Gynecologic Oncology Surgery Research Articles

Sustainability of an enhanced recovery pathway after minimally invasive gynecologic oncology surgery

ObjectiveSame day discharge is safe after minimally invasive gynecology oncology surgery. Our quality improvement peri-operative program based on enhanced recovery after surgery principles led to an increase in same day...

The activity advantage: Objective measurement of preoperative activity is associated with postoperative recovery and outcomes in patients undergoing surgery with gynecologic oncologists

ObjectiveTo examine the association between objectively-measured preoperative physical activity with postoperative outcomes and recovery milestones in patients undergoing gynecologic oncology surgeries. MethodsProspective cohort study of patients undergoing surgery with gynecologic oncologists who wore wearable actigraphy rings before and after surgery from 03/2021–11/2023. Exposures encompassed preoperative activity intensity (moderate- and vigorous-intensity metabolic equivalent of task-minutes [MAVI MET-mins] over seven days) and level (average daily steps over seven days). Intensity was categorized as <500, 500–1000, and >1000 MAVI MET-mins; level categorized as <8000 and ≥8000 steps/day. Primary outcome was 30-day complications. Secondary outcomes included reaching postoperative goal (≥70% of recommended preoperative intensity and level thresholds) and return to baseline (≥70% of individual preoperative intensity and level). ResultsAmong 96 enrolled, 87 met inclusion criteria, which constituted 39% (n = 34) with <500 MET-mins and 56.3% (n = 49) with <8000 steps preoperatively. Those with <500 MET-mins and <8000 steps had higher ECOG scores (p = 0.042 & 0.037) and BMI (p = 0.049 & 0.002) vs those with higher activity; all other perioperative characteristics were similar between groups. Overall, 29.9% experienced a 30-day complication, 29.9% reached postoperative goal, and 64.4% returned to baseline. On multivariable models, higher activity was associated with lower odds of complications: 500–1000 MET-mins (OR = 0.26,95%CI = 0.07–0.92) and >1000 MET-mins (OR = 0.25,95%CI = 0.07–0.94) vs <500 MET-mins; ≥8000 steps (OR = 0.25,95%CI = 0.08–0.73) vs <8000 steps. Higher preoperative activity was associated fewer days to reach postoperative goal. ConclusionPatients with high preoperative activity are associated with fewer postoperative complications and faster attainment of recovery milestones. Physical activity may be considered a modifiable risk factor for adverse postoperative outcomes.

The Influence of Surgical Complexity and Center Experience on Postoperative Morbidity After Minimally Invasive Surgery in Gynecologic Oncology: Lessons Learned from the ROBOGYN-1004 Trial

BackgroundThis study was a secondary analysis of the ROBOGYN-1004 trial conducted between 2010 and 2015. The study aimed to identify factors that affect postoperative morbidity after either robot-assisted laparoscopy (RL) or conventional laparoscopy (CL) in gynecologic oncology.MethodsThe study used two-level logistic regression analyses to evaluate the prognostic and predictive value of patient, surgery, and center characteristics in predicting severe postoperative morbidity 6 months after surgery.ResultsThis analysis included 368 patients. Severe morbidity occurred in 49 (28 %) of 176 patients who underwent RL versus 41 (21 %) of 192 patients who underwent CL (p = 0.15). In the multivariate analysis, after adjustment for the treatment group (RL vs CL), the risk of severe morbidity increased significantly for patients who had poorer performance status, with an odds ratio (OR) of 1.62 for the 1-point difference in the WHO performance score (95 % CI 1.06–2.47; p = 0.027) and according to the type of surgery (p < 0.001). A focus on complex surgical acts showed significant more morbidity in the RL group than in the CL group at the less experienced centers (OR, 3.31; 95 % CI 1.0–11; p = 0.05) compared with no impact at the experienced centers (OR, 0.87; 95 % CI 0.38–1.99; p = 0.75).ConclusionThe findings suggest that the center’s experience may have an impact on the risk of morbidity for patients undergoing complex robot-assisted surgical procedures.

Asian Society for Gynecologic Robotic Surgery consensus guidelines on robotic surgery in gynecological cancer

This document outlines guidelines drafted by the Consensus Panel for Gynecologic Oncology of the Asian Society for Gynecologic Robotic Surgery (ASGRS) based on review of contemporaneous data on robotic surgery and related issues such as sentinel node biopsy and surgery for cervical cancer. These guidelines were also the basis of the Consensus Statement on robotic surgery in gynecologic oncology made at the Asian Summit on Robotic Surgery, November 2022.

Improving the Rate of Same-Day Discharge in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery—An Enhanced Recovery After Surgery Quality Improvement Initiative

SettingSame-day discharge (SDD) in patients undergoing minimally invasive gynecologic oncology (GO) surgery is a recent trend aligned with Enhanced Recovery After Surgery (ERAS) principles. SDD in GO is safe and feasible based on several recent studies, including a quality improvement (QI) initiative in Edmonton, Alberta, which resulted in SDD rates >70%. PatientsA baseline audit of GO patients at our center (Calgary, Alberta) found the SDD rate to be 14%. Given that Edmonton and our center are within the same province, they have similar patient populations and available resources – suggesting that interventions from the Edmonton QI initiative may be translatable. ObjectivesThe objectives of our QI initiative were: 1) to increase the rate of SDD in eligible GO patients to 70%, and 2) to evaluate the ease with which QI methods demonstrated in one study could be applied at another center. DesignA pre/post-intervention design was used (50 patients/group). InterventionsFour interventions were designed to address root causes for failed SDD identified following QI diagnostics: 1) SDD as the default discharge plan, including a “Day Surgery” surgical booking, 2 & 3) development and implementation of ERAS SDD pre-operative and post-operative order sets, and 4) patient education SDD-specific documents. MeasurementsRate of SDD was measured together with patient demographics and surgical outcomes. Process and balancing measures were defined and tracked. Main ResultsSDD in GO increased from 14% (7/50) to 82% (41/50) after the implementation of the above interventions (OR 28, p<0.0001, 95%CI 9.54-82.11). Improved SDD was achieved without negatively impacting post-operative rates of emergency department visits: 8% pre-, 4% post-intervention within 7 days (OR 0.48, p=0.678, 95%CI 0.09-2.74), 12% pre-, 10% post-intervention within 30 days (OR 0.8148, p=1.0, 95% CI 0.2317-2.86). ConclusionsThis ERAS QI initiative resulted in a substantial increase in SDD in GO, without a negative impact on balancing measures. We demonstrate that the “spread” of simple, clearly defined QI interventions across centers (where the patient population is similar) is feasible. This suggests that an ERAS SDD Program for GO could be a realistic goal for other centers with similar characteristics.

Infectious Complications in Laparoscopic Gynecologic Oncology Surgery within an ERAS-Compliant Setting.

Minimally Invasive Surgery (MIS) represents a safe and feasible option for the surgical treatment of gynecologic malignancies, offering benefits, including reduced blood loss, lower complications, and faster recovery, without compromising oncological outcomes in selected patients. MIS is widely accepted in early-stage gynecologic malignancies, including endometrial cancer, cervical tumors measuring 2 cm or less, and early-stage ovarian cancer, considering the risk of surgical spillage. Despite its advantages, MIS does not rule out the possibility of adverse events such as postoperative infections. This retrospective study on 260 patients undergoing laparoscopic surgery at Parma University Hospital for gynecologic malignancies explores the incidence and risk factors of postoperative infectious complications. The Clavien-Dindo classification was used to rank postoperative surgical complications occurring 30 days after surgery and Enhanced Recovery After Surgery (ERAS) recommendations put into practice. In our population, 15 (5.8%) patients developed infectious complications, predominantly urinary tract infections (9, 3.5%). Longer surgical procedures were independently associated with higher postoperative infection risk (p = 0.045). Furthermore, C1 radical hysterectomy correlated significantly with infectious complications (p = 0.001, OR 3.977, 95% CI 1.370-11.544). In conclusion, compared to prior research, our study reported a lower rate of infectious complications occurrence and highlights the importance of adopting infection prevention measures.

Buddy operating in gynaecological oncology surgery: a large UK cancer centre's experience

Buddy operating in gynaecological oncology surgery: a large UK cancer centre's experience

Personalized Predictive Hemodynamic Management for Gynecologic Oncologic Surgery: Feasibility of Cost-Benefit Derivatives of Digital Medical Devices.

Intraoperative hypotension is associated with increased perioperative complications, hospital length of stay (LOS) and healthcare expenditure in gynecologic surgery. We tested the hypothesis that the adoption of a machine learning-based warning algorithm (hypotension prediction index-HPI) might yield an economic advantage, with a reduction in adverse outcomes that outweighs the costs for its implementation as a medical device. A retrospective-matched cohort cost-benefit Italian study in gynecologic surgery was conducted. Sixty-six female patients treated with standard goal-directed therapy (GDT) were matched in a 2:1 ratio with thirty-three patients treated with HPI based on ASA status, diagnosis, procedure, surgical duration and age. The most relevant contributor to medical costs was operating room occupation (46%), followed by hospital stay (30%) and medical devices (15%). Patients in the HPI group had EURO 300 greater outlay for medical devices without major differences in total costs (GDT 5425 (3505, 8127), HPI 5227 (4201, 7023) p = 0.697). A pre-specified subgroup analysis of 50% of patients undergoing laparotomic surgery showed similar medical device costs and total costs, with a non-significant saving of EUR 1000 in the HPI group (GDT 8005 (5961, 9679), HPI 7023 (5227, 11,438), p = 0.945). The hospital LOS and intensive care unit stay were similar in the cohorts and subgroups. Implementation of HPI is associated with a scenario of cost neutrality, with possible economic advantage in high-risk settings.

Patient and Provider Experiences With a Digital App to Improve Compliance With Enhanced Recovery After Surgery (ERAS) Protocols: Mixed Methods Evaluation of a Canadian Experience.

Of all the care provided in health care systems, major surgical interventions are the costliest and can carry significant risks. Enhanced Recovery After Surgery (ERAS) is a bundle of interventions that help improve patient outcomes and experience along their surgical journey. However, given that patients can be overwhelmed by the multiple tasks that they are expected to follow, a digital application, the ERAS app, was developed to help improve the implementation of ERAS. The objective of this work was to conduct a thorough assessment of patient and provider experiences using the ERAS app. Patients undergoing colorectal or gynecological oncology surgery at 2 different hospitals in the province of Alberta, Canada, were invited to use the ERAS app and report on their experiences using it. Likewise, care providers were recruited to participate in this study to provide feedback on the performance of this app. Data were collected by an online survey and using qualitative interviews with participants. NVivo was used to analyze qualitative interview data, while quantitative data were analyzed using Excel and SPSS. Overall, patients found the app to be helpful in preparation for and recovery after surgery. Patients reported having access to reliable unbiased information regarding their surgery, and the app provided them with clarity of actions needed along their surgical journey and enhanced the self-management of their care. Clinicians found that the ERAS app was easy to navigate, was simple for older adults, and has the potential to decrease unnecessary visits and phone calls to care providers. Overall, this proof-of-concept study on the use of a digital health app to accompany patients during their health care journey has shown positive results. This is an important finding considering the massive investment and interest in promoting digital health in health care systems around the world.

Predictors and outcomes of same day discharge after minimally invasive hysterectomy in gynecologic oncology within the National Surgical Quality Improvement Program database

ObjectiveTo assess trends over time of same day discharge after minimally invasive hysterectomy in oncology, identify perioperative factors influencing same day discharge, and evaluate 30 day postoperative morbidity.MethodsA retrospective cohort...

Ferric derisomaltose and Outcomes in the Recovery of Gynecologic oncology: ERAS (Enhanced Recovery After Surgery) (FORGE) – a protocol for a pilot randomised double-blinded parallel-group placebo-controlled study of the feasibility and efficacy of intravenous ferric derisomaltose to correct preoperative iron-deficiency anaemia in patients undergoing gynaecological oncology surgery

IntroductionIron-deficiency anaemia is common in gynaecological oncology patients. Blood transfusions are immunosuppressive and carry immediate and long-term risks. Oral iron replacement remains the standard of care but requires prolonged treatment...

Enhanced Recovery after Surgery (ERAS) for Minimally Invasive Gynecologic Oncology Surgery: A Review.

Enhanced recovery after surgery (ERAS) has established benefits in open gynecologic oncology surgery. However, the benefits for gynecologic oncology patients undergoing minimally invasive surgery (MIS) are less well defined. We conducted a review of this topic after a comprehensive search of the peer-reviewed literature using MEDLINE and PubMed databases. Our search yielded 25 articles, 14 of which were original research articles, in 10 distinct patient cohorts describing ERAS in minimally invasive gynecologic oncology surgery. Major benefits of ERAS in MIS included: decreased length of stay and increased rates of same-day discharge, cost-savings, decreased opioid use, and increased patient satisfaction. ERAS in minimally invasive gynecologic oncology surgery is an area of great promise for both patients and the healthcare system.

Postoperative Sleep Quality of Insomnia Patients After TIVA Anesthesia: A Prospective Study

PurposeThe purpose of this study is to observe the postoperative sleep quality of insomnia patients undergoing laparoscopic gynecologic oncology surgery after total intravenous anesthesia. DesignProspective study. MethodsWe conducted a prospective, observational study in our hospital. All patients underwent propofol-remifentanil anesthesia without other sedative medications before or during the operation. Pittsburgh Sleep Quality Index (PSQI) scores of the baseline value, night-1 (the first night after surgery), night-3, night-5, and night-30 were observed. FindingsSixty-nine female insomnia patients were allocated based on the results of the PSQI and the diagnostic criteria of insomnia. The PSQI global scores were respectively 6 (5–8), 5 (4–6), 5 (3–6), and 6 (5–7) on night-1, night-3, night-5, and night-30, significantly lower than the baseline 7 (6–8) (P < 0.05). The 5 components (subjective sleep quality, sleep latency, sleep duration, sleep efficiency and daytime dysfunction) had significant changes at different postoperative time points (P < 0.05). The daytime dysfunction could also be improved 1 month after the surgery (P < 0.05). In contrast, the variations of sleep disturbance and use of sleep medication had no statistical differences. ConclusionsThe sleep quality of female patients with insomnia was improved on the first night after surgery in the sides of sleep latency and daytime dysfunction, and the improvement could also be obtained 1 month after propofol-remifentanil general anesthesia.

International Variations in Surgical Morbidity and Mortality Post Gynaecological Oncology Surgery: A Global Gynaecological Oncology Surgical Outcomes Collaborative Led Study (GO SOAR1).

Gynaecological malignancies affect women in low and middle income countries (LMICs) at disproportionately higher rates compared with high income countries (HICs) with little known about variations in access, quality, and outcomes in global cancer care. Our study aims to evaluate international variation in post-operative morbidity and mortality following gynaecological oncology surgery between HIC and LMIC settings. Study design consisted of a multicentre, international prospective cohort study of women undergoing surgery for gynaecological malignancies (NCT04579861). Multilevel logistic regression determined relationships within three-level nested-models of patients within hospitals/countries. We enrolled 1820 patients from 73 hospitals in 27 countries. Minor morbidity (Clavien-Dindo I-II) was 26.5% (178/672) and 26.5% (267/1009), whilst major morbidity (Clavien-Dindo III-V) was 8.2% (55/672) and 7% (71/1009) for LMICs/HICs, respectively. Higher minor morbidity was associated with pre-operative mechanical bowel preparation (OR = 1.474, 95%CI = 1.054-2.061, p = 0.023), longer surgeries (OR = 1.253, 95%CI = 1.066-1.472, p = 0.006), greater blood loss (OR = 1.274, 95%CI = 1.081-1.502, p = 0.004). Higher major morbidity was associated with longer surgeries (OR = 1.37, 95%CI = 1.128-1.664, p = 0.002), greater blood loss (OR = 1.398, 95%CI = 1.175-1.664, p ≤ 0.001), and seniority of lead surgeon, with junior surgeons three times more likely to have a major complication (OR = 2.982, 95%CI = 1.509-5.894, p = 0.002). Of all surgeries, 50% versus 25% were performed by junior surgeons in LMICs/HICs, respectively. We conclude that LMICs and HICs were associated with similar post-operative major morbidity. Capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention.

Evolution of the economical impact of ERAS implementation in gynecologic oncology surgery – a five-year study in Canada.

Evolution of the economical impact of ERAS implementation in gynecologic oncology surgery – a five-year study in Canada.

Patient reported opioid usage following vulvar surgery in gynecologic oncology (1217)

Patient reported opioid usage following vulvar surgery in gynecologic oncology (1217)

The NEWS2 score predicts prolonged hospitalization in the intensive care unit in major surgery patients.

Gynecological malignancies are significant causes of mortality and morbidity in women worldwide. Although surgery is an important treatment method, both the extent of the surgery and the factors related to the patient affect postoperative processes. The National Early Warning Score 2 (NEWS2) is a simple, inexpensive, and safe early warning score developed in 2012 and updated in 2017. Although it is not commonly used in surgical patients, its use in patients who will undergo major surgery may provide insights about the postoperative process. This study investigates the importance of NEWS2 and its relationship in patients with for major gynecologic oncology surgery. Forty-four patients with gynecologic malignancies scheduled for major abdominal surgery were included in this study. Patients with a NEWS-2 score of <3 were included in group 1, and patients with a NEWS-2 score of more than 3 were included in groups 2. NEWS2 Score, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation 2 scores (APACHE 2) were calculated. In addition, postoperative routine clinical and laboratory parameters were evaluated. Operation time, duration of intubation in the intensive care unit (ICU), the length of the intensive care stay, and length of hospitalization were recorded. Duration of intubation in the ICU in group 1 with a NEWS2 <3 [8.2 (0-18) vs 16.2 (3-39), respectively; p<0.01], ICU length of stay [21.6 (4-27) vs 47.3 (4-113), respectively; p<0.01], length of hospitalization [11.6 (5-56) vs 18.6 (8-67), respectively; p<0.01]. NEWS2 >3 was significantly higher compared to group 2. The SOFA score was significantly higher in group 2 compared with group 1 [1.2±0.5 vs 4.1±1.9; respectively; p<0.01]. In the correlation analysis, the NEWS2 score level was positively correlated with the SOFA score (p<0.001, r=0.81) and hospitalization time (p<0.001, r=0.60) and neutrophil lymphocyte ratio (NLR) (p<0.001, r=0.47). These findings suggest that the NEWS2 score may be correlated with the length of intensive care intubation, length of intensive care stay, and length of hospitalization. NEWS2 is an effective and simple scoring system that provides information about postoperative outcomes in gynecologic oncology patients scheduled for major surgery.

Intrathecal Analgesia for Gynecologic Oncology Surgery.

Intrathecal Analgesia for Gynecologic Oncology Surgery.

49 Panniculectomy to facilitate minimally invasive hysterectomy is effective for severely obese patients undergoing gynecological oncological surgery

49 Panniculectomy to facilitate minimally invasive hysterectomy is effective for severely obese patients undergoing gynecological oncological surgery

Cost impact analysis of enhanced recovery after minimally invasive gynecologic oncology surgery

ObjectiveThe implementation of a peri-operative care program based on enhanced recovery after surgery principles for minimally invasive gynecologic oncology surgery led to an improvement in same day discharge from 29%...