The Decreasing Length of Hospital Stay following Vaginal Hysterectomy: 2011-2012 vs. 1996-1997 vs. 1995-1996.

! Postoperative management has changed over the last few years towards rapid mobilisation, early oral feeding and rapid rehabilitation. So- called Fast-Track [1 –4] or Enhanced-Recovery- concepts have now also found their way into gy- naecology. The emphasis here is, as well as the cost pressure on public health, above all on the desire of patients to have short hospital stays

! Background/Definition of the Problem: In recent years, postoperative management has changed towards rapid mobilisation, early oral feeding and rapid rehabilitation (known as Fast-Track or Enhanced Recovery Concepts). This study ana- lysed the postoperative length of stay after vagi- nal hysterectomy in 3 different periods of time.

In the period October 2011 – September 2012, 75 patients underwent vaginal hysterectomies (± adnexectomy); another 114 vaginal or laparoscopic hysterectomies with additional operations (e.g. prolapse surgery and incontinence surgery) and malignancies were not included. The time periods August 1995 – July 1996 (n = 50) and October 1996 – September 1997 (n = 96) served as a comparison. Reducing the length of stay was not an explicit goal.

The median postoperative stay was shortened from 7 (5–9) to 5 (3–15) or 3 (0–5) days (p < 0.001). The recovery rate remained un- changed at 2.7 % (n = 2), cf. 2 % (n = 1) and 3.1 % (n = 3). In 40/75 cases (53.3 %), the surgery took place on the day of admission.

The length of hospital stay after vagi- nal hysterectomy has more than halved since 1995/1996 and continues to decline. This devel- opment occurred without a shortened stay being an explicit goal of the clinic. The shortened length of stay does not appear to have a negative impact on postoperative complications and recovery rate. Zusammenfassung ! Hintergrund/Fragestellung: Postoperatives Ma- nagement hat sich in den letzten Jahren in Rich- tung rascher Mobilisierung, frühe orale Nah- rungsaufnahme und rascher Rehabilitation ge- wandelt (sog. Fast-Track- oder Enhanced-Recov- ery-Konzepte). Diese Studie analysiert die post- operative Aufenthaltsdauer nach vaginaler Hys- terektomie in 3 Zeiträumen.

und Methodik: Im Zeitraum 10/2011–9/ 2012 wurde bei 75 Patientinnen eine vaginale Hysterektomie (± Adnexektomie) durchgeführt; weitere 114 vaginale oder laparoskopische Hys- terektomien mit Zusatzoperationen (z. B. Deszen- sus-, Inkontinenz-OP) oder Malignomen wurden nicht eingeschlossen. Als Vergleich dienten die Zeiträume 8/1995 –7/1996 (n = 50) und 10/1996 – 9/1997 (n = 96). Reduktion der Aufenthaltsdauer war kein explizites Ziel. Ergebnisse: Der mediane postoperative Aufent- halt verkürzte sich von 7 (5 –9) auf 5 (3 –15) bzw. 3( 0–5) Tage (p < 0,001). Die Wiederaufnahmerate blieb unverändert bei 2,7 % (n = 2), vgl. 2 % (n = 1) bzw. 3,1 % (n = 3). In 40/75 Fällen (53,3 %) erfolgte die OP am Aufnahmetag. Schlussfolgerung: Die Aufenthaltsdauer nach va- ginaler Hysterektomie hat sich seit 1995/1996 mehr als halbiert und ist weiterhin rückläufig. Diese Entwicklung passierte, ohne dass ein ver- kürzter Aufenthalt ein explizites Ziel der Klinik gewesen wäre. Die verkürzte Aufenthaltsdauer zeigt keine negativen Auswirkungen auf die post- operative Komplikations- bzw. Wiederaufnahme- rate. The Decreasing Length of Hospital Stay following Vaginal Hysterectomy: 2011–2012 vs. 1996 –1997 vs. 1995 –1996 Rückgang der Aufenthaltsdauer nach vaginaler Hysterektomie: 2011–2012 vs. 1996 –1997 vs. 1995 –1996 Authors P. Reif, T. Drobnitsch, T. Aigmüller, R. Laky, D. Ulrich, J. Haas, A. Bader, K. Tamussino Affiliation Obstetrics & Gynecology, Medical University of Graz, Graz, Austria Key words l" vaginal l" hysterectomy l" length of hospital stay l" surgery l" recovery rate Schlüsselwörter l" vaginal l" Hysterektomie l" Aufenthaltsdauer l" Operation l" Wiederaufnahmerate received 9. 4. 2014 revised 16. 4. 2014 accepted 16. 4. 2014

DOI http://dx.doi.org/ 10.1055/s-0034-1368487 Geburtsh Frauenheilk 2014; 74: 449–453 © Georg Thieme Verlag KG Stuttgart · New York · ISSN 0016‑5751 Correspondence Dr. Philipp Reif, M. D. Medical University of Graz Obstetrics & Gynecology Auenbruggerplatz 14 8036 Graz Austria [email protected] 449 Reif P et al. The Decreasing Length … Geburtsh Frauenheilk 2014; 74: 449 –453 Original Article Deutschsprachige Zusatzinformationen online abrufbar unter: www.thieme-connect.de/ ejournals/toc/gebfra and the fastest possible return to their familiar social environ- ment. This is in line with the international trend of shortening the length of hospital stay [5]; this leads to vaginal hysterectomies being carried out in outpatient clinics [6 –7], which 15 years ago still involved an average of one week of hospitalisation [8]. Begin- ning in the 1990s, various changes were made in operating as well as in pre-and postoperative management [9]. These changes continue today with the use of bipolar vessel sealing techniques [10] and combined anaesthesia method [11]. We analysed postoperative length of stay and readmission rates at the University Women ʼs Hospital in Graz following vaginal hysterectomy in 2011–2012 and compared these with previously published results from the years 1995 –1996 and 1996 –1997 [9].

! In the period 1/1/2011 –1/9/2012, vaginal hysterectomies (± ad- nexectomy) were performed in 75 patients with benign indica- tions. A further 114 patients who underwent vaginal or laparo- scopic hysterectomies with additional operations (e.g. due to prolapse or incontinence) or malignancies were not included. The periods 1/8/1995 –1/8/1996 (n = 50) and 1/10/1996 –1/10/ 1997 (n = 96) [9] served as a comparison. The Ethics Committee of the Medical University of Graz (IRB00002556) has issued ap- proval for the study. Perioperative management 1995–1997 The first two periods differ in terms of management in the sense that the patients in the first period (1995 –1996) were given par- enteral infusions (2000 ml of electrolyte and glucose solution) on the first 2 postoperative days, were discharged on the second postoperative day and received no antibiotic prophylaxis. In the second period (1996 –1997), increasing emphasis has been placed on early mobilisation, early oral feeding, active pain man- agement and a general antibiotic prophylaxis (2 g cefotiam or ce- fazolin administered once). Infusions were discontinued after oral feeding was tolerated. In both periods, the operations were carried out based on the technique described by Reiffenstuhl [12], in which the vaginal tamponing ribbons were removed on the second postoperative day in the first period and on the first or second postoperative day in the second period. The use of in- dwelling catheters and the administration of thrombosis prophy- laxis using low molecular weight heparin were not routine in ei- ther time period; furthermore, patients were routinely admitted one day prior to surgery. Perioperative management 2011–2012 In the third period, perioperative management included ele- ments of fast-track concepts. Operations were increasingly scheduled for the day of admission. Mobilisation with the aid of physiotherapists began and some intake of food was recom- mended on the day of surgery. The anaesthetic method of choice was general anaesthesia, supplemented by PONV prophylaxis, and in some cases a spinal anaesthetic was also used. The default schema for PONV prophylaxis consisted of preoperative oral dexamethasone administration and the intraoperative IV admin- istration of droperidol. Increasingly, pre-emptive analgesia (infil- tration of the parametrium with Naropin at the beginning of the operation) was used. A significant change in the operating proce- dure lies in bipolar vessel sealing (LigaSure ®, Covidien, Boulder, CO, USA), which was used in the vast majority of cases to cut the parametrium following clamping and ligature suture of the ute- rosacral ligament. Peritoneal closure was no longer routinely car- ried out and vaginal tamponing ribbons were no longer routinely used. In the case of general anaesthesia, the indwelling catheter was removed immediately after the operation; in the case of the use of spinal anaesthesia, this was done once the effects of the anaesthesia had worn off. While there was postoperative bacter- iological MSU testing of all patients in the first two periods, urine tests were only performed in case of complaints in the current period. The decision to discharge was made jointly with the pa- tient; an early discharge was not an explicit goal of the clinic. Statistical analysis and data evaluation The data evaluation was performed using SPSS 20.0 (SPSS Inc., Chicago, IL). Group comparisons were performed using the Wil- coxon-Mann-Whitney test or the Kruskal-Wallis test as the re- vised time periods did not follow a normal distribution. Categori- cal variables were performed using Pearson ʼs χ 2 test (using the exact option in SPSS) or Fisher ʼs exact test for expected values < 5. A significance level of 0.05 was set for all tests. Data are ex- pressed as mean ± standard deviation (SD) or median ± (mini- mum – maximum).

! Indications for a hysterectomy The age of the patients varied insignificantly with median values of 47 (34 –74), 46 (32 –84) and 48 (34 –88) (p = 0.95). Regarding the indication for hysterectomy, the majority of interventions for uterine fibroids and bleeding disorders were conducted in the years 1995 –1997. Even in the current period, 65 % (n = 49) of patients had a uterine leiomyoma and 37 % (n = 28) experienced bleeding disorders. In 8 % (n = 6) the hysterectomy was the result of atypical endometrial hyperplasia and in 5 % (n = 4) it was the

of recurrent CIN III. This is relatively stable with respect to the identified indications for vaginal hysterectomy in the study population, in contrast to e.g. adenomyosis uteri [13], in the case of which increasingly alternative therapeutic approaches are used. In the current study period, 40 patients (53.3 %) were ad- mitted on the day of surgery. Duration of postoperative stay The median postoperative stay was shortened from 7 (5 –9) to 5 (3–15) or 3 (0 –5) days (p < 0.001, Kruskal-Wallis test; l" Fig. 1). While not a single patient in 1995 –1996, and only one patient 1995 –1996 1996 –1997 2011 –2012 012345678 Fig. 1 Median duration of postoperative stay (d) following vaginal hyster- ectomy in the study periods 1995 –1996, 1996–1997 and 2011 –2012. 450 Reif P et al. The Decreasing Length … Geburtsh Frauenheilk 2014; 74: 449 –453 GebFra Science (2.0 %) in 1996 –1997 was released before the fourth postopera- tive day, 79 % (n = 59) of patients in 2011 –2012 could be sent home by the third postoperative day and 91 % (n = 68) by the fourth postoperative day. Furthermore, two vaginal hysterecto- mies were performed on an outpatient basis [6]. l " Fig. 2 shows the percent distribution of postoperative days. Complication-related readmission The recovery rates (up to the 30th postoperative day) remained virtually unchanged at 2.0 % (n = 1), 3.1 % (n = 3) and 2.7 % (n = 2). In the first period, one patient was readmitted on the 26th post- operative day due to infiltration of the vaginal cuff. In the second period, two patients were readmitted due to postoperative bleeding (on the 11th and 15th postoperative days) and one pa- tient was readmitted due to infiltration of the vaginal cuff (20th postoperative day). In the current period, one patient was read- mitted on the 30th postoperative day for IV antibiosis due to sus- pected pelveoperitonitis. Subsequently, a laparotomy was carried out in this patient due to persistent chronic pelvic pain, in which adhesiolysis and a fistula exclusion were performed. In another patient, a laparoscopy was carried out on the 12th postoperative day due to endometrial growth; the patient also underwent bilat- eral sactosalpinx removal. In the years 1995 –1996, the administration of packed red blood cells was required in one patient (2.0 %). In the 1996–1997 period, the transfusion rate was 1 % (n = 1). In the period 2011–2012, two patients (2.7 %) received pre-interventional packed red blood cells on the basis of data collected within the framework of the laboratory parameters determined during preoperative presen- tation in the gynaecological outpatient clinic, in the sense of the best possible surgical preparation. In a further two (2.7 %), packed red blood cells were administered perioperatively. The rate of postoperative urinary tract infections (UTI) which were detected and treated was 44 % in the period 1995 –1996 (n = 22) and decreased significantly to 27 % in 1996 –1997 (n = 26), p = 0.043. In the current period there was a significant further reduction in the UTI rate to 1.3 % (n = 1, p < 0.001). l " Table 1 shows a summary of the parameters studied.

! The length of hospital stay following vaginal hysterectomy has more than halved since 1995 –1996. This corresponds to the in- ternational trend towards the shortening of postoperative stays, which has begun to affect not only gynaecology, but all other sur- gical disciplines as well. No change has been made by the clinic in terms of patient management with the explicit goal of reducing the length of hospital stays. The health economic impact of re- duced hospital stays is currently reflected in many areas of every- Table 1 Patient data, length of hospital stay and complication rate in patients following vaginal hysterectomy in the study periods 1995 –1996, 1996–1997 and 2011–2012. 1995–1996 1996 –1997 2011 –2012 Number of patients (n) 50 96 75 Age (min – max) 47 (37 –74) 46 (32 –84) 48 (34 –88) Duration of postoperative stay (min – max) 7 (5 –9) 5 (3 –15) 3 (0 –5) Readmission rate up to 30 d postoperatively 1 2.0 % 3 3.1 % 2 2.7 % UTI 22 44.0 % 26 27.1 % 1 1.3 % Intraoperative/postoperative administration of packed red blood cells 1 2.0 % 1 1.0 % 2 2.7 % TVT/PAE 0 0.0 % 0 0.0 % 0 0.0 % Operative review 1 2.0 % 2 2.1 % 2 2.7 % 1995/1996 1996/1997 2011/2012 Percent 50 40 30 20 10 0 0123456 Days 789 1 0 > 1 0 Fig. 2 Percentage distribution of days of postoperative stay (d) in patients following vaginal hysterectomy in the study periods 1995 –1996, 1996–1997 and 2011–2012. 451 Reif P et al. The Decreasing Length … Geburtsh Frauenheilk 2014; 74: 449 –453 Original Article day hospital life. These include the reduction in bed numbers in gynaecological departments which are contained in many struc- ture plans and cost savings, particularly in the nursing field. This trend was driven by the introduction of the DRG in Germany and the LKF system in Austria [14] and was accompanied by massive budget cuts. There exists no cost analysis for gynaecological pro- cedures which, in addition to in-patient savings, also takes into account the costs of effective outpatient follow-up – this would however be desirable for the economic analysis of the subject. Even in the 1990s the model of the outpatient vaginal hysterec- tomy [15–17] was highly propagated, especially in the USA where it now often represents the standard protocol [6]. Approaches to the implementation of short in-patient concepts with durations of up to 24 hours are also becoming increasingly important in Eu- rope [7, 18]. In addition to coordinated perioperative manage- ment, other framework parameters must also be ensured. This represents less a purely medical, and more of an organisational challenge for both the hospital and the patient. It is the broad consensus that ensuring postoperative home care is a corner- stone for the expansion of the operating offering in the outpa- tient setting. With regard to the rate of urinary tract infections in the two pe- riods under review, a significant decrease was observed in terms of frequency, whereby the rate of 1.3 % in the period 2011 –2012 corresponds to international comparison data, which indicates an incidence of 0 –13 % [19]. This probably has several causes. Firstly, postoperative management is moving away from routine postoperative laboratory and urinary testing towards symptom- oriented clarification [20]. This led to discontinuing the antibiotic treatment of asymptomatic urinary tract infections and false- positive (contaminated) findings. For comparison, a meta-analy- sis reveals that this type of perioperative urinary testing shows abnormalities in 1 –34.1 % of cases, but a change in postoperative management in the sense of a specific treatment only occurs in 0.1–2.8 % of cases. Furthermore, a reduction in symptomatic uri- nary tract infections can also be achieved through the sparing use of indwelling catheters, the immediate return of spontaneous urination and the use of aseptic techniques when handling cath- eters [21]. In postoperative care, significant changes were encountered mainly in terms of food intake. In the prior periods fasting was the dominating dogma which was abandoned in favor of early food intake in 2011 –2012. This procedure, which demonstrates good results in colorectal surgery [4], among others, leads to the prevention of catabolic metabolic situations, thus reducing mor- bidity [22], and contributes to a reduction in the length of hospi- tal stay [23]. In addition to economic and social causes, medical innovations and changes in perioperative and postoperative management have led to a reduction in the duration of hospital stays. With re- gard to operational management, the use of bipolar vessel sealing techniques [10] and pre-emptive analgesia play a role in this, es- pecially in regard to the immediate postoperative pain load [24]. Discontinuing the use of vaginal tamponing ribbons leads to a re- duction of the pressure feeling in the lower abdomen and is thus likely to contribute to rapid mobilisation and better spontaneous micturition. Although the present study results come from a ret- rospective study with a limited number of cases, it can be clearly seen that the gradual shortening of the duration of hospital stays for vaginal hysterectomies has no overall negative impact on postoperative complication or readmission rates. A prerequisite for a short stay is sufficient preoperative preparation, carried out in advance on an outpatient basis where appropriate, as well as processing which corresponds to today ʼs fast-track concepts during the hospitalisation phase. This means organisational groundwork in the intramural and extramural fields. In terms of patient-centred surgical planning and the prevention of compli- cations-related readmissions, the outpatient vaginal hysterec- tomy should primarily be made available to a targeted and se- lected group of patients. Ethical Approval ! The Ethics Committee of the Medical University of Graz (IRB00002556) has issued approval for the study. Conflict of Interest ! There exists no conflict of interest for any of the authors. The au- thors received no financial contribution within the framework of the study. Within the framework of training events, financial as- sistance was provided to the Department of Gynaecology at the Medical University of Graz from the company Covidien.

1 Møller C, Kehlet H, Friland SG et al. Fast track hysterectomy. Eur J Obstet Gynecol Reprod Biol 2001; 98: 18 –22 2 Ottesen M, Sørensen M, Rasmussen Y et al. Fast track vaginal surgery. Acta Obstet Gynecol Scand 2002; 81: 138 –146 3 Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003; 362: 1921 –1928 4 Kehlet H. Fast-track colorectal surgery. Lancet 2008; 371: 791 –793 5 Lykke R, Blaakær J, Ottesen B et al. Hysterectomy in Denmark 1977- 2011: changes in rate, indications, and hospitalization. Eur J Obstet Gy- necol Reprod Biol 2013; 171: 333 –338 6 Zakaria MA, Levy BS. Outpatient vaginal hysterectomy: optimizing perioperative management for same-day discharge. Obstet Gynecol 2012; 120: 1355 –1361 7 Ulrich D, Bader A, Bjelic-Radisic V et al. Fast-Track-Hysterektomie: Ein Pilotprojekt. Geburtsh Frauenheilk 2010; 70: 716 –718 8 Tobre H. A renaissance for vaginal hysterectomy. Acta Obstet Gynecol Scand 1997; 164 (Suppl.): 85 –87 9 Tamussino K, Giuliani A, Gücer F et al. Verkürzung des stationären Au- fenthaltes nach vaginaler Hysterektomie. Geburtsh Frauenheilk 1998; 58: 605–608 10 Ghirardini G, Mohamed M, Bartolamasi A et al. Minimally invasive vagi- nal hysterectomy using bipolar vessel sealing: preliminary experience with 500 cases. J Obstet Gynaecol 2013; 33: 79 –81 11 Kroon U‑B, Rådström M, Hjelthe C et al. Fast-track hysterectomy: a ran- domised, controlled study. Eur J Obstet Gynecol Reprod Biol 2010; 151: 203–207 12 Reiffenstuhl G, Platzer W, Knapstein P ‑G. Die vaginalen Operationen. Chirurgische Anatomie und Operationslehre. 2. Aufl. Wien: Urban & Schwarzenberg; 1994 13 Taran FA, Stewart EA, Brucker S. Adenomyosis: epidemiology, risk fac- tors, clinical phenotype and surgical and interventional alternatives to hysterectomy. Geburtsh Frauenheilk 2013; 73: 924 –931 14 Bartolomeyczik S. Short hospital stay – the role of nurse. Pflege & Ge- sellschaft 2007; 12: H.2 15 Stovall TG, Summitt jr. RL, Bran DF et al. Outpatient vaginal hysterec- tomy: a pilot study. Obstet Gynecol 1992; 80: 145 –149 16 Summitt jr. RL, Stovall TG, Lipscomb GH et al. Outpatient hysterectomy: determinants of discharge and rehospitalization in 133 patients. Am J Obstet Gynecol 1994; 171: 1480 –1484; discussion 1484 –1487 17 Reiner IJ. Early discharge after vaginal hysterectomy. Obstet Gynecol 1988; 71 (3 Pt 1): 416 –418 18 Penketh R, Griffiths A, Chawathe S. A prospective observational study of the safety and acceptability of vaginal hysterectomy performed in a 24- hour day case surgery setting. BJOG 2007; 114: 430 –436 452 Reif P et al. The Decreasing Length … Geburtsh Frauenheilk 2014; 74: 449 –453 GebFra Science 19 Nieboer TE, Johnson N, Lethaby A et al. Surgical approach to hysterec- tomy for benign gynaecological disease. Cochrane Database Syst Rev 2009; 3: CD003677 20 Clarke-Pearson DL, Geller EJ. Complications of hysterectomy. Obstet Gy- necol 2013; 121: 654 –673 21 Centers for Disease Control and Prevention. Healthcare associated Infec- tions (HAI). Atlanta, GA: Centers for Disease Control and Prevention; 2012 22 Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24 h of colorectal surgery versus later commencement of feeding for post- operative complications. Cochrane Database Syst Rev 2006; 4: CD004080 23 Charoenkwan K, Phillipson G, Vutyavanich T. Early versus delayed (tra- ditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev 2007; 4: CD004508 24 Lakeman MM, The S, Schellart RP et al. Electrosurgical bipolar vessel sealing versus conventional clamping and suturing for vaginal hyster- ectomy: a randomised controlled trial. BJOG 2012; 119: 1473 –1482 453 Reif P et al. The Decreasing Length … Geburtsh Frauenheilk 2014; 74: 449 –453 Original Article