Myomas are common, with a lifetime risk for women of up to 70–80% and clinically apparent in 12–25% of reproductive aged women.1,2 A national survey of reproductive-aged women with symptomatic leiomyoma found that 43% of women desired fertility-preserving treatment, and 51% expressed interest in preserving the uterus.3 Myomectomies are increasingly performed using minimally invasive techniques.4 Traditionally many patients stay 24–48 hours after surgery as a result of postoperative concerns.5
Approximately 300–400 myomectomies are performed every year within the study service area and approximately 60% are performed laparoscopically or robotically. From our chart review, close to 90% of these patients are discharged the same day as their surgery. The benefits of minimally invasive myomectomy include reduced postoperative pain, shorter hospital stay, reduced adhesions, and fewer postoperative fevers.4–7
We performed a literature search using PubMed and MEDLINE databases from inception of the database until January 2015 searching “leiomyoma/surgery,” “uterine myomectomy,” and “postoperative complications.” To date, no large studies have evaluated same-day discharge after minimally invasive myomectomy; the studies that looked at same-day discharge as a secondary outcome had no more than 100 patients. Readmission rates for laparoscopic myomectomies were noted to be approximately 1%.8,9 Perron-Burdick et al10 assessed same-day discharge in laparoscopic hysterectomy and found a similar low readmission rate.
This study used a retrospective case series to examine the safety of same-day discharge after minimally invasive myomectomy in Kaiser Permanente Northern California. Our primary objective was to evaluate readmission rates of patients discharged home the same day after minimally invasive myomectomy within 48 hours. Secondary objectives included patient and operative characteristics along with postoperative urgent care or emergency visits and admissions.
MATERIALS AND METHODS
This study was approved by the Kaiser Permanente Northern California institutional review board for the protection of human participants. The source population for the study was derived from Kaiser Permanente Northern California, a large, integrated health care delivery system providing comprehensive care for approximately 3.5 million members across Northern California.
We conducted a retrospective case series that captured female patients aged 18 years and older who underwent a minimally invasive myomectomy for leiomyoma(s) and were discharged home the same day. Minimally invasive includes both laparoscopic and robotic abdominal myomectomy. Current Procedural Terminology and International Statistical Classification of Diseases and Related Health Problems, 9th Revision codes were used to identify all patients with leiomyoma who underwent minimally invasive myomectomy from January 2011 to December 2013 and were discharged home the same day or within 12 hours of admission. Admission was defined as the time at which the patient's surgery started. Patients were considered “same-day” discharge if they were discharged within the same calendar date as the myomectomy procedure or if the time interval between procedure close time and discharge time was less than 12 hours.
Exclusion criteria included women younger than age 18 years, myomectomy through laparotomy or conversion to laparotomy, hysteroscopy or vaginal approach, conversion to hysterectomy, and gynecologic malignancy. See Figure 1 for a study participant flowsheet.
Patients with identified minimally invasive myomectomy for leiomyoma underwent chart review of electronic medical records to confirm minimally invasive myomectomies and same-day discharge. Patients with minimally invasive myomectomy and same-day discharge after surgery underwent a more comprehensive chart review of electronic medical records to assess study eligibility, ensure accuracy of coding, and perform data collection. For data variables extracted, refer to Tables 1–3. Descriptive statistics were calculated for patient and surgical characteristics including frequencies, proportions, means, and medians. We estimated hospital readmission rates in 48 hours, 7 days, and up to 3 months. We also estimated rates of subsequent emergency or urgent clinic visits within 48 hours, 7 days, and up to 1 month of surgery. The threshold for interference was defined as P<.05. We used χ2 test or Fisher exact test for frequencies and proportions of categorical variables and t test for mean values of continuously measured variables. Statistical analyses were performed using SAS 9.3.
The minimally invasive myomectomies in this study were performed predominantly by minimally invasive gynecologic surgeons at Kaiser Permanente hospitals throughout Northern California. Many facilities had or were affiliated with residency training programs in obstetrics and gynecology approved by the Accreditation Council for Graduate Medical Education, and there was resident participation in cases done at those centers. Preoperative evaluation often included magnetic resonance imaging for improved assessment of number and location of leiomyomas along with improved diagnosis of adenomyosis compared with pelvic ultrasonography. Surgeries varied by uterine manipulator type, number of port sites, vessel sealing device type, use of preoperative gonadotropin-releasing hormone agonist, and morcellation technique. For the majority of patients, four or five port sites were used, either three or four 5- to 8-mm ports and one to two 10-mm ports. Of note, the study period concluded before the removal of power morcellators from Kaiser Permanente Northern California operating rooms in May 2014.
Intraoperative steps for minimally invasive myomectomies typically included patient positioned with arms tucked in the dorsal lithotomy position, use of a uterine manipulator, rectal misoprostol, and dilute vasopressin injected into the serosa above the leiomyomas. Injection of local anesthetic was standard before incision for postoperative incisional pain reduction. Dexamethasone and ondansetron were commonly administered at the beginning of the procedure and ketorolac was often administered on completion for reduced postoperative nausea and pain control.
Patients undergoing a minimally invasive myomectomy were educated at their preoperative consultation that same-day discharge is routine for all uncomplicated cases. Patients were required to have home support, access to a telephone, and immediate transportation if needed. Patients and caregivers were counseled on the appropriate postoperative recovery course and given strict precautions on when to return to the clinic or hospital. Preoperative bowel preparations were not performed.
Discharge requirements included the ability to ambulate, tolerate oral liquids, and adequate pain control before discharge. Patients were not routinely required to void before discharge and specific postoperative voiding management varied between surgeons. Discharge instructions are routinely given to surgical patients before discharge and include postoperative instructions, medication list and dosing, and advice line numbers. Discharge medications included an anti-inflammatory, a narcotic, an antiemetic, and a stool softener.
Of the 403 minimally invasive myomectomies performed during the study period, 356 (88%) patients were sent home the same day and met criteria for inclusion in this study. Cumulative readmission rates were 0.6% and 1.4% at 48 hours and 3 months (Table 2).
Of the total procedures, 334 (83%) were performed laparoscopically and 69 (17%) were performed robotically (Fig. 1). Two patients were readmitted within 48 hours for postoperative fever. Three additional patients were readmitted after 48 hours but within 3 months for an inferior epigastric hematoma, ileus, and acute pyelonephritis.
Urgent care and emergency department visits after same-day discharge were also uncommon. Of the 356 patients discharged home the same day, no patients presented to the urgent care clinic within 7 days and 3.4% (n=12) presented to the emergency department within 7 days for postoperative-related issues. The most common reasons for emergency department visits were pain or urinary retention (n=3 and 3, respectively). Other reasons for emergency department visits included constipation, bleeding, and fever. Table 3 describes diagnoses for emergency department and urgent clinic visits.
The study population was diverse with 71% of patients being nonwhite. Twenty-two percent of patients who were discharged home the same day were obese, with body mass indexes (calculated as weight (kg)/[height (m)]2) greater than 30, and approximately 19% had a history of a previous abdominal surgery. Menopausal status data were not collected; however, five women (1.4%) were older than 51 years of age. One patient desired to preserve fertility and two patients refused hysterectomy despite counseling. Two had pedunculated leiomyomas with a preoperative diagnosis of an adnexal mass. Patient characteristics are shown in Table 1.
The most common indications for myomectomy among patients undergoing minimally invasive procedures included pain and pressure (70%), bleeding (46%), infertility (28%), and anemia (15%). The median estimated blood loss was 75 mL (mean 129 mL, range 2–1,300 mL) and the median leiomyoma weight was 204 g (mean 280 g, range 2–4,785 g). The median surgical time was 157 minutes (mean 167 minutes, range 27–485 minutes). No intraoperative blood transfusions were required for any patients (Table 1). Figure 2 histograms show the distribution of myoma weight, estimated blood loss, and operative time.
Forty-seven (12%) procedures were excluded as a result of admission after the procedure. Reason for postoperative admission included surgeon preference (49%), intraoperative blood loss or anemia (19%), urinary retention (9%), pain control (6%), or nausea (4%), Initially there were three surgeons who had traditionally admitted patients overnight but changed their practices during the study period.
The benefits of minimally invasive myomectomy include reduced postoperative pain, time to return to normal function, and blood loss.6–8 This is a large study evaluating same-day discharge after minimally invasive myomectomy in a relatively healthy patient population. None of the readmissions, visits to the emergency department, or urgent care were surgical or life-threatening events.
Minimally invasive myomectomies within Kaiser Northern California are predominantly performed by minimally invasive gynecologic specialists. At the time of this study, there were 11 surgeons who performed the majority of minimally invasive myomectomies in the region, only four of whom were fellowship-trained.
As a result of the U.S. Food and Drug Administration statement on the use of the power morcellator, in May of 2014, the device was removed from operating rooms in Kaiser Permanente Hospitals in Northern California.
A particular strength of this study includes comprehensive documentation of the postoperative course as a result of the use of electronic medical records. The large patient population and detailed electronic medical records allowed for detailed data extraction. The Kaiser Permanente Northern California region provides health care to approximately one third of the overall population in Northern California. Because of the extensive network of Kaiser clinics and hospitals in this region, very few patients seek care for postoperative issues outside of the Kaiser network. However, because the Kaiser system does not always have access to outside hospital records, it is possible that additional data were missed if the patient presented to a non-Kaiser facility. The diversity of the patient population is reflective of Northern California, which is another asset of the study.11
Limitations of the study include the very low readmission rate, which could be addressed by a larger sample size. Additionally, this study did not have a nonsame-day discharge comparison group because same-day discharge for minimally invasive myomectomies have become routine. As a result of this shift in the standard of care, it would have been difficult to find an appropriate comparison group. In addition, the specialized group of gynecologic surgeons who performed the surgeries, the multimodal care model, and the extent of resources may limit generalizability.
To facilitate same-day discharge, it is important that the surgeon's clinic staff, anesthesiology department, and preoperative and postoperative nursing care teams all understand the expectation of same-day discharge. Having a team of anesthesiologists that provides specific antiemetic protocols has been shown to reduce postoperative nausea.12 Providing patients and their families with a detailed written version of postoperative instructions, including pain expectation and management, along with nausea prevention, is a central step in postoperative management in addition to traditional verbal counseling.
Emphasizing resources such as telephone advice lines and the surgeon availability by e-mail can also help patients with less acute access information and obtain reassurance. Routine follow-up by telephone or video visits within 24–48 hours of surgery can also help ameliorate patient anxiety, which may prevent unnecessary urgent visits.13,14 Many urgent visits can be resolved with reassurance and supportive care. Safety and feasibility are only one component of this practice; future studies should investigate patient satisfaction of this practice.
In conclusion, this study demonstrates that same-day discharge after a minimally invasive myomectomy performed in a healthy patient population has a very low readmission rate. Same-day discharge reduces the health care burden for hospital stay and nosocomial infections. Readmission rates are low and optimized when guidelines include detailed preoperative counseling, expectation management, standardized intraoperative and postoperative medication procedure as well as patient follow-up (Box 1). This study is an important example of reduction in health care cost without compromising patient care.
Box 1 Guidelines for Same-Day Discharge for Minimally Invasive Myomectomy* Cited Here...
- Mental capacity and reasoning ability
- Access to ancillary care including phone advice nurse and outpatient clinic numbers
- Access to emergency services
- Reliable caretaker at home for at least 24 h
- Enhanced Recovery After Surgery (ERAS): preoperative scopolamine patch, intravenous dexamethasone, intravenous acetaminophen, ketorolac, ondansetron
- Use of intraoperative vasopressin, rectal misoprostol
- Ability to tolerate oral fluids and medication
- Sent home and instructed to use around-the-clock nonsteroidal anti-inflammatory drugs and narcotics as needed for approximately 48 h
- Sent home with oral antiemetics and stool softener to use as needed
- Use of abdominal binder for reduced postoperative pain
- Patients are usually called by the registered nurses, medical doctors, or both the next day
Of note, there is health care provider variation and practice within our medical group.
*Similar guideline for same-day hysterectomy discharge.
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