Sept. 30, 2022

Mayo Clinic Gynecologic Oncology investigators and collaborators found a significant trend from inpatient to outpatient hysterectomy for endometrial cancer over the last two decades. During the period studied, they found a 41.3% movement from inpatient to outpatient hysterectomy for this disease. Furthermore, there was no change in patient outcomes including post-discharge 30-day readmissions and complications. The shift to outpatient surgery resulted in a savings of $2,500 a case.

Interestingly, the route of hysterectomy also changed during the period studied. While abdominal hysterectomy decreased, robotic hysterectomy increased.

"This is pretty significant, as there was a large shift to more outpatient hysterectomy and improved costs, yet clinical outcomes remained the same," says Carrie L. Langstraat, M.D., a Gynecologic Oncology surgeon at Mayo Clinic's campus in Minnesota and study senior author. "This is also a big shift for endometrial cancer treatment — a 50% drop in open hysterectomy. This affects 65,620 U.S. women yearly, as hysterectomy is the treatment cornerstone for this disease, and now 70% of it is occurring in the outpatient setting."

The Mayo Clinic investigators and research collaborators from Global Health Economics and Outcomes Research, Intuitive Surgical Inc., and Fondazione Policlinico Universitario A. Gemelli, IRCCS, published their findings in a 2021 issue of International Journal of Gynecological Cancer. They performed a retrospective cohort study that included 41,246 women identified in the Premier Healthcare Database. The investigators selected patients ages 18 and older who underwent hysterectomy for endometrial cancer between 2008 and 2015. Factors correlated with outpatient hysterectomies included midsize hospital, more recent year of surgery and robotic route of hysterectomy. Factors correlated to inpatient surgery included Black race, older age, Medicare insurance, greater number of comorbidities, concomitant procedures and abdominal hysterectomy route.

Trend drivers toward outpatient hysterectomy

While some may suspect that hospital or payer resource managers prompted this shift toward outpatient hysterectomy for endometrial cancer, Dr. Langstraat says it is actually the rise in a minimally invasive surgical approach. An increase in laparoscopic or robotic surgery — more practical and doable in an outpatient setting — has boosted same-day dismissal of patients undergoing hysterectomy.

A study by Rettermaier and colleagues published in a 2012 issue of Oncology proved outpatient hysterectomy for endometrial cancer to be safe and effective.

Another contributing factor to the trend toward outpatient hysterectomy for endometrial cancer is the shift from full lymph node assessment to only sentinel lymph node assessment, which investigators found reduced morbidity, says Dr. Langstraat.

Further, good outcomes with outpatient hysterectomy influenced expansion of this approach.

Naysayers transform to believers

Dr. Langstraat admits that when first presented with the concept of performing outpatient hysterectomy, she did not see the value in it and was not an early adopter. However, she quickly realized that what she thought was simply a cost-driven option for patients — outpatient hysterectomy — was actually providing equivalent care and outcomes while hastening patient recovery.

As outpatient hysterectomies became the norm at Mayo Clinic, and now that four years of performing them have passed, Dr. Langstraat's opinion has evolved. She now feels confident in this approach due to her experience as well as safety data from other studies. She explains that the majority of her patients who undergo outpatient hysterectomy do well with pain and are up and moving sooner than with open surgery. She estimates that infection rates are the same or better than with an open surgical approach.

Dr. Langstraat says that it's a "leap of faith" for many patients to have outpatient hysterectomy. "Initially they are shocked when I explain that the hysterectomy will be outpatient," she says. "They often say something like 'How could you send me home right away?'

"Even if they look at me with doubts, I know they will be more comfortable at home, and we are here in case they need anything," she says.

She recounts that 2 to 5 days after outpatient hysterectomy, patients remark how smoothly the surgery went and how good they feel.

"Even reluctant patients have felt that the surgery went very well," she says.

When circumstances warrant inpatient hysterectomy

In some people with endometrial cancer, gynecologic oncologists determine that an open abdominal inpatient surgery is in the patient's best interest.

"Some patients are not candidates for outpatient hysterectomy," says Dr. Langstraat. "And these patients need some time to reach their milestones and can't go home the same day."

In people in whom an open hysterectomy for endometrial cancer is used, surgeons usually anticipate complexities, such as extrauterine disease, and require at least one night's stay in the hospital. Other surgical goals, such as removal of large lymph nodes, also may entail an open surgery.

When circumstances warrant no hysterectomy and alternate treatment

In certain cases, Dr. Langstraat says that hysterectomy is not indicated for a patient's endometrial cancer, leading to a D&C plus progesterone agent treatment. Such cases entail either:

• Fertility needs. When the surgeon presumes a patient has grade 1 endometrial cancer and the patient wants to maintain fertility, the surgeon may opt to avoid uterine removal.
• Unfitness for full hysterectomy. Due to deconditioning, other medical conditions and bodily habitus, a hysterectomy may be contraindicated.

Challenges of minimally invasive approaches used with outpatient hysterectomy

Critics have pointed out that the expense of a robotic, minimally invasive approach to hysterectomy is not feasible for all facilities, leading to disparities.

Dr. Langstraat hopes that minimally invasive outpatient hysterectomy will be accessible to all women who need the surgery because of the following benefits compared with open surgery:

• Less intra-abdominal infection
• Reduced bleeding
• Lower transfusion rates
• Faster recovery with return to regular activities, including work, sooner than with open surgery
• Less pain

Some patients who have minimally invasive outpatient hysterectomy are ready to go back to work in two weeks, others in four weeks, she says.

Thus, in the best interest of the patient, Dr. Langstraat encourages gynecologists whose facilities lack access to minimally invasive, outpatient hysterectomy to refer to medical centers offering this service, such as Mayo Clinic.

For more information

Cappuccio S, et. al. The shift from inpatient to outpatient hysterectomy for endometrial cancer in the United States: trends, enabling factors, cost, and safety. International Journal of Gynecological Cancer. 2021;31:686.

Rettenmaier MA, et al. Same-day discharge in clinical stage I endometrial cancer patients treated with total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and bilateral pelvic lymphadenectomy. Oncology 2012;82:321.

Refer a patient to Mayo Clinic.