Fast-Track in Minimally Invasive Gynecology: A Randomized Trial Comparing Costs and Clinical Outcomes

Abstract

Study Objective: Evaluate the effects of a fast-track (FT) protocol on costs and post-operative recovery.Methods: One hundred and seventy women undergoing total laparoscopic hysterectomy for a benign indication were randomized in a FT protocol or a usual care protocol. A FT protocol included the combination of minimally invasive surgery, analgesia optimization, early oral refeeding and rapid mobilization of patients was compared to a usual care protocol. Primary outcome was costs. Secondary outcomes were length of stay, post-operative morbidity and patient satisfaction.Main Results: The mean total cost in the FT group was 13,070 ± 4,321 Euros (EUR) per patient, and that in the usual care group was 3.5% higher at 13,527 ± 3,925 EUR (p = 0.49). The FT group had lower inpatient surgical costs but higher total ambulatory costs during the first post-operative month. The mean hospital stay in the FT group was 52.7 ± 26.8 h, and that in the usual care group was 20% higher at 65.8 ± 33.7 h (p = 0.006). Morbidity during the first post-operative month was not significantly different between the two groups. On their day of discharge, the proportion of patients satisfied with pain management was similar in both groups [83% in FT and 78% in the usual care group (p = 0.57)]. Satisfaction with medical follow-up 1 month after surgery was also similar [91% in FT and 88% in the usual care group (p = 0.69)].Conclusion: Implementation of a FT protocol in laparoscopic hysterectomy for benign indications has minimal non-significant effects on costs but significantly reduces hospital stay without increasing post-operative morbidity nor decreasing patient satisfaction.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04839263.

Fast-Track surgery protocol in perioperative care for gynecological laparoscopy

“…[11][12][13] abdominal hysterectomy (AH Emery et al observed a significant (by 20%) reduction in hospitalization time for FTS compared to usual care surgery for benign laparoscopic hysterectomy. 14 Studies by Meyer et al and Yoong et al also showed that FTS was associated with a decreased LOS in cancer patients who underwent gynecologic laparotomy and vaginal hysterectomy, respectively. 15,16 This observed difference in LOS may be explained by the primary objective of FTS as a multimodal approach to patient care: to prevent or minimize factors that can negatively affect patient recovery throughout the entire perioperative period, such as discomfort levels, stress and anxiety, inadequate pain management, * p-value statistically significant, $ Wilcoxon rank sum test with continuity correction was used to assess the difference in operative characteristics and postoperative degree of pain, # Fisher's exact test was used to assess the difference in frequency of postoperative complications between groups, VAS: visual analog scale; LOS: length of stay.…”

Retrospective Comparison of Non-descent Vaginal Hysterectomy and Total Laparoscopic Hysterectomy for Bulky Uterine Fibroids

“…The ability to extirpate the non-descent uteri vaginally is the hallmark of the real gynecologic surgeon (11,22,64). TVH is the gold stranded for benign uterine condition for uterine size up to 12 weeks or up to 280 grams according to ACOG, SOGC, ISGE, RCOG, AAGL, DHA, SGS (4,5,8,9,10,13,66) as TVH is the most costeffective, value-based over TAH, TLH (7,34,36,37,39,42,47,48,58,59,60,61,62,64,67,68 ).…”

“…The ability to extirpate the non-descent uteri vaginally is the hallmark of the real gynecologic surgeon (11,22,64). TVH is the gold stranded for benign uterine condition for uterine size up to 12 weeks or up to 280 grams according to ACOG, SOGC, ISGE, RCOG, AAGL, DHA, SGS (4,5,8,9,10,13,66) as TVH is the most costeffective, value-based over TAH, TLH (7,34,36,37,39,42,47,48,58,59,60,61,62,64,67,68 ). A pioneer in gynecologic surgery takes multiple steps in TVH beyond this edge and tried all cited contraindications with excellent success as prior pelvic surgeries include cesarean sections, larger uteri up to 3 kilograms, nulliparity, absent prior vaginal birth, morbid obesity, need for oophorectomy (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)63,66).…”