
Generally, re-admission rates were low in all the studies included.
This could simply reflect the scope of the present study-studies focused on same-day discharge that included patients undergoing surgery using techniques associated with a low risk of re-admission.
An important issue identified by Melamed et al. 32 was that patients discharged on the day after surgery were more likely to have an emergency-room or care visit compared with patients discharged before midnight; however, no difference in re-admission rates was reported. This study also suggested that younger patients, those with a lower body mass index, and those undergoing simpler procedures were particularly good candidates for same-day discharge. 32 Jennings et al. 33 reported a re-admission rate of 3.1% among 8890 patients.
The study identified diabetes, chronic obstructive disease, disseminated cancer, chronic steroid use, daily alcohol use above two drinks, and bleeding disorders as pre-operative factors associated with an in- is not able to make valid comparisons between patients who underwent robotic-assisted laparoscopy and those treated with conventional laparoscopy. It is questionable whether such a study will ever be performed but, based on existing data, we believe that in the future the two surgical approaches will be used interchangeable depending on the complexity of the procedure and the preferences and skills of individual surgeons. The increasing use of minimally invasive surgery is likely to change surgeon attitudes toward early patient discharge generally. It is suggested that the present review assists in elucidating the possibility of same-day discharge for a large proportion of patients, independent of the specific laparoscopic technique applied, and that there could be scope to expand the use of same-day discharge in the future.
The main limitation of the present study was the comparatively poor quality of the available literature on outcomes and interven- The observational studies reviewed suggested that same-day discharge was feasible for a high percentage of patients following minimally invasive hysterectomy. Several factors were associated with same-day discharge, including pre-planning same-day discharge and careful patient selection. Same-day discharge would likely reduce healthcare costs.

AUTHOR CONTRIBUTIONS
MK was responsible for designing and planning the study, designing the search strategy, searching the literature databases, screening article titles and abstracts, discussing full-text articles to decide on the articles included, conducting data analysis, completing the risk-of-bias checklist, and writing and revising the manuscript. OM was responsible for designing and planning the study, designing the search strategy, and writing and revising the manuscript. MMJ was responsible for screening article titles and abstracts, discussing full-text articles to decide on the articles included, conducting data analysis, completing the risk-of-bias checklist, and writing and revising the manuscript.
VKL was responsible for discussing full-text articles to decide on the articles included, and writing and revising the manuscript. KT was responsible for planning the study, the selection of the articles, and writing and revising the manuscript. PTJ was responsible for designing and planning the study, designing the search strategy, discussing fulltext articles to decide on the articles included, conducting data analysis, and writing and revising the manuscript. All authors have reviewed the final version of the manuscript and approved its submission.

ACKNOWLEDGMENTS
Iørn Hegelund is acknowledged for making substantial contributions to the preparation of the manuscript.