Direct Medical Costs and Length of Stay Associated with Postoperative Bloodstream Infections in Gynecologic Surgery: A Propensity Score-Matched Case-Control Study

Direct Medical Costs and Length of Stay Associated with Postoperative Bloodstream Infections in Gynecologic Surgery: A Propensity Score-Matched Case-Control Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Direct Medical Costs and Length of Stay Associated with Postoperative Bloodstream Infections in Gynecologic Surgery: A Propensity Score-Matched Case-Control Study Yan Luo, Wei Li, Mao Ran, Lan Chen, Yu Lyu, Pingping Wang, Hui Wang, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6850353/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The economic burden of post-operative bloodstream infection (PBSI) in gynecologic surgery is poorly understood. This study aimed to quantify the impact of PBSI on direct medical costs and length of stay (LOS) for patients undergoing gynecologic procedures. Methods A retrospective case-control study was performed in a tertiary hospital in China, which included patients who received gynecologic surgery between January 2022 and December 2024. A 1:3 propensity-score matching (PSM) was applied to account for baseline characteristics of patients with PBSI (the case group) and patients without PBSI (the control group). The primary outcomes were direct medical costs and LOS. Results Following PSM, a total of 203 cases and 609 controls were analyzed, with baseline covariates well-balanced. Total medical costs were significantly higher in the case group compared to controls (€3779.94 vs. €2130.49; p < 0.001), with a median difference of €1446.59. Patients with PBSI also incurred a longer overall LOS (12 vs. 6 days; p < 0.001) entirely driven by a longer post-operative LOS (9 vs. 4 days; p < 0.001). These findings were consistent across surgery types. Conclusions PBSI following gynecologic surgery substantially increases direct medical costs and prolongs LOS. These findings highlight the significant economic and resource burden of this complication. Implementing and investing in effective PBSI prevention strategies is critical for improving patient outcomes, reducing healthcare expenditures, and optimizing resource utilization. Gynecologic Surgery Postoperative Bloodstream Infection Propensity score matching Direct medical cost Length of stay Case-control study Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Gynecologic surgery not only serves as a pillar in the care of gynecologic concerns, but also represents an opportunity to improve women's quality of life [ 1 ]. Globally, the volume of gynecologic surgery is substantial, with an estimated 5 million hysterectomies worldwide completed in 2021, including 600,000 hysterectomies in the United States and 2.82 million in China [ 2 , 3 ]. Given the ongoing technological advancements and ever-increasing needs for health, the percentage of minimally invasive gynecologic surgery continues to grow annually [ 4 ]. Post-operative infection is among the most deleterious complications of gynecologic surgery, endangering patients, prolonging hospitalization, escalating resource consumption, and imposing major economic burdens on families and society [ 5 ]. U.S. data show that a Staphylococcus aureus surgical-site infection (SSI) after elective hysterectomy raises total hospital costs to US $ 18,261, nearly triple those of uninfected cases, and markedly increases emergency visits, readmissions, and re-operations [ 6 ]. U.K. multicenter surveillance likewise demonstrated an excess stay of 3.3 days and an additional £959 per SSI case, with deep or organ/space infections further extending hospitalization and heightening mortality [ 7 ]. Published researches has focused on the burden of SSI, whereas post-operative bloodstream infection (PBSI) remains under-studied, despite its likely higher mortality, re-operation rate, ICU demand, and economic impact. Quantitative estimates of PBSI burden in gynecology are lacking. To address this gap, we used propensity-score matching (PSM) to control confounding and assessed the effect of PBSI on direct medical costs and length of stay (LOS) in gynecologic surgery. These findings will inform the value of infection prevention and control, particularly amid China’s 2019 shift from Fee-for-service to Diagnosis Related Groups/ Diagnosis-Intervention Packet (DRG/DIP)-based payment models. Methods Settings The Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital is one of the largest tertiary healthcare facilities in southwestern China. The facility has more than 4300 inpatient beds, of which 120 are dedicated to gynecology, including more than 6000 gynecologic surgeries each year. Study design and data sources A retrospective case–control design was adopted. Potential confounding was addressed by 1:3 nearest-neighbour PSM. Cases were gynecologic surgical patients who developed PBSI. Controls were gynecologic surgical patients without PBSI. Data were extracted from the Department of Gynecology surgical database at Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, covering all surgeries performed between January 2022 and December 2024. Variables captured included patient demographics, clinical diagnoses, laboratory results, operative details, postoperative complications and direct medical costs. All data were de-identified and processed in accordance with ethical principles. Study participants The participant inclusion criteria were: (1) age ≥ 18 years; (2) availability of preoperative laboratory results (complete blood count, liver/renal function panels); (3) documented height, weight, and preexisting comorbidities. Exclusion criteria were: (1) non-operating-room procedures; (2) incomplete critical data. Variable definition Case definition Post-operative bloodstream infection (PBSI) was defined, with reference to the previous studies[ 8 , 9 ], as the simultaneous fulfillment of all four criteria below:(1) axillary temperature > 38.0°C persisting for ≥ 2 consecutive days after surgery; and (2) no identifiable focus of infection; and (3) initiation of systemic antimicrobial therapy; and (4) at least one blood culture obtained, irrespective of the culture result. Matching covariates Matching covariates included patient demographic characteristics (age, ethnicity, BMI and smoking), preexisting comorbidities (diabetes and hypertension), preoperative laboratory tests (WBC, HGB, PLT, CREA, GFR, ALT, AST, TBIL and ALB) and surgery related information (vaginal preparation, operation duration, intraoperative blood loss, surgical approaches, ASA score, incision type, prophylactic antimicrobials and surgery type). Outcome variables Direct medical costs . Direct medical costs were defined as all healthcare–related expenses documented in the electronic medical record (EMR), comprising: service costs (nursing service fees, medical service fees), diagnostic costs (pathological diagnostic fees, clinical diagnostic fees, laboratory diagnostic fees, imaging diagnostic fees), therapeutic costs (non-surgical clinical physical therapy fees, rehabilitation fees, surgical therapeutic fees, general therapeutic procedure fees), material costs (disposable medical material fees for examinations, surgeries and treatments), pharmaceutical costs and other costs. Costs are calculated in local currency CNY(¥) and converted to EUR(€). Length of stay. Length of stay (LOS) was defined as the days from patient admission to discharge and was further subdivided into length of pre-operative preparation stay (LPPS) which was the days from admission to surgery, and length of post-operative stay (LPOS) which was the days from surgery to discharge. Statistical methods Statistical analyses were performed in R software, version 4.4.1. Descriptive statistics were calculated on the data before and after matching. Continuous variables were reported as mean ± standard deviation (SD) or median (interquartile range, IQR), depending on distribution. Categorical variables were reported as frequencies (%). Standardized mean differences (SMDs) of covariates were tested for balance before and after matching with SMD < 0.1 representing adequate balance. Between-group comparisons of continuous variables were assessed with t-test if normally distributed, or Mann–Whitney U test if not normally distributed. Statistical significance was defined as two-tailed α = 0.05. Additionally, subgroup analyses were performed according to surgical site, with procedures categorized into the following types: uterine; ovarian and adnexal; vulvar, vaginal and cervical; and other. Results The participant selection and matching After screening records of patients who underwent gynecologic surgery between January 2022 and December 2024 from the database, and subsequent PSM, 203 patients were included in the case group and 609 patients in the control group for the final comparative analysis. The detailed patient selection and matching flowchart is presented in Fig. 1 . Before PSM, significant differences (SMD > 0.1) were observed between the case and control groups across several baseline characteristics. These included demographic characteristics (age), preexisting comorbidities (diabetes), preoperative laboratory tests (GFR, ALT, AST), and surgery-related information (operation duration, surgical approaches, ASA score, incision type, prophylactic antimicrobials, and surgery type), as detailed in Table 1 . After PSM, all baseline characteristics were well-balanced between the groups, all SMDs < 0.1 (Fig. 2 ). The propensity score distributions of the two groups demonstrated considerable overlap and were concentrated within similar score ranges (Fig. 3 ). This indicates that PSM effectively balanced the propensity scores between the groups. Table 1 Baseline characteristics of case and control group before and after PSM Variables Pre- PSM Post- PSM Case group Control group SMD Case group Control group SMD n 203 17626 203 609 Demographic characteristics Ethnicity Han 185 (91.1%) 15884 (90.1%) 0.035 185 (91.1%) 564 (92.6%) 0.042 Zang 12 (5.9%) 1261 (7.2%) 0.050 12 (5.9%) 33 (5.4%) 0.036 Others 6 (3.0%) 481 (2.7%) 0.014 6 (3.0%) 12 (2.0%) 0.020 Age(years) 49.00 (40.0–56.00) 45.00 (35.00–52.00) 0.301 49.00 (40.00–56.00) 48.00 (39.00–57.00) 0.023 BMI 22.83 (20.76–25.10) 22.66 (20.70-24.97) 0.019 22.83 (20.76–25.10) 22.83 (20.70-25.07) 0.021 Smoking 0 (0.0%) 10 (0.1%) 0.034 0 (0.0%) 0 (0.0%) - Preexisting comorbidities Diabetes 15 (7.4%) 712 (4.0%) 0.144 15 (7.4%) 53 (8.7%) 0.060 Hypertension 27 (13.3%) 1891 (10.7%) 0.079 27 (13.3%) 99 (16.3%) 0.014 Preoperative laboratory tests WBC(10 9 /L) 9.69 (7.08–12.10) 9.37 (7.55–11.17) 0.082 9.69 (7.08–12.10) 9.41 (7.28–11.70) 0.014 HGB(g/L) 106.00 (85.50–125.00) 117.00 (106.00-127.00) 0.001 106.00 (85.50–125.00) 116.00 (102.00-126.00) 0.033 PLT(10 9 /L) 201.00 (159.00-258.00) 209.00 (177.00-244.00) 0.008 201.00 (159.00-258.00) 209.00 (166.00-252.00) 0.002 CREA(µmol/L) 72.16 (61.00-92.04) 81.05 (71.67–93.54) 0.082 72.16 (61.00-92.04) 79.90 (65.00-91.99) 0.023 GFR(ml/min/1.73m 2 ) 106.66 (97.33-115.69) 108.47 (103.03–114.10) 0.112 106.66 (97.33-115.69) 108.18 (98.03-113.81) 0.003 ALT(U/L) 14.00 (10.00–21.00) 15.00 (12.00–20.00) 0.103 14.00 (10.00–21.00) 15.00 (11.00–21.00) 0.041 AST(U/L) 22.00 (17.00–27.00) 22.00 (19.00–25.00) 0.112 22.00 (17.00–27.00) 22.00 (18.00–27.00) 0.070 TBIL(µmol/L) 11.40 (8.05–16.50) 13.20 (10.90–15.80) 0.071 11.40 (8.05–16.50) 13.20 (9.30–15.90) 0.069 ALB(g/L) 41.20 (34.95–45.90) 43.90 (42.10–45.60) 0.039 41.20 (34.95–45.90) 43.90 (39.20–46.30) 0.008 Surgery related information Vaginal preparation 32 (15.8%) 2816 (16.0%) 0.013 32 (15.8%) 101 (16.6%) 0.030 Operation duration(min) 150.00 (100.00-250.00) 65.00 (25.00-105.00) 0.624 150.00 (100.00-250.00) 85.00 (45.00-147.00) 0.051 Intraoperative blood loss (mL) 0.00 (0.00–0.00) 0.00 (0.00–0.00) 0.320 0.00 (0.00–0.00) 0.00 (0.00–0.00) 0.072 Surgical approaches 0.491 0.035 Open 62 (30.5%) 1964 (11.1%) 62 (30.5%) 167 (27.4%) laparoscope 141 (69.5%) 15662 (88.9%) 141 (69.5%) 442 (72.6%) ASA score 0.395 0.014 Ⅰ,Ⅱ 173 (85.2%) 16996 (96.4%) 173 (85.2%) 525 (86.2%) Ⅲ,Ⅳ,Ⅴ 30 (14.8%) 630 (3.6%) 30 (14.8%) 84 (13.8%) Incision type 0.262 0.053 Ⅰ,Ⅱ 11 (5.4%) 2276 (12.9%) 11 (5.4%) 24 (3.9%) Ⅲ 192 (94.6%) 15350 (87.1%) 192 (94.6%) 585 (96.1%) Prophylactic antimicrobials 160 (78.8%) 10614 (60.2%) 0.412 160 (78.8%) 501 (82.3%) 0.024 Surgery type Uterine surgery 79 (38.9%) 10528 (59.7%) 0.425 79 (38.9%) 216 (35.5%) 0.068 Ovarian and adnexal surgery 74 (36.5%) 4482 (25.4%) 0.240 74 (36.5%) 219 (36.0%) 0.007 Vulvar, vaginal and cervical surgery 49 (24.1%) 1932 (11.0%) 0.351 49 (24.1%) 171 (28.1%) 0.079 Other 1 (0.5%) 684 (3.9%) 0.233 1 (0.5%) 3 (0.5%) 0.099 Values presented as n (%) or median (IQR), SMD The standardized mean difference Direct medical costs analysis The total medical costs were significantly higher in the case group compared to the control group (€3779.94 vs. €2130.49, p < 0.001). The median difference in total medical costs was €1446.59. Specifically, all itemized medical costs for the case group were significantly higher than those for the control group (all p < 0.001). These included costs related to therapeutics, consumables, diagnostics, medical services, medications, nursing care, and other costs, as detailed in Table 2 . Table 2 Comparison of itemized medical costs between the case and control group Medical cost items Case group (n = 203) Median(IQR) Control group (n = 609) Median(IQR) Difference Median(IQR) p -value Service costs 128.08 (85.01–215.43) 53.85 (37.20–90.62) 65.54 (19.31–129.70) < 0.001 Nursing service fees 42.25 (28.43–69.00) 20.88 (14.73–32.08) 21.24 (6.16–40.17) < 0.001 Medical service fees 82.70 (53.11–135.56) 33.51 (20.43–57.96) 43.65 (12.31–90.55) < 0.001 Diagnostic costs 723.97 (454.50–1157.00) 328.79 (249.58–501.03) 321.78 (84.35–750.87) < 0.001 Pathological diagnostic fees 128.06 (59.33–313.52) 50.81 (14.59–123.23) 62.88 (-16.89–206.52) < 0.001 Clinical diagnostic fees 13.76 (9.89–49.37) 10.99 (5.19–23.18) 4.83 (-5.79–27.38) < 0.001 Laboratory diagnostic fees 370.31 (282.56–553.05) 203.95 (164.27–250.79) 171.73 (72.30–339.36) < 0.001 Imaging diagnostic fees 123.11 (48.98–305.07) 54.92 (31.48–107.64) 39.35 (-9.66–183.57) < 0.001 Therapeutic costs 1144.67 (859.36–1666.51) 777.31 (518.02–1062.98) 412.81 (-20.30–883.32) < 0.001 Non-surgical clinical physical therapy fees 48.76 (26.31–114.46) 23.90 (9.66–57.96) 19.80 (-8.33–75.31) < 0.001 Rehabilitation fees 0.00 (0.00–13.76) 0.00 (0.00–13.76) 0.00 (-8.02–8.69) 0.372 Surgical therapeutic fees 946.73 (705.95–1329.16) 684.52 (479.86–947.04) 285.15 (-50.95–633.76) < 0.001 General therapeutic procedure fees 101.75 (64.27–185.63) 39.83 (26.07–64.70) 51.24 (18.67–115.03) < 0.001 Material Costs 938.98 (632.80–1532.00) 653.22 (294.12–1169.86) 327.17 (-153.67–894.68) < 0.001 Disposable material fees for examinations 3.11 (2.42–11.82) 2.14 (1.65–6.48) 1.15 (-0.63–8.59) < 0.001 Disposable material fees for surgeries 751.64 (464.41–1,315.90) 525.60 (195.92–990.07) 249.41 (-180.93–741.46) < 0.001 Disposable material fees for treatments 154.48 (118.01–222.57) 98.78 (50.90–142.35) 68.82 (0.70–123.83) < 0.001 Pharmaceutical costs 386.87 (265.04–849.67) 182.02 (117.89–251.33) 204.30 (58.34–614.18) < 0.001 Other costs 9.66 (4.83–9.66) 4.83 (4.83–9.66) 0.00 (-4.83–4.83) < 0.001 Total costs 3779.94 (2488.12–5381.87) 2130.49 (1320.69–3538.60) 1446.59 (157.65–3130.38) < 0.001 Direct medical costs analysis by surgery type When analyzing total direct medical costs by surgery type, costs for patients in the case group remained significantly higher than those in the control group across all evaluated procedures (all p < 0.001). For uterine surgeries, the median cost difference was €1582.08 (€2874.36 vs. €2058.22, p < 0.001); for ovarian and adnexal surgeries, it was €1374.43 (€3195.38 vs. €2062.23, p < 0.001); and for vulvar, vaginal, and cervical surgeries, it was €1921.54 (€5100.22 vs. €3353.68, p < 0.001). Detailed breakdowns of these costs by surgery type are provided in Table 3 . Table 3 Comparison of total direct medical costs between the case and control group for different surgical type Surgery type Case Group Control Group Difference Median(IQR) p -value n Total Medical Cost Median(IQR) n Total Medical Cost Median(IQR) Uterine surgery 79 2874.36 (2393.41–4094.82) 217 2058.22 (832.78–2477.02) 1582.08 (447.38–2494.36) < 0.001 Ovarian and adnexal surgery 74 3195.38 (2073.44–5989.83) 224 2062.23 (1671.14–2792.27) 1374.43 (-7.09–3522.16) < 0.001 Vulvar, vaginal and cervical surgery 49 5100.22 (3922.12–5744.98) 168 3353.68 (813.13–3913.34) 1921.54 (632.18–3362.62) < 0.001 Other 1 - 3 - - - Total 203 3779.94 (2488.12–5,381.87) 609 2130.49 (1320.69–3538.60) 1446.59 (157.65–3130.38) < 0.001 Analysis of length of stay Details are shown in Fig. 4 . Patients in the case group had a significantly longer LPOS (9 vs. 4 days, p < 0.001) and LOS (12 vs. 6 days, p 0.05). Details are shown in Fig. 4 . Among the three surgery types included in the analysis, there were no statistically significant differences in LPPS (all p > 0.05). However, LPOS and LOS were significantly longer for the case group in all three surgery types (all p < 0.001). Details are shown in Fig. 5 . Discussion This propensity score-matched case-control study shows that PBSI in gynecologic surgery incurs a significant economic and resource burden. Our results show that patients with a PBSI incurred significantly higher direct medical costs (€3779.94 vs €2130.49, p < 0.001), with a median difference of €1446.59, for a 67.9% increase compared to matched controls. Furthermore, PBSI was associated with a median increased overall 5 days LPOS and 6 days LOS. To our knowledge, this is the first study to quantify the disease burden of PBSI of gynecologic surgery, filling a knowledge gap of the burden of postoperative infections around the gynecologic surgery. The comprehensive cost increase observed across all expenditure categories reflects the multifaceted resource demands of managing PBSI, including treatment, consumables, diagnostics, medical services, pharmaceuticals, and nursing care. The treatment of PBSI typically necessitates extended courses of antimicrobials, sometimes including costly reserve antibiotics for resistant organisms [ 10 ]. Diagnostic expenses rise due to repeated blood cultures, additional laboratory tests to monitor organ function and inflammatory markers, and potential imaging examinations to identify metastatic foci of infection [ 11 ]. The need for more intensive monitoring and management of potential sepsis sequelae further drives up medical service and nursing costs [ 12 ]. Consumable expenditures increase with extended intravenous access needs and additional wound care supplies [ 10 ]. The increase in LOS is nearly entirely postoperative (9 vs. 4 days, p 0.05). This clearly demonstrates that PBSI directly correlates to a longer LOS, and not to differing preoperative management. Longer LOS incurs substantial direct costs and also has a range of sequelae that are not always captured, e.g., increased risk of hospital-acquired complications (such as pressure injuries and venous thromboembolism), longer time to functional recovery, inferior patient experience, and impacted hospital bed capacity and throughput [ 13 , 14 ].The median increase of LOS by 6 days represents a large loss of opportunity cost for these healthcare systems with limited capacity for beds. Research addressing the economic and resource impact of PBSI in gynecologic surgery is exceptionally limited, highlighting the novelty and importance of our findings. Nonetheless, there are some studies on burden of disease due to healthcare-associated infections (HAIs) and other postoperative infections reporting similar findings. A systematic review assessing the economic cost associated with surgical site infections (SSIs) in low- and middle-income countries (LMICs) and high-income European countries found that the extra cost related to SSIs was similar across the studies, with additional costs listed in LMIC countries ranging from $ 174- $ 29,610, and European countries ranging from $ 21- $ 34,000 additional dollars. SSIs also extended length of stay (LOS) significantly- extending LOS by anywhere from 3 to 35 days in LMIC countries. The extreme economic burden and resource burden with SSIs was consistent between both settings, despite differences in healthcare system design and methods of cost accounting [ 15 ]. Our observed cost increase of 67.9% ( €1446.59) and extended LOS of 6 days is within the same range, adding support that the burden of PBSI in gynecologic surgery is similar to that of infection burden in the other surgical areas. Greco et al. demonstrated in a prospective multicenter cohort of adult cardiac operations, that developing a PBSI nearly doubled the total hospital cost (86% increase), resulting in an average cost of $ 38200 prior to PBSI and $ 70900 after PBSI [ 16 ]. This figure aligns closely with our own observation of increased cost following PBSI. Digiovine et al. found for primary nosocomial bloodstream infections (BSI) in the ICU, costs were 65% greater and length of stay was just over 7.5 days longer for patients with a BSI [ 17 ]. These observations also support the veracity of findings across settings and the large impact of BSI. The study by Steiner et al. estimated that the occurrence of SSI after hysterectomy would incur an additional direct medical cost of approximately $ 5,000 [ 18 ]. Although there is no direct research evidence indicating how much additional direct medical cost is incurred by PBSI in hysterectomy, it is expected that due to the systemic nature of bloodstream infections, which often require more intensive antimicrobial therapy, closer monitoring, and management of potential sepsis-related complications. This suggests that PBSI may represent an even greater economic burden than localized infections in gynecologic surgery patients. An evaluation of the data on surgery type identified distinct cost variations, with vulvar, vaginal, and cervical surgeries exhibiting the greatest differential (€1921.54). Two main factors were hypothesized to contribute to this point. First, the anatomical sites of the vulva, vagina and cervix contain high-density, diverse communities of microbes which may result in polymicrobial infections that are difficult to treat [ 19 ]. Second, surgeries to the aforementioned anatomical sites may include more complicated reconstruction or rearrangement of tissue (especially on oncologic cases) that can potentially create spaces or devascularize tissue. Thus tractable infection can be challenging [ 20 ]. The significant economic burden identified in this study of €1446.59 per PBSI case, makes the case for investment in prevention strategies compelling. This amount multiplies across the thousands of gynecologic surgeries performed annually, representing significant potential health care systems and payer savings. Furthermore, the additional 6 days of LOS associated with each PBSI case also represents considerable opportunity costs in bed availability and patient throughput, particularly in limited resource settings or during times of high hospital occupancy [ 21 ]. From a cost-effectiveness perspective, our findings suggest that even relatively expensive PBSI prevention bundles would likely be justified. Evidence-based interventions such as appropriate antimicrobial prophylaxis, chlorhexidine bathing, meticulous attention to aseptic technique, and prompt removal of unnecessary invasive devices could yield substantial returns on investment [ 22 , 23 ]. Our prior studies, along with others, supported that for gynecological surgeries, particularly those involving the vaginal area, adequate preoperative vaginal preparation (such as vaginal scrubbing or douching with antiseptic solutions) could effectively reduce the risk of PBSI [ 24 , 25 ]. This intervention is evidently highly cost-effective when compared to the increased costs associated with treating PBSI. Our results provide a foundation for larger evaluations of the economic burden of PBSI in gynecologic surgery. However, there are limitations to this study. First, as a retrospective analysis, we cannot eliminate the possibility of unmeasured confounding factors affecting our findings despite the use of PSM. Second, our single-center design may limit generalizability to other healthcare systems with different patient populations and clinical practice and financial arrangements. Third, we only considered direct medical costs related to the index hospitalization; we did not include indirect costs, such as loss of productivity and caregiver burden, or post-discharge costs, such readmission and outpatient care, that may further underestimate the total economic burden. Finally, we did not consider potential differences in the type of pathogen or pattern of resistance which may impact the costs of treatment and outcomes. Future multicenter, prospective studies will be needed to confirm external validity and to provide tighter control for confounding factors, and examine long-term and post-discharge costs, including quality-of-life decrements. Cost-effectiveness analyses of targeted prevention approaches, stratified by procedure-specific risk factors and pathogen-specific risk factors (i.e., species and resistance profiles) will better inform resource allocation decisions. Finally, including indirect costs, such as loss of productivity, caregiver burden and disability, into societal-perspective analyses would provide policymakers with a fuller foundation to consider financing and quality-improvement decisions. Conclusions This propensity score-matched study provides robust evidence that PBSI in gynecologic surgery substantially increases direct medical costs and prolongs LOS. These findings underscore the critical importance of infection prevention and control measures in gynecologic surgical practice. Beyond improving patient outcomes, effective PBSI prevention strategies offer significant potential for cost savings and optimization of healthcare resource utilization. As healthcare systems increasingly focus on value-based care delivery, targeting preventable complications with substantial economic impact, such as PBSI, represents a high-yield approach to simultaneously enhancing quality and controlling costs. Abbreviations ALB: Albumin ALT: Alanine Aminotransferase ASA: American Society of Anesthesiologists AST: Aspartate Aminotransferase BMI: Body Mass Index BSI: Bloodstream Infection CNY: Chinese Yuan CREA: Creatinine DRG/DIP: Diagnosis Related Groups/ Diagnosis-Intervention Packet EMR: Electronic Medical Record EUR: Euro GFR: Glomerular Filtration Rate HAIs: Healthcare-Associated Infections HGB: Hemoglobin ICU: Intensive Care Unit IQR: Interquartile Range LMICs: Low- and Middle-Income Countries LOS: Length of Stay LPOS: Length of Post-Operative Stay LPPS: Length of Pre-operative Preparation Stay PBSI: Post-operative Bloodstream Infection PLT: Platelet PSM: Propensity-Score Matching SD: Standard Deviation SMD: Standardized Mean Difference SSI: Surgical-Site Infection TBIL: Total Bilirubin WBC: White Blood Cell Declarations Ethics approval and consent to participate The research protocol was reviewed and approved by the Conjoint Health Research Ethics Board of Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital (2025-144, February 28th, 2025). Availability of data and materials The datasets of this study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This study was supported by the National Natural Science Foundation of China (No. 22476032), 2023 Natural Science Foundation of Sichuan Province (No. 2023NSFSC0534) and the Multi-Campus Hospital Systems project (NIHA24YYDQ23) of the National Institute of Hospital Administration of China. Authors' contributions Study design:Na Xiao, Qian Xiang. Data collection: Pingping Wang, Hui Wang, Chen Wang, Daoqiong Wei, Xiaoyan Jiang, Minhong Cai, Jing Chen, Hongrong Cao, Li Ding, Tianfen Liao, Xiaojia Zheng. Data analysis: Yan Luo, Lan Chen, Wei Li, Yu Lyu. Manuscript writing: Yan Luo, Wei Li, Mao Ran, Lan Chen. Manuscript revision: Yu Lyu, Jiayu Wu, Qian Xiang. All authors read and approved the final manuscript. Acknowledgements We would like to extend our sincere gratitude to all staff members of the Department of Gynecology at Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital for their invaluable contributions to this study. References Zimmermann, J. S. M., Sima, R.-M., Radosa, M. P., Radosa, C. G., Ples, L., Wagenpfeil, S., et al. (2022). Quality of life and sexual function in patients aged 35 years or younger undergoing hysterectomy for benign gynecologic conditions: A prospective cohort study. Journal of Minimally Invasive Gynecology , 29 (7), 887–895. https://doi.org/10.1016/j.jmig.2022.05.003 Chen, Y.. (2007). Current Status and Prospects of Transvaginal Uterine Surgery. Journal of Practical Obstetrics and Gynecology , (1), 3-5. Peng, C., & Zhou, Y. (2020). Experience and reflections on laparoscopic hysterectomy for deep infiltrating endometriosis. Chinese Journal of Laparoscopic Surgery (Electronic Edition) , 13 (2), 77–80. Alkatout, I., O'Sullivan, O., Peters, G., & Maass, N. (2023). Expanding Robotic-Assisted Surgery in Gynecology Using the Potential of an Advanced Robotic System. Medicina (Kaunas, Lithuania) , 60(1), 53. https://doi.org/10.3390/medicina60010053 Allegranzi, B., Bagheri Nejad, S., Combescure, C., Graafmans, W., Attar, H., Donaldson, L., et al. (2011). Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet (London, England) , 377(9761), 228–241. https://doi.org/10.1016/S0140-6736(10)61458-4 Rashid, N., Begier, E., Lin, K. J., & Yu, H. (2020). Culture-confirmed Staphylococcus aureus infection after elective hysterectomy: Burden of disease and risk factors. Surgical Infections , 21(2), 169-178. https://doi.org/10.1089/sur.2019.043 Coello, R., Charlett, A., Wilson, J., Ward, V., 3.Pearson, A., & Borriello, P. (2005). Adverse impact of surgical site infections in English hospitals. 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Epidemiology and outcome of nosocomial and community-onset bloodstream infection. Journal of clinical microbiology , 41(8), 3655–3660. https://doi.org/10.1128/JCM.41.8.3655-3660.2003 Kaye, K. S., Marchaim, D., Chen, T. Y., Baures, T., Anderson, D. J., Choi, Y., et al. (2014). Effect of nosocomial bloodstream infections on mortality, length of stay, and hospital costs in older adults. Journal of the American Geriatrics Society , 62(2), 306–311. https://doi.org/10.1111/jgs.12634 Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis . 2003;9(2):196-203. doi:10.3201/eid0902.020232 de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control . 2009;37(5):387-397. doi:10.1016/j.ajic.2008.12.010 Monahan, M., Jowett, S., Pinkney, T., Brocklehurst, P., Morton, D. G., Abdali, Z., et al. (2020). Surgical site infection and costs in low- and middle-income countries: A systematic review of the economic burden. PloS one , 15(6), e0232960. https://doi.org/10.1371/journal.pone.0232960 Greco, G., Shi, W., Michler, R. E., Meltzer, D. O., Ailawadi, G., Hohmann, S. F., et al. (2015). Costs associated with health care-associated infections in cardiac surgery. Journal of the American College of Cardiology , 65(1), 15–23. https://doi.org/10.1016/j.jacc.2014.09.079 Digiovine, B., Chenoweth, C., Watts, C., & Higgins, M. (1999). The attributable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit. American journal of respiratory and critical care medicine , 160(3), 976–981. https://doi.org/10.1164/ajrccm.160.3.9808145 Steiner, H. L., & Strand, E. A. (2017). Surgical-site infection in gynecologic surgery: pathophysiology and prevention. American journal of obstetrics and gynecology , 217(2), 121–128. https://doi.org/10.1016/j.ajog.2017.02.014 Soper D. E. (2020). Bacterial vaginosis and surgical site infections. American journal of obstetrics and gynecology , 222(3), 219–223. https://doi.org/10.1016/j.ajog.2019.09.002 Pavlov, A., Bhatt, N., Damitz, L., & Ogunleye, A. A. (2021). A Review of Reconstruction for Vulvar Cancer Surgery. Obstetrical & gynecological survey , 76(2), 108–113. https://doi.org/10.1097/OGX.0000000000000866 Graves, N., Halton, K., & Lairson, D. (2007). Economics and preventing hospital-acquired infection: broadening the perspective. Infection control and hospital epidemiology , 28(2), 178–184. https://doi.org/10.1086/510787 Anderson, D. J., Podgorny, K., Berríos-Torres, S. I., Bratzler, D. W., Dellinger, E. P., Greene, L., et al. (2014). Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infection control and hospital epidemiology , 35(6), 605–627. https://doi.org/10.1086/676022 Yokoe, D. S., Anderson, D. J., Berenholtz, S. M., Calfee, D. P., Dubberke, E. R., Ellingson, K. D., et al. Society for Healthcare Epidemiology of America (SHEA) (2014). A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. Infection control and hospital epidemiology , 35(8), 967–977. https://doi.org/10.1086/677216 Buppasiri, P., Chongsomchai, C., Wongproamas, N., Ounchai, J., Suwannachat, B., & Lumbiganon, P. (2004). Effectiveness of vaginal douching on febrile and infectious morbidities after total abdominal hysterectomy: a multicenter randomized controlled trial. Journal of the Medical Association of Thailand = Chotmaihet thangphaet, 87(1), 16–23. Skeith, A. E., Morgan, D. M., & Schmidt, P. C. (2021). Vaginal preparation with povidone-iodine or chlorhexidine before hysterectomy: a propensity score matched analysis. American journal of obstetrics and gynecology, 225(5), 560.e1–560.e9. https://doi.org/10.1016/j.ajog.2021.08.035 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6850353","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":483730587,"identity":"cd5f76ee-9274-4cf1-a820-25f3ce4c0d89","order_by":0,"name":"Yan Luo","email":"","orcid":"","institution":"Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Luo","suffix":""},{"id":483730588,"identity":"5e165227-f804-4658-8691-4072acaafd6b","order_by":1,"name":"Wei 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03:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6850353/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6850353/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86767321,"identity":"42051b0a-e3b7-407c-97bd-1299d8c6c95a","added_by":"auto","created_at":"2025-07-15 11:11:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43755,"visible":true,"origin":"","legend":"\u003cp\u003eThe participant selection process\u003c/p\u003e","description":"","filename":"Figure1.Theparticipantselectionprocess.png","url":"https://assets-eu.researchsquare.com/files/rs-6850353/v1/c5d60c5f1a205210dc542c31.png"},{"id":86767320,"identity":"9bb4086c-5288-4ac8-a093-b33351383d69","added_by":"auto","created_at":"2025-07-15 11:11:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59573,"visible":true,"origin":"","legend":"\u003cp\u003eThe SMD of case and control group before and after PSM\u003c/p\u003e","description":"","filename":"Figure2.TheSMDofcaseandcontrolgroupbeforeandafterPSM.png","url":"https://assets-eu.researchsquare.com/files/rs-6850353/v1/46b3a8dba0b34c81165f16e8.png"},{"id":86767323,"identity":"7468d927-8c1a-4316-82dd-65bf20d9eae0","added_by":"auto","created_at":"2025-07-15 11:11:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":57432,"visible":true,"origin":"","legend":"\u003cp\u003eThe distribution of propensity scores before and after matching\u003c/p\u003e","description":"","filename":"Figure3.Thedistributionofpropensityscoresbeforeandaftermatching.png","url":"https://assets-eu.researchsquare.com/files/rs-6850353/v1/aa4ffd0602562e56ca1b92dd.png"},{"id":86767325,"identity":"e77e54dd-28e8-40bc-ad00-d5ae1339399a","added_by":"auto","created_at":"2025-07-15 11:11:41","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":49055,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of LPPS, LPOS and LOS between the case and control group\u003c/p\u003e","description":"","filename":"Figure4.ComparisonofLPPSLPOSandLOSbetweenthecaseandcontrolgroup.png","url":"https://assets-eu.researchsquare.com/files/rs-6850353/v1/ce0fa34e0d143a49b23a61bf.png"},{"id":86767327,"identity":"28a8a9be-7f2f-40e0-ae52-29e6ecc5a9d6","added_by":"auto","created_at":"2025-07-15 11:11:41","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":74323,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of LPPS, LPOS and LOS between the case and control group by surgery type\u003c/p\u003e","description":"","filename":"Figure5.ComparisonofLPPSLPOSandLOSbetweenthecaseandcontrolgroupbysurgerytype.png","url":"https://assets-eu.researchsquare.com/files/rs-6850353/v1/30f2840d0cf765150aba65e4.png"},{"id":91132351,"identity":"632f3623-5e7c-4d3f-82da-fe0e8e04ee39","added_by":"auto","created_at":"2025-09-12 02:16:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1909426,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6850353/v1/0918bba5-f646-460a-86ff-a6ed5d7e9eb0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Direct Medical Costs and Length of Stay Associated with Postoperative Bloodstream Infections in Gynecologic Surgery: A Propensity Score-Matched Case-Control Study","fulltext":[{"header":"Background","content":"\u003cp\u003eGynecologic surgery not only serves as a pillar in the care of gynecologic concerns, but also represents an opportunity to improve women's quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Globally, the volume of gynecologic surgery is substantial, with an estimated 5\u0026nbsp;million hysterectomies worldwide completed in 2021, including 600,000 hysterectomies in the United States and 2.82\u0026nbsp;million in China [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Given the ongoing technological advancements and ever-increasing needs for health, the percentage of minimally invasive gynecologic surgery continues to grow annually [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePost-operative infection is among the most deleterious complications of gynecologic surgery, endangering patients, prolonging hospitalization, escalating resource consumption, and imposing major economic burdens on families and society [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. U.S. data show that a \u003cem\u003eStaphylococcus aureus\u003c/em\u003e surgical-site infection (SSI) after elective hysterectomy raises total hospital costs to US \u003cspan\u003e$\u003c/span\u003e18,261, nearly triple those of uninfected cases, and markedly increases emergency visits, readmissions, and re-operations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. U.K. multicenter surveillance likewise demonstrated an excess stay of 3.3 days and an additional \u0026pound;959 per SSI case, with deep or organ/space infections further extending hospitalization and heightening mortality [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePublished researches has focused on the burden of SSI, whereas post-operative bloodstream infection (PBSI) remains under-studied, despite its likely higher mortality, re-operation rate, ICU demand, and economic impact. Quantitative estimates of PBSI burden in gynecology are lacking. To address this gap, we used propensity-score matching (PSM) to control confounding and assessed the effect of PBSI on direct medical costs and length of stay (LOS) in gynecologic surgery. These findings will inform the value of infection prevention and control, particularly amid China\u0026rsquo;s 2019 shift from Fee-for-service to Diagnosis Related Groups/ Diagnosis-Intervention Packet (DRG/DIP)-based payment models.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSettings\u003c/h2\u003e\u003cp\u003eThe Sichuan Academy of Medical Sciences \u0026amp; Sichuan Provincial People's Hospital is one of the largest tertiary healthcare facilities in southwestern China. The facility has more than 4300 inpatient beds, of which 120 are dedicated to gynecology, including more than 6000 gynecologic surgeries each year.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy design and data sources\u003c/h3\u003e\n\u003cp\u003eA retrospective case\u0026ndash;control design was adopted. Potential confounding was addressed by 1:3 nearest-neighbour PSM. Cases were gynecologic surgical patients who developed PBSI. Controls were gynecologic surgical patients without PBSI. Data were extracted from the Department of Gynecology surgical database at Sichuan Academy of Medical Sciences \u0026amp; Sichuan Provincial People\u0026rsquo;s Hospital, covering all surgeries performed between January 2022 and December 2024. Variables captured included patient demographics, clinical diagnoses, laboratory results, operative details, postoperative complications and direct medical costs. All data were de-identified and processed in accordance with ethical principles.\u003c/p\u003e\n\u003ch3\u003eStudy participants\u003c/h3\u003e\n\u003cp\u003eThe participant inclusion criteria were: (1) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (2) availability of preoperative laboratory results (complete blood count, liver/renal function panels); (3) documented height, weight, and preexisting comorbidities. Exclusion criteria were: (1) non-operating-room procedures; (2) incomplete critical data.\u003c/p\u003e\n\u003ch3\u003eVariable definition\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eCase definition\u003c/h2\u003e\u003cp\u003ePost-operative bloodstream infection (PBSI) was defined, with reference to the previous studies[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], as the simultaneous fulfillment of all four criteria below:(1) axillary temperature\u0026thinsp;\u0026gt;\u0026thinsp;38.0\u0026deg;C persisting for \u0026ge;\u0026thinsp;2 consecutive days after surgery; and (2) no identifiable focus of infection; and (3) initiation of systemic antimicrobial therapy; and (4) at least one blood culture obtained, irrespective of the culture result.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eMatching covariates\u003c/h2\u003e\u003cp\u003eMatching covariates included patient demographic characteristics (age, ethnicity, BMI and smoking), preexisting comorbidities (diabetes and hypertension), preoperative laboratory tests (WBC, HGB, PLT, CREA, GFR, ALT, AST, TBIL and ALB) and surgery related information (vaginal preparation, operation duration, intraoperative blood loss, surgical approaches, ASA score, incision type, prophylactic antimicrobials and surgery type).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcome variables\u003c/h3\u003e\n\u003cp\u003e\u003cb\u003eDirect medical costs\u003c/b\u003e. Direct medical costs were defined as all healthcare\u0026ndash;related expenses documented in the electronic medical record (EMR), comprising: service costs (nursing service fees, medical service fees), diagnostic costs (pathological diagnostic fees, clinical diagnostic fees, laboratory diagnostic fees, imaging diagnostic fees), therapeutic costs (non-surgical clinical physical therapy fees, rehabilitation fees, surgical therapeutic fees, general therapeutic procedure fees), material costs (disposable medical material fees for examinations, surgeries and treatments), pharmaceutical costs and other costs. Costs are calculated in local currency CNY(\u0026yen;) and converted to EUR(\u0026euro;).\u003c/p\u003e\u003cp\u003e\u003cb\u003eLength of stay.\u003c/b\u003e Length of stay (LOS) was defined as the days from patient admission to discharge and was further subdivided into length of pre-operative preparation stay (LPPS) which was the days from admission to surgery, and length of post-operative stay (LPOS) which was the days from surgery to discharge.\u003c/p\u003e\n\u003ch3\u003eStatistical methods\u003c/h3\u003e\n\u003cp\u003eStatistical analyses were performed in R software, version 4.4.1. Descriptive statistics were calculated on the data before and after matching. Continuous variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median (interquartile range, IQR), depending on distribution. Categorical variables were reported as frequencies (%). Standardized mean differences (SMDs) of covariates were tested for balance before and after matching with SMD\u0026thinsp;\u0026lt;\u0026thinsp;0.1 representing adequate balance. Between-group comparisons of continuous variables were assessed with t-test if normally distributed, or Mann\u0026ndash;Whitney U test if not normally distributed. Statistical significance was defined as two-tailed α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003eAdditionally, subgroup analyses were performed according to surgical site, with procedures categorized into the following types: uterine; ovarian and adnexal; vulvar, vaginal and cervical; and other.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eThe participant selection and matching\u003c/h2\u003e\u003cp\u003eAfter screening records of patients who underwent gynecologic surgery between January 2022 and December 2024 from the database, and subsequent PSM, 203 patients were included in the case group and 609 patients in the control group for the final comparative analysis. The detailed patient selection and matching flowchart is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBefore PSM, significant differences (SMD\u0026thinsp;\u0026gt;\u0026thinsp;0.1) were observed between the case and control groups across several baseline characteristics. These included demographic characteristics (age), preexisting comorbidities (diabetes), preoperative laboratory tests (GFR, ALT, AST), and surgery-related information (operation duration, surgical approaches, ASA score, incision type, prophylactic antimicrobials, and surgery type), as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. After PSM, all baseline characteristics were well-balanced between the groups, all SMDs\u0026thinsp;\u0026lt;\u0026thinsp;0.1 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The propensity score distributions of the two groups demonstrated considerable overlap and were concentrated within similar score ranges (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This indicates that PSM effectively balanced the propensity scores between the groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of case and control group before and after PSM\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003ePre- PSM\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003ePost- PSM\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCase group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSMD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCase group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSMD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e203\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17626\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e203\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e609\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eDemographic characteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eEthnicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e185\u003c/p\u003e\u003cp\u003e(91.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15884\u003c/p\u003e\u003cp\u003e(90.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e185\u003c/p\u003e\u003cp\u003e(91.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e564\u003c/p\u003e\u003cp\u003e(92.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.042\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eZang\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003cp\u003e(5.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1261\u003c/p\u003e\u003cp\u003e(7.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.050\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12\u003c/p\u003e\u003cp\u003e(5.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e33\u003c/p\u003e\u003cp\u003e(5.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e(3.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e481\u003c/p\u003e\u003cp\u003e(2.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e(3.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e12\u003c/p\u003e\u003cp\u003e(2.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.020\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge(years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49.00\u003c/p\u003e\u003cp\u003e(40.0\u0026ndash;56.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45.00\u003c/p\u003e\u003cp\u003e(35.00\u0026ndash;52.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.301\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e49.00\u003c/p\u003e\u003cp\u003e(40.00\u0026ndash;56.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e48.00\u003c/p\u003e\u003cp\u003e(39.00\u0026ndash;57.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.83\u003c/p\u003e\u003cp\u003e(20.76\u0026ndash;25.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.66\u003c/p\u003e\u003cp\u003e(20.70-24.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22.83\u003c/p\u003e\u003cp\u003e(20.76\u0026ndash;25.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e22.83\u003c/p\u003e\u003cp\u003e(20.70-25.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003cp\u003e(0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003cp\u003e(0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003cp\u003e(0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003cp\u003e(0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003ePreexisting comorbidities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eDiabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003cp\u003e(7.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e712\u003c/p\u003e\u003cp\u003e(4.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e15\u003c/p\u003e\u003cp\u003e(7.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e53\u003c/p\u003e\u003cp\u003e(8.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.060\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003cp\u003e(13.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1891\u003c/p\u003e\u003cp\u003e(10.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.079\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e27\u003c/p\u003e\u003cp\u003e(13.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e99\u003c/p\u003e\u003cp\u003e(16.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003ePreoperative laboratory tests\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eWBC(10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.69\u003c/p\u003e\u003cp\u003e(7.08\u0026ndash;12.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.37\u003c/p\u003e\u003cp\u003e(7.55\u0026ndash;11.17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.082\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e9.69\u003c/p\u003e\u003cp\u003e(7.08\u0026ndash;12.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e9.41\u003c/p\u003e\u003cp\u003e(7.28\u0026ndash;11.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHGB(g/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e106.00\u003c/p\u003e\u003cp\u003e(85.50\u0026ndash;125.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e117.00\u003c/p\u003e\u003cp\u003e(106.00-127.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e106.00\u003c/p\u003e\u003cp\u003e(85.50\u0026ndash;125.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e116.00\u003c/p\u003e\u003cp\u003e(102.00-126.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePLT(10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e201.00\u003c/p\u003e\u003cp\u003e(159.00-258.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e209.00\u003c/p\u003e\u003cp\u003e(177.00-244.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e201.00\u003c/p\u003e\u003cp\u003e(159.00-258.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e209.00\u003c/p\u003e\u003cp\u003e(166.00-252.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCREA(\u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72.16\u003c/p\u003e\u003cp\u003e(61.00-92.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.05\u003c/p\u003e\u003cp\u003e(71.67\u0026ndash;93.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.082\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e72.16\u003c/p\u003e\u003cp\u003e(61.00-92.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e79.90\u003c/p\u003e\u003cp\u003e(65.00-91.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eGFR(ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e106.66\u003c/p\u003e\u003cp\u003e(97.33-115.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e108.47\u003c/p\u003e\u003cp\u003e(103.03\u0026ndash;114.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e106.66\u003c/p\u003e\u003cp\u003e(97.33-115.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e108.18\u003c/p\u003e\u003cp\u003e(98.03-113.81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eALT(U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.00\u003c/p\u003e\u003cp\u003e(10.00\u0026ndash;21.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.00\u003c/p\u003e\u003cp\u003e(12.00\u0026ndash;20.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e14.00\u003c/p\u003e\u003cp\u003e(10.00\u0026ndash;21.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e15.00\u003c/p\u003e\u003cp\u003e(11.00\u0026ndash;21.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.041\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAST(U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.00\u003c/p\u003e\u003cp\u003e(17.00\u0026ndash;27.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.00\u003c/p\u003e\u003cp\u003e(19.00\u0026ndash;25.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22.00\u003c/p\u003e\u003cp\u003e(17.00\u0026ndash;27.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e22.00\u003c/p\u003e\u003cp\u003e(18.00\u0026ndash;27.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.070\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTBIL(\u0026micro;mol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.40\u003c/p\u003e\u003cp\u003e(8.05\u0026ndash;16.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.20\u003c/p\u003e\u003cp\u003e(10.90\u0026ndash;15.80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e11.40\u003c/p\u003e\u003cp\u003e(8.05\u0026ndash;16.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e13.20\u003c/p\u003e\u003cp\u003e(9.30\u0026ndash;15.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.069\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eALB(g/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.20\u003c/p\u003e\u003cp\u003e(34.95\u0026ndash;45.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43.90\u003c/p\u003e\u003cp\u003e(42.10\u0026ndash;45.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.039\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e41.20\u003c/p\u003e\u003cp\u003e(34.95\u0026ndash;45.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e43.90\u003c/p\u003e\u003cp\u003e(39.20\u0026ndash;46.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eSurgery related information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVaginal preparation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003cp\u003e(15.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2816\u003c/p\u003e\u003cp\u003e(16.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e32\u003c/p\u003e\u003cp\u003e(15.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e101\u003c/p\u003e\u003cp\u003e(16.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.030\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOperation duration(min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e150.00\u003c/p\u003e\u003cp\u003e(100.00-250.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e65.00\u003c/p\u003e\u003cp\u003e(25.00-105.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.624\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e150.00\u003c/p\u003e\u003cp\u003e(100.00-250.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e85.00\u003c/p\u003e\u003cp\u003e(45.00-147.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.051\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eIntraoperative blood loss (mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003cp\u003e(0.00\u0026ndash;0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003cp\u003e(0.00\u0026ndash;0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.320\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003cp\u003e(0.00\u0026ndash;0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003cp\u003e(0.00\u0026ndash;0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.072\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSurgical approaches\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.491\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOpen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62\u003c/p\u003e\u003cp\u003e(30.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1964\u003c/p\u003e\u003cp\u003e(11.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e62\u003c/p\u003e\u003cp\u003e(30.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e167\u003c/p\u003e\u003cp\u003e(27.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003elaparoscope\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e141\u003c/p\u003e\u003cp\u003e(69.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15662\u003c/p\u003e\u003cp\u003e(88.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e141\u003c/p\u003e\u003cp\u003e(69.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e442\u003c/p\u003e\u003cp\u003e(72.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eASA score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.395\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eⅠ,Ⅱ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e173\u003c/p\u003e\u003cp\u003e(85.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16996\u003c/p\u003e\u003cp\u003e(96.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e173\u003c/p\u003e\u003cp\u003e(85.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e525\u003c/p\u003e\u003cp\u003e(86.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eⅢ,Ⅳ,Ⅴ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003cp\u003e(14.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e630\u003c/p\u003e\u003cp\u003e(3.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e30\u003c/p\u003e\u003cp\u003e(14.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e84\u003c/p\u003e\u003cp\u003e(13.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eIncision type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.262\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eⅠ,Ⅱ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003cp\u003e(5.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2276\u003c/p\u003e\u003cp\u003e(12.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e11\u003c/p\u003e\u003cp\u003e(5.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e24\u003c/p\u003e\u003cp\u003e(3.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eⅢ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e192\u003c/p\u003e\u003cp\u003e(94.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15350\u003c/p\u003e\u003cp\u003e(87.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e192\u003c/p\u003e\u003cp\u003e(94.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e585\u003c/p\u003e\u003cp\u003e(96.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eProphylactic antimicrobials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e160\u003c/p\u003e\u003cp\u003e(78.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10614\u003c/p\u003e\u003cp\u003e(60.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.412\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e160\u003c/p\u003e\u003cp\u003e(78.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e501\u003c/p\u003e\u003cp\u003e(82.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSurgery type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUterine surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79\u003c/p\u003e\u003cp\u003e(38.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10528\u003c/p\u003e\u003cp\u003e(59.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.425\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e79\u003c/p\u003e\u003cp\u003e(38.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e216\u003c/p\u003e\u003cp\u003e(35.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.068\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOvarian and adnexal surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74\u003c/p\u003e\u003cp\u003e(36.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4482\u003c/p\u003e\u003cp\u003e(25.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.240\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e74\u003c/p\u003e\u003cp\u003e(36.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e219\u003c/p\u003e\u003cp\u003e(36.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVulvar, vaginal and cervical surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49\u003c/p\u003e\u003cp\u003e(24.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1932\u003c/p\u003e\u003cp\u003e(11.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.351\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e49\u003c/p\u003e\u003cp\u003e(24.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e171\u003c/p\u003e\u003cp\u003e(28.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.079\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003cp\u003e(0.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e684\u003c/p\u003e\u003cp\u003e(3.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.233\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003cp\u003e(0.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e(0.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.099\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eValues presented as n (%) or median (IQR), SMD The standardized mean difference\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eDirect medical costs analysis\u003c/h2\u003e\u003cp\u003eThe total medical costs were significantly higher in the case group compared to the control group (\u0026euro;3779.94 vs. \u0026euro;2130.49, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The median difference in total medical costs was \u0026euro;1446.59. Specifically, all itemized medical costs for the case group were significantly higher than those for the control group (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These included costs related to therapeutics, consumables, diagnostics, medical services, medications, nursing care, and other costs, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of itemized medical costs between the case and control group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMedical cost items\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCase group (n\u0026thinsp;=\u0026thinsp;203)\u003c/p\u003e\u003cp\u003eMedian(IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;609)\u003c/p\u003e\u003cp\u003eMedian(IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDifference\u003c/p\u003e\u003cp\u003eMedian(IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eService costs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e128.08 (85.01\u0026ndash;215.43)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e53.85 (37.20\u0026ndash;90.62)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e65.54 (19.31\u0026ndash;129.70)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNursing service fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.25 (28.43\u0026ndash;69.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.88 (14.73\u0026ndash;32.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.24 (6.16\u0026ndash;40.17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedical service fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82.70 (53.11\u0026ndash;135.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33.51 (20.43\u0026ndash;57.96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e43.65 (12.31\u0026ndash;90.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiagnostic costs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e723.97 (454.50\u0026ndash;1157.00)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e328.79 (249.58\u0026ndash;501.03)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e321.78 (84.35\u0026ndash;750.87)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePathological diagnostic fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e128.06 (59.33\u0026ndash;313.52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50.81 (14.59\u0026ndash;123.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.88 (-16.89\u0026ndash;206.52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical diagnostic fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.76 (9.89\u0026ndash;49.37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.99 (5.19\u0026ndash;23.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.83 (-5.79\u0026ndash;27.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLaboratory diagnostic fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e370.31 (282.56\u0026ndash;553.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e203.95 (164.27\u0026ndash;250.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e171.73 (72.30\u0026ndash;339.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImaging diagnostic fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e123.11 (48.98\u0026ndash;305.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54.92 (31.48\u0026ndash;107.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e39.35 (-9.66\u0026ndash;183.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTherapeutic costs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e1144.67 (859.36\u0026ndash;1666.51)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e777.31 (518.02\u0026ndash;1062.98)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e412.81 (-20.30\u0026ndash;883.32)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-surgical clinical physical therapy fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.76 (26.31\u0026ndash;114.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.90 (9.66\u0026ndash;57.96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.80 (-8.33\u0026ndash;75.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRehabilitation fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.00 (0.00\u0026ndash;13.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.00 (0.00\u0026ndash;13.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.00 (-8.02\u0026ndash;8.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.372\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSurgical therapeutic fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e946.73 (705.95\u0026ndash;1329.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e684.52 (479.86\u0026ndash;947.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e285.15 (-50.95\u0026ndash;633.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeneral therapeutic procedure fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e101.75 (64.27\u0026ndash;185.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39.83 (26.07\u0026ndash;64.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51.24 (18.67\u0026ndash;115.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMaterial Costs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e938.98 (632.80\u0026ndash;1532.00)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e653.22 (294.12\u0026ndash;1169.86)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e327.17 (-153.67\u0026ndash;894.68)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDisposable material fees for examinations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.11 (2.42\u0026ndash;11.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.14 (1.65\u0026ndash;6.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.15 (-0.63\u0026ndash;8.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDisposable material fees for surgeries\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e751.64 (464.41\u0026ndash;1,315.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e525.60 (195.92\u0026ndash;990.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e249.41 (-180.93\u0026ndash;741.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDisposable material fees for treatments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e154.48 (118.01\u0026ndash;222.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e98.78 (50.90\u0026ndash;142.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e68.82 (0.70\u0026ndash;123.83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePharmaceutical costs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e386.87 (265.04\u0026ndash;849.67)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e182.02 (117.89\u0026ndash;251.33)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e204.30 (58.34\u0026ndash;614.18)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOther costs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e9.66 (4.83\u0026ndash;9.66)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e4.83 (4.83\u0026ndash;9.66)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.00 (-4.83\u0026ndash;4.83)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal costs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e3779.94\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(2488.12\u0026ndash;5381.87)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e2130.49\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(1320.69\u0026ndash;3538.60)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e1446.59\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(157.65\u0026ndash;3130.38)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eDirect medical costs analysis by surgery type\u003c/h2\u003e\u003cp\u003eWhen analyzing total direct medical costs by surgery type, costs for patients in the case group remained significantly higher than those in the control group across all evaluated procedures (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). For uterine surgeries, the median cost difference was \u0026euro;1582.08 (\u0026euro;2874.36 vs. \u0026euro;2058.22, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); for ovarian and adnexal surgeries, it was \u0026euro;1374.43 (\u0026euro;3195.38 vs. \u0026euro;2062.23, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); and for vulvar, vaginal, and cervical surgeries, it was \u0026euro;1921.54 (\u0026euro;5100.22 vs. \u0026euro;3353.68, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Detailed breakdowns of these costs by surgery type are provided in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of total direct medical costs between the case and control group for different surgical type\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSurgery type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCase Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eControl Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDifference\u003c/p\u003e\u003cp\u003eMedian(IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal Medical Cost\u003c/p\u003e\u003cp\u003eMedian(IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTotal Medical Cost\u003c/p\u003e\u003cp\u003eMedian(IQR)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUterine surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2874.36\u003c/p\u003e\u003cp\u003e(2393.41\u0026ndash;4094.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e217\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2058.22\u003c/p\u003e\u003cp\u003e(832.78\u0026ndash;2477.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1582.08\u003c/p\u003e\u003cp\u003e(447.38\u0026ndash;2494.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOvarian and adnexal surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3195.38\u003c/p\u003e\u003cp\u003e(2073.44\u0026ndash;5989.83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2062.23\u003c/p\u003e\u003cp\u003e(1671.14\u0026ndash;2792.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1374.43\u003c/p\u003e\u003cp\u003e(-7.09\u0026ndash;3522.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVulvar, vaginal and cervical surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5100.22\u003c/p\u003e\u003cp\u003e(3922.12\u0026ndash;5744.98)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e168\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3353.68\u003c/p\u003e\u003cp\u003e(813.13\u0026ndash;3913.34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1921.54\u003c/p\u003e\u003cp\u003e(632.18\u0026ndash;3362.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e203\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e3779.94\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(2488.12\u0026ndash;5,381.87)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e609\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e2130.49\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(1320.69\u0026ndash;3538.60)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e1446.59\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(157.65\u0026ndash;3130.38)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis of length of stay\u003c/h2\u003e\u003cp\u003eDetails are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Patients in the case group had a significantly longer LPOS (9 vs. 4 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and LOS (12 vs. 6 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to control patients. The LPPS was not statistically different between the two groups (3 vs. 2 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Details are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAmong the three surgery types included in the analysis, there were no statistically significant differences in LPPS (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, LPOS and LOS were significantly longer for the case group in all three surgery types (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Details are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis propensity score-matched case-control study shows that PBSI in gynecologic surgery incurs a significant economic and resource burden. Our results show that patients with a PBSI incurred significantly higher direct medical costs (\u0026euro;3779.94 vs \u0026euro;2130.49, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with a median difference of \u0026euro;1446.59, for a 67.9% increase compared to matched controls. Furthermore, PBSI was associated with a median increased overall 5 days LPOS and 6 days LOS. To our knowledge, this is the first study to quantify the disease burden of PBSI of gynecologic surgery, filling a knowledge gap of the burden of postoperative infections around the gynecologic surgery.\u003c/p\u003e\u003cp\u003eThe comprehensive cost increase observed across all expenditure categories reflects the multifaceted resource demands of managing PBSI, including treatment, consumables, diagnostics, medical services, pharmaceuticals, and nursing care. The treatment of PBSI typically necessitates extended courses of antimicrobials, sometimes including costly reserve antibiotics for resistant organisms [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Diagnostic expenses rise due to repeated blood cultures, additional laboratory tests to monitor organ function and inflammatory markers, and potential imaging examinations to identify metastatic foci of infection [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The need for more intensive monitoring and management of potential sepsis sequelae further drives up medical service and nursing costs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Consumable expenditures increase with extended intravenous access needs and additional wound care supplies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe increase in LOS is nearly entirely postoperative (9 vs. 4 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while there was no difference in LPOS (3 vs. 2 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This clearly demonstrates that PBSI directly correlates to a longer LOS, and not to differing preoperative management. Longer LOS incurs substantial direct costs and also has a range of sequelae that are not always captured, e.g., increased risk of hospital-acquired complications (such as pressure injuries and venous thromboembolism), longer time to functional recovery, inferior patient experience, and impacted hospital bed capacity and throughput [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].The median increase of LOS by 6 days represents a large loss of opportunity cost for these healthcare systems with limited capacity for beds.\u003c/p\u003e\u003cp\u003eResearch addressing the economic and resource impact of PBSI in gynecologic surgery is exceptionally limited, highlighting the novelty and importance of our findings. Nonetheless, there are some studies on burden of disease due to healthcare-associated infections (HAIs) and other postoperative infections reporting similar findings.\u003c/p\u003e\u003cp\u003eA systematic review assessing the economic cost associated with surgical site infections (SSIs) in low- and middle-income countries (LMICs) and high-income European countries found that the extra cost related to SSIs was similar across the studies, with additional costs listed in LMIC countries ranging from \u003cspan\u003e$\u003c/span\u003e174-\u003cspan\u003e$\u003c/span\u003e29,610, and European countries ranging from \u003cspan\u003e$\u003c/span\u003e21-\u003cspan\u003e$\u003c/span\u003e34,000 additional dollars. SSIs also extended length of stay (LOS) significantly- extending LOS by anywhere from 3 to 35 days in LMIC countries. The extreme economic burden and resource burden with SSIs was consistent between both settings, despite differences in healthcare system design and methods of cost accounting [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Our observed cost increase of 67.9% ( \u0026euro;1446.59) and extended LOS of 6 days is within the same range, adding support that the burden of PBSI in gynecologic surgery is similar to that of infection burden in the other surgical areas. Greco et al. demonstrated in a prospective multicenter cohort of adult cardiac operations, that developing a PBSI nearly doubled the total hospital cost (86% increase), resulting in an average cost of \u003cspan\u003e$\u003c/span\u003e38200 prior to PBSI and \u003cspan\u003e$\u003c/span\u003e70900 after PBSI [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This figure aligns closely with our own observation of increased cost following PBSI. Digiovine et al. found for primary nosocomial bloodstream infections (BSI) in the ICU, costs were 65% greater and length of stay was just over 7.5 days longer for patients with a BSI [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These observations also support the veracity of findings across settings and the large impact of BSI.\u003c/p\u003e\u003cp\u003eThe study by Steiner et al. estimated that the occurrence of SSI after hysterectomy would incur an additional direct medical cost of approximately \u003cspan\u003e$\u003c/span\u003e5,000 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although there is no direct research evidence indicating how much additional direct medical cost is incurred by PBSI in hysterectomy, it is expected that due to the systemic nature of bloodstream infections, which often require more intensive antimicrobial therapy, closer monitoring, and management of potential sepsis-related complications. This suggests that PBSI may represent an even greater economic burden than localized infections in gynecologic surgery patients.\u003c/p\u003e\u003cp\u003eAn evaluation of the data on surgery type identified distinct cost variations, with vulvar, vaginal, and cervical surgeries exhibiting the greatest differential (\u0026euro;1921.54). Two main factors were hypothesized to contribute to this point. First, the anatomical sites of the vulva, vagina and cervix contain high-density, diverse communities of microbes which may result in polymicrobial infections that are difficult to treat [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Second, surgeries to the aforementioned anatomical sites may include more complicated reconstruction or rearrangement of tissue (especially on oncologic cases) that can potentially create spaces or devascularize tissue. Thus tractable infection can be challenging [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe significant economic burden identified in this study of \u0026euro;1446.59 per PBSI case, makes the case for investment in prevention strategies compelling. This amount multiplies across the thousands of gynecologic surgeries performed annually, representing significant potential health care systems and payer savings. Furthermore, the additional 6 days of LOS associated with each PBSI case also represents considerable opportunity costs in bed availability and patient throughput, particularly in limited resource settings or during times of high hospital occupancy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFrom a cost-effectiveness perspective, our findings suggest that even relatively expensive PBSI prevention bundles would likely be justified. Evidence-based interventions such as appropriate antimicrobial prophylaxis, chlorhexidine bathing, meticulous attention to aseptic technique, and prompt removal of unnecessary invasive devices could yield substantial returns on investment [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Our prior studies, along with others, supported that for gynecological surgeries, particularly those involving the vaginal area, adequate preoperative vaginal preparation (such as vaginal scrubbing or douching with antiseptic solutions) could effectively reduce the risk of PBSI [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This intervention is evidently highly cost-effective when compared to the increased costs associated with treating PBSI.\u003c/p\u003e\u003cp\u003eOur results provide a foundation for larger evaluations of the economic burden of PBSI in gynecologic surgery. However, there are limitations to this study. First, as a retrospective analysis, we cannot eliminate the possibility of unmeasured confounding factors affecting our findings despite the use of PSM. Second, our single-center design may limit generalizability to other healthcare systems with different patient populations and clinical practice and financial arrangements. Third, we only considered direct medical costs related to the index hospitalization; we did not include indirect costs, such as loss of productivity and caregiver burden, or post-discharge costs, such readmission and outpatient care, that may further underestimate the total economic burden. Finally, we did not consider potential differences in the type of pathogen or pattern of resistance which may impact the costs of treatment and outcomes. Future multicenter, prospective studies will be needed to confirm external validity and to provide tighter control for confounding factors, and examine long-term and post-discharge costs, including quality-of-life decrements. Cost-effectiveness analyses of targeted prevention approaches, stratified by procedure-specific risk factors and pathogen-specific risk factors (i.e., species and resistance profiles) will better inform resource allocation decisions. Finally, including indirect costs, such as loss of productivity, caregiver burden and disability, into societal-perspective analyses would provide policymakers with a fuller foundation to consider financing and quality-improvement decisions.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis propensity score-matched study provides robust evidence that PBSI in gynecologic surgery substantially increases direct medical costs and prolongs LOS. These findings underscore the critical importance of infection prevention and control measures in gynecologic surgical practice. Beyond improving patient outcomes, effective PBSI prevention strategies offer significant potential for cost savings and optimization of healthcare resource utilization. As healthcare systems increasingly focus on value-based care delivery, targeting preventable complications with substantial economic impact, such as PBSI, represents a high-yield approach to simultaneously enhancing quality and controlling costs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eALB: Albumin\u003c/p\u003e\n\u003cp\u003eALT: Alanine Aminotransferase\u003c/p\u003e\n\u003cp\u003eASA: American Society of Anesthesiologists\u003c/p\u003e\n\u003cp\u003eAST: Aspartate Aminotransferase\u003c/p\u003e\n\u003cp\u003eBMI: Body Mass Index\u003c/p\u003e\n\u003cp\u003eBSI: Bloodstream Infection\u003c/p\u003e\n\u003cp\u003eCNY: Chinese Yuan\u003c/p\u003e\n\u003cp\u003eCREA: Creatinine\u003c/p\u003e\n\u003cp\u003eDRG/DIP: Diagnosis Related Groups/ Diagnosis-Intervention Packet\u003c/p\u003e\n\u003cp\u003eEMR: Electronic Medical Record\u003c/p\u003e\n\u003cp\u003eEUR: Euro\u003c/p\u003e\n\u003cp\u003eGFR: Glomerular Filtration Rate\u003c/p\u003e\n\u003cp\u003eHAIs: Healthcare-Associated Infections\u003c/p\u003e\n\u003cp\u003eHGB: Hemoglobin\u003c/p\u003e\n\u003cp\u003eICU: Intensive Care Unit\u003c/p\u003e\n\u003cp\u003eIQR: Interquartile Range\u003c/p\u003e\n\u003cp\u003eLMICs: Low- and Middle-Income Countries\u003c/p\u003e\n\u003cp\u003eLOS: Length of Stay\u003c/p\u003e\n\u003cp\u003eLPOS: Length of Post-Operative Stay\u003c/p\u003e\n\u003cp\u003eLPPS: Length of Pre-operative Preparation Stay\u003c/p\u003e\n\u003cp\u003ePBSI: Post-operative Bloodstream Infection\u003c/p\u003e\n\u003cp\u003ePLT: Platelet\u003c/p\u003e\n\u003cp\u003ePSM: Propensity-Score Matching\u003c/p\u003e\n\u003cp\u003eSD: Standard Deviation\u003c/p\u003e\n\u003cp\u003eSMD: Standardized Mean Difference\u003c/p\u003e\n\u003cp\u003eSSI: Surgical-Site Infection\u003c/p\u003e\n\u003cp\u003eTBIL: Total Bilirubin\u003c/p\u003e\n\u003cp\u003eWBC: White Blood Cell\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research protocol was reviewed and approved by the Conjoint Health Research Ethics Board of Sichuan Academy of Medical Sciences \u0026amp; Sichuan Provincial People's Hospital (2025-144, February 28th, 2025).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets of this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Natural Science Foundation of China (No. 22476032), 2023 Natural Science Foundation of Sichuan Province (No. 2023NSFSC0534) and the Multi-Campus Hospital Systems project (NIHA24YYDQ23) of the National Institute of Hospital Administration of China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy design:Na Xiao, Qian Xiang. Data collection: Pingping Wang, Hui Wang, Chen Wang, Daoqiong Wei, Xiaoyan Jiang, Minhong Cai, Jing Chen, Hongrong Cao, Li Ding, Tianfen Liao, Xiaojia Zheng. Data analysis: Yan Luo, Lan Chen, Wei Li, Yu Lyu. Manuscript writing: Yan Luo, Wei Li, Mao Ran, Lan Chen. Manuscript revision: Yu Lyu, Jiayu Wu, Qian Xiang. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to extend our sincere gratitude to all staff members of the Department of Gynecology at Sichuan Academy of Medical Sciences \u0026amp; Sichuan Provincial People's Hospital for their invaluable contributions to this study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZimmermann, J. S. M., Sima, R.-M., Radosa, M. P., Radosa, C. G., Ples, L., Wagenpfeil, S., et al. (2022). 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Surgical site infection and costs in low- and middle-income countries: A systematic review of the economic burden. \u003cem\u003ePloS one\u003c/em\u003e, 15(6), e0232960. https://doi.org/10.1371/journal.pone.0232960\u003c/li\u003e\n\u003cli\u003eGreco, G., Shi, W., Michler, R. E., Meltzer, D. O., Ailawadi, G., Hohmann, S. F., et al. (2015). Costs associated with health care-associated infections in cardiac surgery. \u003cem\u003eJournal of the American College of Cardiology\u003c/em\u003e, 65(1), 15\u0026ndash;23. https://doi.org/10.1016/j.jacc.2014.09.079\u003c/li\u003e\n\u003cli\u003eDigiovine, B., Chenoweth, C., Watts, C., \u0026amp; Higgins, M. (1999). The attributable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit. \u003cem\u003eAmerican journal of respiratory and critical care medicine\u003c/em\u003e, 160(3), 976\u0026ndash;981. https://doi.org/10.1164/ajrccm.160.3.9808145\u003c/li\u003e\n\u003cli\u003eSteiner, H. L., \u0026amp; Strand, E. A. (2017). Surgical-site infection in gynecologic surgery: pathophysiology and prevention. \u003cem\u003eAmerican journal of obstetrics and gynecology\u003c/em\u003e, 217(2), 121\u0026ndash;128. https://doi.org/10.1016/j.ajog.2017.02.014\u003c/li\u003e\n\u003cli\u003eSoper D. E. (2020). Bacterial vaginosis and surgical site infections. \u003cem\u003eAmerican journal of obstetrics and gynecology\u003c/em\u003e, 222(3), 219\u0026ndash;223. https://doi.org/10.1016/j.ajog.2019.09.002\u003c/li\u003e\n\u003cli\u003ePavlov, A., Bhatt, N., Damitz, L., \u0026amp; Ogunleye, A. A. (2021). A Review of Reconstruction for Vulvar Cancer Surgery. \u003cem\u003eObstetrical \u0026amp; gynecological survey\u003c/em\u003e, 76(2), 108\u0026ndash;113. https://doi.org/10.1097/OGX.0000000000000866\u003c/li\u003e\n\u003cli\u003eGraves, N., Halton, K., \u0026amp; Lairson, D. (2007). 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A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. \u003cem\u003eInfection control and hospital epidemiology\u003c/em\u003e, 35(8), 967\u0026ndash;977. https://doi.org/10.1086/677216\u003c/li\u003e\n\u003cli\u003eBuppasiri, P., Chongsomchai, C., Wongproamas, N., Ounchai, J., Suwannachat, B., \u0026amp; Lumbiganon, P. (2004). Effectiveness of vaginal douching on febrile and infectious morbidities after total abdominal hysterectomy: a multicenter randomized controlled trial. Journal of the Medical Association of Thailand = Chotmaihet thangphaet, 87(1), 16\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eSkeith, A. E., Morgan, D. M., \u0026amp; Schmidt, P. C. (2021). Vaginal preparation with povidone-iodine or chlorhexidine before hysterectomy: a propensity score matched analysis. American journal of obstetrics and gynecology, 225(5), 560.e1\u0026ndash;560.e9. https://doi.org/10.1016/j.ajog.2021.08.035\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Gynecologic Surgery, Postoperative Bloodstream Infection, Propensity score matching, Direct medical cost, Length of stay, Case-control study","lastPublishedDoi":"10.21203/rs.3.rs-6850353/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6850353/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe economic burden of post-operative bloodstream infection (PBSI) in gynecologic surgery is poorly understood. This study aimed to quantify the impact of PBSI on direct medical costs and length of stay (LOS) for patients undergoing gynecologic procedures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA retrospective case-control study was performed in a tertiary hospital in China, which included patients who received gynecologic surgery between January 2022 and December 2024. A 1:3 propensity-score matching (PSM) was applied to account for baseline characteristics of patients with PBSI (the case group) and patients without PBSI (the control group). The primary outcomes were direct medical costs and LOS.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFollowing PSM, a total of 203 cases and 609 controls were analyzed, with baseline covariates well-balanced. Total medical costs were significantly higher in the case group compared to controls (\u0026euro;3779.94 vs. \u0026euro;2130.49; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with a median difference of \u0026euro;1446.59. Patients with PBSI also incurred a longer overall LOS (12 vs. 6 days; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) entirely driven by a longer post-operative LOS (9 vs. 4 days; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings were consistent across surgery types.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003ePBSI following gynecologic surgery substantially increases direct medical costs and prolongs LOS. These findings highlight the significant economic and resource burden of this complication. Implementing and investing in effective PBSI prevention strategies is critical for improving patient outcomes, reducing healthcare expenditures, and optimizing resource utilization.\u003c/p\u003e","manuscriptTitle":"Direct Medical Costs and Length of Stay Associated with Postoperative Bloodstream Infections in Gynecologic Surgery: A Propensity Score-Matched Case-Control Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 11:11:36","doi":"10.21203/rs.3.rs-6850353/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"510c9cca-6a49-4c88-b764-8e76cd353282","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-12T02:08:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 11:11:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6850353","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6850353","identity":"rs-6850353","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}