Same day discharge (SDD) after surgery for gynecologic cancer patients in Germany ?

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Anja Petzel, Hendrik Jütte, Holger Voss, Nils Eckert, Norbert Richter, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8768631/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Apr, 2026 Read the published version in Journal of Cancer Research and Clinical Oncology → Version 1 posted 17 You are reading this latest preprint version Abstract Aim Ambulatory surgery is well established outside Europe for women diagnosed with gynecologic cancer. Overstrained hospital staff, multi-resistant nosocomial hospital germs and pending pandemics are arguments for same day discharge (SDD). What is the reason that this option is not offered to patients in Germany? Does lack of surgical skills of gynecologic oncologists explain this phenomenon? Patients and Methods Between April 2024 and December 2025 83 consecutive cancer patients underwent outpatient surgery at Eviamed Oncology Center. The majority of patients were diagnosed with cervical cancer (n=41), followed by cancer of vulva (n=27), corpus uteri (n=8), vagina (n=5) or ovary (n=1). Major surgery was performed laparoscopically in 35 patients by lymphadenectomy (LNE) alone or vaginal-assisted simple (LAVH) or radical hysterectomy (VALRH) and in 15 patients by inguinal LNE combined with vulvectomy. Pre- and postoperative findings were presented and discussed in an interdisciplinary tumor board. Postoperatively all patients were contacted by phone for their well-being and received a check-up examination by the responsible surgeon. We made sure that the patients had family support up to postoperative day 5. Results In the laparoscopy group mean age of was 49 (24 - 87)years, mean BMI 27.3 (18.8-43.8), interval between incision and suture 147 (70-288) min, duration of narcosis 183 (90-338) minand of postoperative observation 151 (83-260) min. Vulva patients were on average 18 years older with similar BMI and up to 40% shorter time intervals. There were no intraoperative complications, no conversion to laparotomy and no hospital admission within 30 days post surgery. One ureter leakage, 3 symptomatic lymphoceles and one urinary tract infection had to be treated in the laparoscopy group and 1 symptomatic lymphocele in the vulva group. A cost-utility analysis using the actual German reimbursement system showed a considerable deficit for the surgical part of LAVH & LNE. Conclusion The reason that SDD is not offered to patients in Germany is not incompetence of the gynecologic oncologists but inadequate reimbursement by the health insurance providers. Figures Figure 1 Introduction Minimal-invasive surgery is by definition a surgical technique which is destined for same day discharge (SDD) of the patient. Over the last decade several studies have been performed to evaluate the safety and acceptance of SDD in gynecology. For benign diseases comparison of outpatient hysterectomy (OH) versus inpatient hysterectomy (IH) revealed in a meta-analysis of eight studies of 104,466 patients fewer complications, a lower readmission rate, lower blood loss, a shorter surgery time and a cost benefit for OH. However IH patients had a better health-related quality of life up to postoperative day 7 (Ellinides et al., 2021). Risk factors making OH difficult were older age, beginning surgery later than 1 p.m. and completing surgery later than 6 p.m., longer duration of operation, and high estimated blood loss in a metaanalysis of 15 studies with 11.992 patients and a mean SDD rate of 72.7%, (range 20.9–100%)(Korsholm et al. 2017). A recent meta-analysis evaluated 29 reports with 218.192 patients treated by minimally invasive hysterectomy for non-malignant (90.6%) or malignant (9.4%) gynecologic disease (Liu et al., 2024 ). Planned SDD could be achieved in 47% of patients. Old age, high body mass index (BMI), comorbidities such as diabetes and chronic obstructive pulmonary disease (COPD), radical hysterectomy, surgery starting after 2 p.m., longer surgical time, intraoperative and postoperative complications and surgeons preference were factors preventing SDD. Old age, long distance to home and increase in surgical time did not prevent SDD. However, start time and body mass index were especially important in patients with malignant disease. With respect to minimal invasive surgery in patients diagnosed with gynecologic malignancies endometrial cancer is the main indication: in a metaanalysis of 9 studies with a total of 16.423 patients with successful SDD in 60,4% (varying between 12.4 and 83.7%) 15860 patients were diagnosed with endometrial cancer versus 563 patients with other neoplasms (Sanabria et al., 2019). Presence of comorbidities which require follow-up in the hospital post surgery, age > 70 years, start of surgery later than1 p.m., duration of surgery more than 2 hours, vascular or urinary intraoperative complications and/or conversion to laparotomy, inadequate postoperative course with respect to oral intake or spontaneous voiding or refusal of SDD by the patient were factors identified as negatively associated with SDD. Thus, following proper selection criteria even women with malignant disease SDD can safely be offered, allowing uncomplicated recovery in the family environment. Evidently SDD is successfully performed in Canada and the US since more than 15 years for patients diagnosed with gynecologic cancers. We asked ourselves why SDD is not offered to German women with identical diagnoses. We investigated if lack of training, ignorance of specific surgical techniques and/or deficit in talent could explain this phenomenon over an initial period of 21 months. Patients and Methods Between April 2024 and December 2025 83 patients with cervical cancer (n = 41), followed by cancer of vulva (n = 28), corpus uteri (n = 8), vagina (n = 5) or ovary (n = 1) underwent ambulatory surgery with SDD in our institution. All patients had been examined and diagnosed in one of our eight colposcopy clinics. Patients were informed about the diagnosis by the responsible colposcopist. Bringing bad news in a patient-oriented fashion using the six-step protocol for delivering bad news (SPIKES) is considered mandatory. Since continuing treatment in the same institution is preferred by the patient we established high-tech laparoscopic theaters to provide also major surgery with SDD only. All clinical findings were discussed in an interdisciplinary conference and treatment recommendations were presented to the patients. All patients had the choice between outpatient or inpatient treatment. All treatments were performed in accordance with the relevant guidelines and regulations . Patients with cervical cancer were informed about the current preference for hysterectomy by laparotomy and the results of our retrospective study showing the advantages of a laparoscopic approach when oncologic hygiene is respected which is also referenced in the German S3 guideline ( https://register.awmf.org/assets/guidelines/032-033OLl_S3_Diagnostik_Therapie_Nachsorge_Zervixkarzinom_2022-03.pdf ). It was mandatory to perform hysterectomy without manipulator or laparoscopic colpotomy. Sentinel-lymph nodes were labelled with indocyanine green (ICG) and in vulvar cancer additionally with Technetium. In patients with advanced cervical cancer laparoscopic staging included systematic pelvic and paraaortic lymphadenectomy prior to chemo radiation. Our surgical techniques are described in detail ( Köhler et al. 2004 ; Kö hler et al. 2004; Altgassen et al. 2008 ) and have been appraised for SDD by the Ethical Commission of the Medical Association of Berlin Eth-SB-25-089. Only patients with a vaginal phase in the procedure received perioperatively antibiotic prophylaxis with cephalosporin and metronidazole. All patients used heparin prophylaxis for 7–14 days depending on their risk for postoperative thrombosis. We made sure that patients had help at home during postoperative convalescence for at least five days. All patients were regularly contacted postoperatively by their surgeon ensuring their well-being und were seen in the outpatient-clinic at least once within 10 postoperative days. All patients gave written consent that their clinical data could be analysed anonymously. Our surgical results are registered and evaluated routinely in the yearly audit for the DIN certificate and in the current application at the German Cancer Society for certification as Gynecologic Cancer Center . Prices for consumables, instruments, OR infrastructure and equipment, personnel and rent were calculated. These costs were compared in a cost-utility analysis to the reimbursement for the surgical part of LAVH & bilateral salpingectomy (BSO) & LNE. The datasets analysed for this manuscript are available from the corresponding author on reasonable request. All authors report no conflict of interests within the last 5 years which includes 3 years prior to the beginning of our first surgery with SDD. The clinical dataset used in this report is routinely registered and analysed for quality control of our surgical performance. Thus, no sponsoring or financial support was used for this analysis. Results 15 patients with cervical cancer Ia1, 13 patients with vulvar cancer Ia and 5 patients with vaginal cancer underwent minor surgery such as loop-excision, laser excision or biopsies, respectively. These patients will not be further analysed and we focus on all patients who underwent laparoscopic surgery and all patients with major surgery for vulvar cancer. cone=conization; SLN=sentinel lymphadenectomy; LAVH=laparoscopic assisted vaginal hysterectomy; LNE=lymphadenectomy; VALRH=vaginally assisted laparoscopic radical hysterectomy 26 patients with cervical cancer, 6 patients with endometrial cancer, 2 patients with carcinosarcoma of the uterus and one patient with borderline tumor of the ovary underwent laparoscopy alone or in combination with a vaginal approach (see Fig. 1 ). Fifteen patients with vulvar cancer underwent partial or complete vulvectomy combined with sentinel LNE. In the laparoscopy group mean age was 18 years lower when compared to the vulva group (see Table 1). The oldest patient in the laparoscopy group was 87 years old and diagnosed with cervical cancer stage Ia2 and underwent LAVH & BSO (bilateral salping-oophorectomy) & pelvic sentinel-lymphadencetomy (SLNectomy). In the vulva group the oldest patients was 90 years old and was treated by partial vulvectomy & inguinal LNE. Mean BMI was similar in both groups with the highest value of 43.8 in the laparoscopy group. Duration of the surgical part of the operation was with 2.45 hours versus 1.3 hours almost twice as long for the laparoscopy group. Narcosis pre-incision and post-suture lasted on average 36 minutes in the laparoscopy versus 38 minutes in the vulva group. Post surgery observation took on average 2.5 hours in the laparoscopy group versus 1.7 hours in the vulva group. There were no intraoperative complications, no conversion to laparotomy and no hospital admission within 30 days post surgery in both groups. Postoperative complications were as follows: Leakage of the right ureter close to the bladder was noticed in a 54-years old patient with non-HPV associated p53 mutated adenocarcinoma of the cervix stage IIb where radical hysterectomy had to be performed prior to chemo radiation. The leakage started 14 days post surgery and a stent was placed as an outpatient procedure. A paraaortic lymphocele in a 52 year old patient with adenocarcinoma of the cervix stage IIb had to be opened 75 days postoperatively when induction chemotherapy had been completed and chemo radiation was to be started. Fourteen days post SDD antibiotic treatment for urinary tract infection was necessary in a 86 year old patient with cervical cancer stage Ia2 post LAVH & BSO & LNE. The patient had not been catheterized during surgery. A 73 year old patient with vulvar cancer stage Ib developed a lymphocele in the right groin on postoperative day 12 which was successfully treated ambulatory by repeated aspiration and compression till postoperative day 35. All patients were seen in our outpatient clinic post SDD within 10 days. They reported fast mobilisation since postoperative day 1 under pain medication with metamizol for up to 5 days and, if indicated, opioid analgesia for up to 2 days. Discussion Table 2 Overview of publications containing data on minimal invasive surgery with option for SDD for patients diagnosed with gynecological cancer CX & EN & other CA Number of patinets Period Cancer Operation Readmission ≤ 30 days Reoperation ≤ 30 days Riskfactors for admission Gien 2010 Canada 147 of 303 (49%). 6.9% conversion to laparotomy 3.5 yrs All patients: CX (n = 78; 26%) EN (n = 150; 50%) OV (n = 40; 14% ) total laparoscopic simple or radical hysterectomies or radical trachelectomy +/− salpingo-oophorectomy +/− pelvic and para-aortic lymphonodectomy +/− omentectomy 4.8% Not mentioned Age, surgeon, conversion to laparotomy, radical hysterectomy, length of surgery, start time >1PM Lee 2014 USA 157 of 200 (79%) 2.4 yrs SDD patients: CX (n = 7; 4.5%), EN (n = 63; 40%), OV (n = 3; 2%), non-gynecologic cancer or benign (n = 84; 54%) Simple: TLH+/-BSO. Complex: TLH+/-BSO with sentinel node mapping, pelvic and/or aortic nodal dissection, appendectomy, or omentectomy 4/157 (2.5%) vs 3/43 (7.0%) Not mentioned Esteemed blood loss, room time, operative time, time case ended and intraoperative ketorolac use Rivard 2014 USA 90 of 140 (64%) 1 yr SDD patients: EN (n = 57; 49%) other CA* (n = 16; 14%) Outpatients: Hysterectomy ± BSO (n = 57; 49%) Staging (n = 55; 48%) Hysterectomy or Debulking (n = 3; 3%) 2.2% Not mentioned Older age, late surgery Penner 2015 USA 118 of 144 4 yrs SDD CX (n = 22; 19%) EN (n = 96; 81%) Laparoscopic (n = 20; 17%) Robotic (n = 98; 83%) 11% vs 17% Not mentioned Severe pain postop., delayed oral intake, laparoscopic vs robotic-assisted, late surgery Philip 2017 Canada 75 of 119 10 yrs CX (n = 119; 100%) LRH 5%) 3% Older age, late surgery, intraoperative complication Fountain 2017 Canada 43 SDD vs 26 non-SDD 5 months Not specified Minimally invasive hysterectomy ± pelvic LNE Higher patient complexity, later case end time, longer operative time, and robot-assisted cases. Patient education videos alone did not increase SDD. Kim 2021 Canada Preintervention n = 100 Active Intervention n = 102 SDD increase 29 to 75% 1 yr CX (n = 3 vs 3) EN (n = 85 vs 71) OV (n = 1 vs 10) OV benign/borderline (n = 11 vs 15) Laparoscopic (n = 63 vs 81) Robotic (n = 37 vs 21) 2% vs 2% 3% vs 1% Nausea and vomiting, complications of pre-existing comorbidities, urinary retention Haight 2023 USA 15 SDD of 169 ≥ 70 yrs 3 yrs EN most common* Minimally invasive hysterectomy 12.5% depending on frailty index 0% No higher likelihood of early post-operative complications (44.4% vs 55.6%), higher likelihood of ED visit within 30 days of discharge (15.3 vs 3.1%), higher rate of 30-day hospital readmission (12.5% vs 4.1%) Mc Cracken 2024 USA 75 of 102 active intervention vs 72 of 100 post intervention SDD stable 75% vs 72% 1 yr CX (n = 3 vs 8) EN (n = 71 vs 65) OV (n = 10 vs 6) OV benign/borderline (n = 15 vs 21) others (n = 2 vs 0) Minimally invasive gynecology oncology surgery 2% vs 3% 1% vs 1% Start time, ward narcotic use Analyzing studies on minimally invasive surgery in gynecology with option for SDD which include patients treated for cervical cancer the first report is from Canada (Gien et al., 2011 )(see Table 2 ). Patients were treated between January 2006 and June 2009. 6.9% of laparoscopic operations had to be converted to open surgery. Out of 303 patients 48.5% had SDD. 4.8% had to be readmitted within a 21 days period. No major postoperative complication was seen in SDD patients. Significantly negative associated with SDD are age > 70 years, less experienced surgeon, conversion to laparotomy), radicality of hysterectomy, 4 hours surgery, and surgery start time after 1PM. The authors conclude that SDD has low morbidity and few readmissions when patient selection and operating room scheduling is refined. Another case-series is reported from New York USA where between July 2010 und December 2012 where simple (55%) or complex (45%) robotic-assisted hysterectomy was performed on 200 patients of which 4% were treated for cervical cancer (Lee et al. 2014 ) (see Table 2 ). In 78% SDD was accomplished. 2.5% of SDD patients required readmission. The authors conclude that SDD in this cohort of patients is feasible and safe. . A Canadian study from the same year evaluated charts of 140 oncologic patients from January till December 2013 who were treated with robotic-assisted minimally invasive surgery (Rivard et al. 2014)(see Table 2 ). From the manuscript it is not clear how many patients were treated for cervical cancer. 64% were discharged the day of surgery. 1.4% of patients were readmitted within 30 days. Older age and later surgery end time were associated with unsuccessful SDD. In their cohort SDD is safe and feasible for most gynecologic oncology patients. Minimally surgical staging was evaluated in the US in 141 patients treated for cervical and endometrial cancer between January 2008 and December 2011(Penner et al. 2015 )(see Table 2 ). 84% received SDD of which 11% needed readmission. Successful SCC was significantly negatively influenced by severe postoperative pain, delayed oral intake, traditional laparoscopic vs robotic-assisted technique and time of incision > 2:00 pm. Extending their study in Canada from 2011 119 patients diagnosed with cervical cancer were treated with laparoscopic radical hysterectomy (Philip et al., 2017)(see Table 2 ). 63% received SDD of which 13% had to be reevaluated and 5% readmitted within 30 days. Mulitivariant analysis showed older age, late start of surgery and intra-operative complications to be significantly negative predictive for SDD success. In conclusion SDD after laparoscopic radical hysterectomy is considered safe with low morbidity and readmission. In North Carolina, USA, preoperative patient education videos, provider education, and postoperative care standardisation was used to promote SDD in patients receiving minimally invasive simple or radical hysterectomy for benign or malignant disease, either robot-assisted, conventional laparoscopic (Fountain and Havrilesky, 2017)(see Table 2 ). 43 SDD to 26 non–SDD patients but also potentially feasible for SDD were compared. It was concluded that in a selected population SDD is safe and feasible, with at least similar patient satisfaction compared to non-SDD. Short operative time, early case end time, low patient complexity, and non–robot-assisted approach increase the likelihood of SDD. Patient education videos did not increase SDD. Expanding the Canadian experience a quality improvement program was evaluated to increase the rate of SDD from 30% to 75% over a 12 months period treating 102 cancer patients with minimally invasive hysterectomy and comparing them to a pre-intervention cohort of 100 patients (Kim et al., 2021)(see Table 2 ). Intervention lead to an increase in SDD from 29% to 75%. Long and late surgery and narcotic use on the ward influence negatively SDD success in multivariate analysis. 89% ranked their SDD experience as ‘very good’ or ‘excellent’, and 87% their length of stay as adequate. No difference in complications, readmissions, reoperations, emergency department visits, or mortality’s seen between the pre- and intervention cohort.. Safety and feasibility of SDD after minimally invasive hysterectomy (MIH) in 169 elderly patients was evaluated between 2018 and 2020 in a study from Ohio, USA (Haight et al. 2023 )(see Table 2 ). 8.9% underwent SDD. SDD patients had no early post-operative complications or hospital readmissions. It was concluded the elderly patients presenting objective criteria for frailty represent a more vulnerable population not suitable for SDD. To follow-up on the SDD success of their quality improvement program (Kim et al. 2021) complication rates and negative predictive factors of the 102 intervention cohort (IC) in 2020 was compared to 100 post-intervention cohort (PIC) in 2021 (McCracken et al., 2024)(see Table 2 ). SDD rate remained 72%. PIC were operated longer. 30-day complications, readmission, reoperation, or emergency room visits were not significantly different between IC and PIC. 30-day post-operative clinic visits decreased from 18% to 5% in the PIC. Overnight stay was significantly associated with second OR case and postoperative narcotic use in the ward. It is concluded that being first case of the day receiving no post-operative narcotics will bring a high likelihood of SDD success. With respect to SDD and cost savings in a study from the US data from 128,634 women who underwent laparoscopic hysterectomy between 2000 and 2010 were analysed: same-day discharge was associated with reduced costs compared to longer hospital stays (Schiavone et al. 2012 ). For patients discharged on postoperative day 1 costs were $ 207 higher compared to patients with SDD. In another study from the US 215 patients underwent complex robotic assisted hysterectomy in 2018 and 41 (19%) underwent SDD (McAlarnen et al., 2021 ). $ 1,975 were saved per SDD per patients with no increase to readmission or emergency room visits within 30 days post surgery. All referenced studies are either from Canada or the USA. In these countries outpatient surgery has a long tradition and an excellent infrastructure to secure the safety of patients post ambulatory surgery. This tradition is mainly based on a reimbursement system which differs from the European and especially German standards. Our first experience with surgical procedures of intermediate to high complexity in gynecological cancer patients is similar to the results reported in the literature. There was no intra- or postoperative complication and no readmission within 30 days. 35 patients with laparoscopically based surgery and 15 patients with advanced vulvar surgery is a small number and our case series will be expanded and prospective follow-up will be performed. However, this case-series allows already a preliminary answer to our initial question „ Does lack of surgical skills of gynecologic oncologists explain the phenomenon that ambulatory surgery is not offered to German women diagnosed with gynecologic cancer?“ The answer is „No“. Table 3 Cost-utility analysis for LAVH & bilateral SO & pelvic & paraaortic Sentinel LNE Cost category Operating theatre & Recovery room Postoperative care Total EBM Reimbursement Deficit Workforce OR nurse: 35 € × 2 hours = 70 € Standby nurse: 30 € × 2 hours = 60 € Surgeon: 100 €/2 hours = 200 € Assistant surgeon: 100 €/2 hours = 200 € Surgeon: 100 €/hour = 100 € 660,00 € Consumables 482,91 € 482,91 € Disposable instruments 604,04 € 604,04 € OR infrastructure& Equipment & Instruments * 211,22 € 211,22 € Sterilsation 92,00 € 92,00 € Antibiotics 12,93 € 12,93 € Administration Codierung Bei 100 €/Stunde: 100 € × 0.5 = 50 € 50,00 € Rent 66,67 € 66,67 € 2179,77 € 616,19 € -1.563,58 € *Cost Calculation for OR Equipment, Devices & Instruments Cost calculation for OR equipment (€289,468) & devices & instruments (€222,150): the investment of €511,618 is depreciated over 5 years and operations are performed for 1,550 hours per year (8 hours per working day) Repair and maintenance costs amount to approximately 12% of the investment sum per year. Annual repair and maintenance costs: €511,618 × 12% = €61,394 per year Total costs over 5 years: €61,394 × 5 = €306,970 Additional costs per hour: €306,970 ÷ 7,750 hours = €39.58 per hour Total Cost per OR Hour: Depreciation per year: €511,618 ÷ 5 years = €102,324 per year €102,324 ÷ 1,550 hours = €66.03 per hour Total hourly cost: Depreciation (€66.03) + Maintenance (€39.58) = €105.61 per hour Cost for a 2-hour operation: €105.61 × 2 = €211.22 The cost for a 2-hour operation is €211.22 (assuming even usage and an annual repair rate of 12% of the investment sum). The referenced literature is empty with respect to a detailed cost-utility analysis of SDD. Our cost-utility analysis using the actual German reimbursement system showed a deficit of 1564 Euros for the surgical part of LAVH & BSO & LNE. (see Table 3 ). Thus, in the current German health care system outpatient surgery is clearly underfinanced and therefore there is no economic incentive for offering patients SDD for the providers. This is the main reason that SDD based surgery is not offered to German patients so far. Since we showed that the surgical quality standards established in Canada and the US can be met, the German reimbursement system must be changed as next major step. Only then also women in Germany will have the option for a treatment modality which is more patient oriented. In addition to the personal benefit for the patient potential economic benefits are savings of inpatient stay charges (room fees, nursing care, meals), freeing of hospital beds and staff and minimizing risk of hospital-acquired infections (HAIs). Declarations Author Contribution A.S. wrote the manuscript and performed the majority of operations. All authors reviewed the manuscript. A.P performed surgeries and provided data for cost-utility analysis. H.J. performed macro- and histopathologic evaluation of surgical specimen. H.V., N.E., N.R. performed anaesthesia of all patients. T.W. initiated, planned and funded the ambulatory surgical unit and all colposcopy clinics. Acknowledgement Without the support of our lab technicians, clinic nurses and OP staff the effort of introducing laparoscopic procedures of high complexity and SDD would not have been possible.We thankfully acknowledge the help with surgical expertise by Christhardt Köhler M.D. and Martin Voss M.D. and with technical support by Viola Schneider M.D..We appreciate the support by Peter Oppelt M.D. for literature review. References Liu J, Chen Y, Tan X, Chen H (2024) Factors influencing same-day discharge after minimally invasive hysterectomy for malignant and non-malignant gynecological diseases: a systematic review and meta-analysis. 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PMID: 25956576 Sanabria D, Rodriguez J, Pecci P, Ardila E, Pareja R (2020 May-Jun) Same-Day Discharge in Minimally Invasive Surgery Performed by Gynecologic Oncologists: A Review of Patient Selection. J Minim Invasive Gynecol 27(4):816–825. 10.1016/j.jmig.2019.10.023 Epub 2019 Nov 9. PMID: 31715304 Fu H, Zhang J, Zhao S, He N (2023) Survival outcomes of robotic-assisted laparoscopy versus conventional laparoscopy and laparotomy for endometrial cancer: A systematic review and meta-analysis. Gynecol Oncol 174:55–67 Epub 2023 May 5. PMID: 37149906 Schiavone MB, Herzog TJ, Ananth CV, Wilde ET, Lewin SN, Burke WM, Lu YS, Neugut AI, Hershman DL, Wright JD (2012) Feasibility and economic impact of same-day discharge for women who undergo laparoscopic hysterectomy. Am J Obstet Gynecol. ;207(5):382.e1-9. 10.1016/j.ajog.2012.09.014 . Epub 2012 Sep 17. PMID: 23107080 McAlarnen L, Monroe A, Erin E, Hopp E, Rader J, Bradley W, Streitenberger K, Uyar D (2021) Same-day discharge after robotic hysterectomy for gynecologic malignancy: a study of cost analysis and resource utilization. Gynecol Oncol 162:S270 Table 1 Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Cite Share Download PDF Status: Published Journal Publication published 21 Apr, 2026 Read the published version in Journal of Cancer Research and Clinical Oncology → Version 1 posted Editorial decision: Revision requested 21 Mar, 2026 Reviews received at journal 19 Mar, 2026 Reviews received at journal 19 Mar, 2026 Reviews received at journal 18 Mar, 2026 Reviewers agreed at journal 18 Mar, 2026 Reviews received at journal 15 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviewers invited by journal 10 Mar, 2026 Editor assigned by journal 09 Mar, 2026 Submission checks completed at journal 05 Mar, 2026 First submitted to journal 05 Mar, 2026 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. 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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-8768631","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603920605,"identity":"54f2483b-d947-4c25-88f2-089974978d6e","order_by":0,"name":"Anja Petzel","email":"","orcid":"","institution":"Eviamed ambulantes Diagnostik- und OP Zentrum MVZ Zweigpraxis MVZ Fürstenbergkarree","correspondingAuthor":false,"prefix":"","firstName":"Anja","middleName":"","lastName":"Petzel","suffix":""},{"id":603920606,"identity":"7573309e-59e7-46b0-89d6-48dbd0e3ee42","order_by":1,"name":"Hendrik Jütte","email":"","orcid":"","institution":"Eviamed ambulantes Diagnostik- und OP Zentrum MVZ Zweigpraxis MVZ Fürstenbergkarree","correspondingAuthor":false,"prefix":"","firstName":"Hendrik","middleName":"","lastName":"Jütte","suffix":""},{"id":603920607,"identity":"fa9fca5f-3df4-47ec-841c-379e509c24b9","order_by":2,"name":"Holger Voss","email":"","orcid":"","institution":"Anästhesiepraxis Eckert \u0026 Voss","correspondingAuthor":false,"prefix":"","firstName":"Holger","middleName":"","lastName":"Voss","suffix":""},{"id":603920608,"identity":"8cc9f24d-2dea-4e0e-8257-597c3eaceb34","order_by":3,"name":"Nils Eckert","email":"","orcid":"","institution":"Anästhesiepraxis Eckert \u0026 Voss","correspondingAuthor":false,"prefix":"","firstName":"Nils","middleName":"","lastName":"Eckert","suffix":""},{"id":603920609,"identity":"eb696f75-276f-430e-998f-0e59e3e4c6cf","order_by":4,"name":"Norbert Richter","email":"","orcid":"","institution":"Dr. Waskow \u0026 Richter, Fachärzte für Anästhesie","correspondingAuthor":false,"prefix":"","firstName":"Norbert","middleName":"","lastName":"Richter","suffix":""},{"id":603920610,"identity":"7a2a570a-b7d6-4bdb-969c-13266330470f","order_by":5,"name":"Thomas Welcker","email":"","orcid":"","institution":"EVIAMED","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Welcker","suffix":""},{"id":603920611,"identity":"5795ad14-042c-4f8a-8267-79d0ca7d9f7b","order_by":6,"name":"Romy Richter","email":"","orcid":"","institution":"Eviamed ambulantes Diagnostik- und OP Zentrum MVZ Zweigpraxis MVZ Fürstenbergkarree","correspondingAuthor":false,"prefix":"","firstName":"Romy","middleName":"","lastName":"Richter","suffix":""},{"id":603920612,"identity":"f034827b-70d3-44d7-b488-9f7de431b889","order_by":7,"name":"Nadine Wolff","email":"","orcid":"","institution":"Eviamed ambulantes Diagnostik- und OP Zentrum MVZ Zweigpraxis MVZ 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20:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8768631/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8768631/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00432-026-06475-z","type":"published","date":"2026-04-21T15:58:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":104667954,"identity":"d2381b95-be6e-4e5d-a738-0ea874052790","added_by":"auto","created_at":"2026-03-15 16:50:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":215078,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8768631/v1/f0195262b6dbff4b6f68765c.png"},{"id":107928488,"identity":"be30a003-acd1-41f5-aee8-ba561cc4ec4b","added_by":"auto","created_at":"2026-04-27 16:11:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":521701,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8768631/v1/fd475e82-9dbb-4b94-976a-396d5604a365.pdf"},{"id":104667953,"identity":"bf8e1ff4-b15e-47b2-88cd-030aad880984","added_by":"auto","created_at":"2026-03-15 16:50:38","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18464,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8768631/v1/616013767d8a4b15a91dea5c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Same day discharge (SDD) after surgery for gynecologic cancer patients in Germany ?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMinimal-invasive surgery is by definition a surgical technique which is destined for same day discharge (SDD) of the patient. Over the last decade several studies have been performed to evaluate the safety and acceptance of SDD in gynecology.\u003c/p\u003e \u003cp\u003eFor benign diseases comparison of outpatient hysterectomy (OH) versus inpatient hysterectomy (IH) revealed in a meta-analysis of eight studies of 104,466 patients fewer complications, a lower readmission rate, lower blood loss, a shorter surgery time and a cost benefit for OH. However IH patients had a better health-related quality of life up to postoperative day 7 (Ellinides et al., 2021). Risk factors making OH difficult were older age, beginning surgery later than 1 p.m. and completing surgery later than 6 p.m., longer duration of operation, and high estimated blood loss in a metaanalysis of 15 studies with 11.992 patients and a mean SDD rate of 72.7%, (range 20.9\u0026ndash;100%)(Korsholm et al. 2017).\u003c/p\u003e \u003cp\u003eA recent meta-analysis evaluated 29 reports with 218.192 patients treated by minimally invasive hysterectomy for non-malignant (90.6%) or malignant (9.4%) gynecologic disease (Liu et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Planned SDD could be achieved in 47% of patients. Old age, high body mass index (BMI), comorbidities such as diabetes and chronic obstructive pulmonary disease (COPD), radical hysterectomy, surgery starting after 2 p.m., longer surgical time, intraoperative and postoperative complications and surgeons preference were factors preventing SDD. Old age, long distance to home and increase in surgical time did not prevent SDD. However, start time and body mass index were especially important in patients with malignant disease.\u003c/p\u003e \u003cp\u003eWith respect to minimal invasive surgery in patients diagnosed with gynecologic malignancies endometrial cancer is the main indication: in a metaanalysis of 9 studies with a total of 16.423 patients with successful SDD in 60,4% (varying between 12.4 and 83.7%) 15860 patients were diagnosed with endometrial cancer versus 563 patients with other neoplasms (Sanabria et al., 2019). Presence of comorbidities which require follow-up in the hospital post surgery, age\u0026thinsp;\u0026gt;\u0026thinsp;70 years, start of surgery later than1 p.m., duration of surgery more than 2 hours, vascular or urinary intraoperative complications and/or conversion to laparotomy, inadequate postoperative course with respect to oral intake or spontaneous voiding or refusal of SDD by the patient were factors identified as negatively associated with SDD.\u003c/p\u003e \u003cp\u003eThus, following proper selection criteria even women with malignant disease SDD can safely be offered, allowing uncomplicated recovery in the family environment. Evidently SDD is successfully performed in Canada and the US since more than 15 years for patients diagnosed with gynecologic cancers. We asked ourselves why SDD is not offered to German women with identical diagnoses. We investigated if lack of training, ignorance of specific surgical techniques and/or deficit in talent could explain this phenomenon over an initial period of 21 months.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003e Between April 2024 and December 2025 83 patients with cervical cancer (n\u0026thinsp;=\u0026thinsp;41), followed by cancer of vulva (n\u0026thinsp;=\u0026thinsp;28), corpus uteri (n\u0026thinsp;=\u0026thinsp;8), vagina (n\u0026thinsp;=\u0026thinsp;5) or ovary (n\u0026thinsp;=\u0026thinsp;1) underwent ambulatory surgery with SDD in our institution. All patients had been examined and diagnosed in one of our eight colposcopy clinics. Patients were informed about the diagnosis by the responsible colposcopist. Bringing bad news in a patient-oriented fashion using the six-step protocol for delivering bad news (SPIKES) is considered mandatory. Since continuing treatment in the same institution is preferred by the patient we established high-tech laparoscopic theaters to provide also major surgery with SDD only.\u003c/p\u003e \u003cp\u003eAll clinical findings were discussed in an interdisciplinary conference and treatment recommendations were presented to the patients. All patients had the choice between outpatient or inpatient treatment. \u003cb\u003eAll treatments were performed in accordance with the relevant guidelines and regulations\u003c/b\u003e. \u003cb\u003ePatients with cervical cancer were informed about the current preference for hysterectomy by laparotomy and the results of our retrospective study showing the advantages of a laparoscopic approach when oncologic hygiene is respected which is also referenced in the German S3 guideline\u003c/b\u003e (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://register.awmf.org/assets/guidelines/032-033OLl_S3_Diagnostik_Therapie_Nachsorge_Zervixkarzinom_2022-03.pdf\u003c/span\u003e\u003cspan address=\"https://register.awmf.org/assets/guidelines/032-033OLl_S3_Diagnostik_Therapie_Nachsorge_Zervixkarzinom_2022-03.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e).\u003c/span\u003e\u003c/p\u003e \u003cp\u003eIt was mandatory to perform hysterectomy without manipulator or laparoscopic colpotomy. Sentinel-lymph nodes were labelled with indocyanine green (ICG) and in vulvar cancer additionally with Technetium. In patients with advanced cervical cancer laparoscopic staging included systematic pelvic and paraaortic lymphadenectomy prior to chemo radiation. \u003cb\u003eOur surgical techniques are described in detail (\u003c/b\u003eK\u0026ouml;hler et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; K\u0026ouml;\u003cb\u003ehler et al. 2004;\u003c/b\u003e Altgassen et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) \u003cb\u003eand have been appraised for SDD by the Ethical Commission of the Medical Association of Berlin Eth-SB-25-089.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOnly patients with a vaginal phase in the procedure received perioperatively antibiotic prophylaxis with cephalosporin and metronidazole.\u003c/p\u003e \u003cp\u003eAll patients used heparin prophylaxis for 7\u0026ndash;14 days depending on their risk for postoperative thrombosis.\u003c/p\u003e \u003cp\u003eWe made sure that patients had help at home during postoperative convalescence for at least five days. All patients were regularly contacted postoperatively by their surgeon ensuring their well-being und were seen in the outpatient-clinic at least once within 10 postoperative days.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAll patients gave written consent that their clinical data could be analysed anonymously. Our surgical results are registered and evaluated routinely in the yearly audit for the DIN certificate and in the current application at the German Cancer Society for certification as Gynecologic Cancer Center .\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePrices for consumables, instruments, OR infrastructure and equipment, personnel and rent were calculated. These costs were compared in a cost-utility analysis to the reimbursement for the surgical part of LAVH \u0026amp; bilateral salpingectomy (BSO) \u0026amp; LNE.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe datasets analysed for this manuscript are available from the corresponding author on reasonable request.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAll authors report no conflict of interests within the last 5 years which includes 3 years prior to the beginning of our first surgery with SDD.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eThe clinical dataset used in this report is routinely registered and analysed for quality control of our surgical performance. Thus, no sponsoring or financial support was used for this analysis.\u003c/b\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e15 patients with cervical cancer Ia1, 13 patients with vulvar cancer Ia and 5 patients with vaginal cancer underwent minor surgery such as loop-excision, laser excision or biopsies, respectively.\u003c/p\u003e \u003cp\u003eThese patients will not be further analysed and we focus on all patients who underwent laparoscopic surgery and all patients with major surgery for vulvar cancer.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003econe=conization; SLN=sentinel lymphadenectomy; LAVH=laparoscopic assisted vaginal hysterectomy; LNE=lymphadenectomy; VALRH=vaginally assisted laparoscopic radical hysterectomy\u003c/p\u003e \u003cp\u003e26 patients with cervical cancer, 6 patients with endometrial cancer, 2 patients with carcinosarcoma of the uterus and one patient with borderline tumor of the ovary underwent laparoscopy alone or in combination with a vaginal approach (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFifteen patients with vulvar cancer underwent partial or complete vulvectomy combined with sentinel LNE.\u003c/p\u003e \u003cp\u003eIn the laparoscopy group mean age was 18 years lower when compared to the vulva group (see Table\u0026nbsp;1). The oldest patient in the laparoscopy group was 87 years old and diagnosed with cervical cancer stage Ia2 and underwent LAVH \u0026amp; BSO (bilateral salping-oophorectomy) \u0026amp; pelvic sentinel-lymphadencetomy (SLNectomy). In the vulva group the oldest patients was 90 years old and was treated by partial vulvectomy \u0026amp; inguinal LNE.\u003c/p\u003e \u003cp\u003eMean BMI was similar in both groups with the highest value of 43.8 in the laparoscopy group.\u003c/p\u003e \u003cp\u003eDuration of the surgical part of the operation was with 2.45 hours versus 1.3 hours almost twice as long for the laparoscopy group.\u003c/p\u003e \u003cp\u003eNarcosis pre-incision and post-suture lasted on average 36 minutes in the laparoscopy versus 38 minutes in the vulva group.\u003c/p\u003e \u003cp\u003ePost surgery observation took on average 2.5 hours in the laparoscopy group versus 1.7 hours in the vulva group.\u003c/p\u003e \u003cp\u003eThere were no intraoperative complications, no conversion to laparotomy and no hospital admission within 30 days post surgery in both groups.\u003c/p\u003e \u003cp\u003ePostoperative complications were as follows:\u003c/p\u003e \u003cp\u003eLeakage of the right ureter close to the bladder was noticed in a 54-years old patient with non-HPV associated p53 mutated adenocarcinoma of the cervix stage IIb where radical hysterectomy had to be performed prior to chemo radiation. The leakage started 14 days post surgery and a stent was placed as an outpatient procedure.\u003c/p\u003e \u003cp\u003eA paraaortic lymphocele in a 52 year old patient with adenocarcinoma of the cervix stage IIb had to be opened 75 days postoperatively when induction chemotherapy had been completed and chemo radiation was to be started.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFourteen days post SDD antibiotic treatment for urinary tract infection was necessary in a 86 year old patient with cervical cancer stage Ia2 post LAVH \u0026amp; BSO \u0026amp; LNE. The patient had not been catheterized during surgery.\u003c/p\u003e \u003cp\u003eA 73 year old patient with vulvar cancer stage Ib developed a lymphocele in the right groin on postoperative day 12 which was successfully treated ambulatory by repeated aspiration and compression till postoperative day 35.\u003c/p\u003e \u003cp\u003eAll patients were seen in our outpatient clinic post SDD within 10 days. They reported fast mobilisation since postoperative day 1 under pain medication with metamizol for up to 5 days and, if indicated, opioid analgesia for up to 2 days.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of publications containing data on minimal invasive surgery with option for SDD for patients diagnosed with gynecological cancer\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\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCX \u0026amp; EN \u0026amp; other CA\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of patinets\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePeriod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCancer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eReadmission\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;30 days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eReoperation\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;30 days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRiskfactors for admission\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGien 2010 Canada\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e147 of 303 (49%). 6.9% conversion to laparotomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.5 yrs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAll patients: CX (n\u0026thinsp;=\u0026thinsp;78; 26%) EN (n\u0026thinsp;=\u0026thinsp;150; 50%) OV (n\u0026thinsp;=\u0026thinsp;40; 14% )\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003etotal laparoscopic simple or radical hysterectomies or radical trachelectomy +/\u0026minus; salpingo-oophorectomy +/\u0026minus; pelvic and para-aortic lymphonodectomy +/\u0026minus; omentectomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.8%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNot mentioned\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAge, surgeon, conversion to laparotomy, radical hysterectomy, length of surgery, start time \u0026gt;1PM\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\u003e\u003cb\u003eLee 2014 USA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e157 of 200 (79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.4 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSDD patients: CX (n\u0026thinsp;=\u0026thinsp;7; 4.5%), EN (n\u0026thinsp;=\u0026thinsp;63; 40%), OV (n\u0026thinsp;=\u0026thinsp;3; 2%), non-gynecologic cancer or benign (n\u0026thinsp;=\u0026thinsp;84; 54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSimple: TLH+/-BSO. Complex: TLH+/-BSO with sentinel node mapping, pelvic and/or aortic nodal dissection, appendectomy, or omentectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4/157 (2.5%) vs 3/43 (7.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNot mentioned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eEsteemed blood loss, room time, operative time, time case ended and intraoperative ketorolac use\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\u003e\u003cb\u003eRivard 2014 USA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90 of 140 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 yr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSDD patients: EN (n\u0026thinsp;=\u0026thinsp;57; 49%) other CA* (n\u0026thinsp;=\u0026thinsp;16; 14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOutpatients: Hysterectomy\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;BSO (n\u0026thinsp;=\u0026thinsp;57; 49%) Staging (n\u0026thinsp;=\u0026thinsp;55; 48%) Hysterectomy or Debulking (n\u0026thinsp;=\u0026thinsp;3; 3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNot mentioned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOlder age, late surgery\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\u003e\u003cb\u003ePenner 2015 USA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118 of 144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSDD CX (n\u0026thinsp;=\u0026thinsp;22; 19%) EN (n\u0026thinsp;=\u0026thinsp;96; 81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLaparoscopic (n\u0026thinsp;=\u0026thinsp;20; 17%) Robotic (n\u0026thinsp;=\u0026thinsp;98; 83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11% vs 17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNot mentioned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSevere pain postop., delayed oral intake, laparoscopic vs robotic-assisted, late surgery\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\u003e\u003cb\u003ePhilip 2017 Canada\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 of 119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCX (n\u0026thinsp;=\u0026thinsp;119; 100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLRH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOlder age, late surgery, intraoperative complication\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\u003e\u003cb\u003eFountain 2017 Canada\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 SDD vs 26 non-SDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMinimally invasive hysterectomy\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;pelvic LNE\u003c/p\u003e \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\u003eHigher patient complexity, later case end time, longer operative time, and robot-assisted cases. Patient education videos alone did not increase SDD.\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\u003e\u003cb\u003eKim 2021 Canada\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePreintervention n\u0026thinsp;=\u0026thinsp;100 Active Intervention n\u0026thinsp;=\u0026thinsp;102 SDD increase 29 to 75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 yr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCX (n\u0026thinsp;=\u0026thinsp;3 vs 3) EN (n\u0026thinsp;=\u0026thinsp;85 vs 71) OV (n\u0026thinsp;=\u0026thinsp;1 vs 10) OV benign/borderline (n\u0026thinsp;=\u0026thinsp;11 vs 15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLaparoscopic (n\u0026thinsp;=\u0026thinsp;63 vs 81) Robotic (n\u0026thinsp;=\u0026thinsp;37 vs 21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2% vs 2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3% vs 1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNausea and vomiting, complications of pre-existing comorbidities, urinary retention\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\u003e\u003cb\u003eHaight 2023 USA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 SDD of 169\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;70 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEN most common*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMinimally invasive hysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.5% depending on frailty index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo higher likelihood of early post-operative complications (44.4% vs 55.6%), higher likelihood of ED visit within 30 days of discharge (15.3 vs 3.1%), higher rate of 30-day hospital readmission (12.5% vs 4.1%)\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\u003e\u003cb\u003eMc Cracken 2024 USA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 of 102 active intervention vs 72 of 100 post intervention SDD stable 75% vs 72%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 yr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCX (n\u0026thinsp;=\u0026thinsp;3 vs 8) EN (n\u0026thinsp;=\u0026thinsp;71 vs 65) OV (n\u0026thinsp;=\u0026thinsp;10 vs 6) OV benign/borderline (n\u0026thinsp;=\u0026thinsp;15 vs 21) others (n\u0026thinsp;=\u0026thinsp;2 vs 0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMinimally invasive gynecology oncology surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2% vs 3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1% vs 1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStart time, ward narcotic use\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAnalyzing studies on minimally invasive surgery in gynecology with option for SDD which include patients treated for cervical cancer the first report is from Canada (Gien et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2011\u003c/span\u003e)(see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Patients were treated between January 2006 and June 2009. 6.9% of laparoscopic operations had to be converted to open surgery. Out of 303 patients 48.5% had SDD. 4.8% had to be readmitted within a 21 days period. No major postoperative complication was seen in SDD patients. Significantly negative associated with SDD are age\u0026thinsp;\u0026gt;\u0026thinsp;70 years, less experienced surgeon, conversion to laparotomy), radicality of hysterectomy, 4 hours surgery, and surgery start time after 1PM. The authors conclude that SDD has low morbidity and few readmissions when patient selection and operating room scheduling is refined.\u003c/p\u003e \u003cp\u003eAnother case-series is reported from New York USA where between July 2010 und December 2012 where simple (55%) or complex (45%) robotic-assisted hysterectomy was performed on 200 patients of which 4% were treated for cervical cancer (Lee et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In 78% SDD was accomplished. 2.5% of SDD patients required readmission. The authors conclude that SDD in this cohort of patients is feasible and safe. .\u003c/p\u003e \u003cp\u003eA Canadian study from the same year evaluated charts of 140 oncologic patients from January till December 2013 who were treated with robotic-assisted minimally invasive surgery\u003c/p\u003e \u003cp\u003e(Rivard et al. 2014)(see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). From the manuscript it is not clear how many patients were treated for cervical cancer. 64% were discharged the day of surgery. 1.4% of patients were readmitted within 30 days. Older age and later surgery end time were associated with unsuccessful SDD. In their cohort SDD is safe and feasible for most gynecologic oncology patients.\u003c/p\u003e \u003cp\u003eMinimally surgical staging was evaluated in the US in 141 patients treated for cervical and endometrial cancer between January 2008 and December 2011(Penner et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)(see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e84% received SDD of which 11% needed readmission. Successful SCC was significantly negatively influenced by severe postoperative pain, delayed oral intake, traditional laparoscopic vs robotic-assisted technique and time of incision\u0026thinsp;\u0026gt;\u0026thinsp;2:00 pm.\u003c/p\u003e \u003cp\u003eExtending their study in Canada from 2011 119 patients diagnosed with cervical cancer were treated with laparoscopic radical hysterectomy (Philip et al., 2017)(see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). 63% received SDD of which 13% had to be reevaluated and 5% readmitted within 30 days. Mulitivariant analysis showed older age, late start of surgery and intra-operative complications to be significantly negative predictive for SDD success. In conclusion SDD after laparoscopic radical hysterectomy is considered safe with low morbidity and readmission.\u003c/p\u003e \u003cp\u003eIn North Carolina, USA, preoperative patient education videos, provider education, and postoperative care standardisation was used to promote SDD in patients receiving minimally invasive simple or radical hysterectomy for benign or malignant disease, either robot-assisted, conventional laparoscopic (Fountain and Havrilesky, 2017)(see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). 43 SDD to 26 non\u0026ndash;SDD patients but also potentially feasible for SDD were compared. It was concluded that in a selected population SDD is safe and feasible, with at least similar patient satisfaction compared to non-SDD. Short operative time, early case end time, low patient complexity, and non\u0026ndash;robot-assisted approach increase the likelihood of SDD. Patient education videos did not increase SDD.\u003c/p\u003e \u003cp\u003eExpanding the Canadian experience a quality improvement program was evaluated to increase the rate of SDD from 30% to 75% over a 12 months period treating 102 cancer patients with minimally invasive hysterectomy and comparing them to a pre-intervention cohort of 100 patients (Kim et al., 2021)(see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Intervention lead to an increase in SDD from 29% to 75%. Long and late surgery and narcotic use on the ward influence negatively SDD success in multivariate analysis. 89% ranked their SDD experience as \u0026lsquo;very good\u0026rsquo; or \u0026lsquo;excellent\u0026rsquo;, and 87% their length of stay as adequate. No difference in complications, readmissions, reoperations, emergency department visits, or mortality\u0026rsquo;s seen between the pre- and intervention cohort..\u003c/p\u003e \u003cp\u003eSafety and feasibility of SDD after minimally invasive hysterectomy (MIH) in 169 elderly patients was evaluated between 2018 and 2020 in a study from Ohio, USA (Haight et al. \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)(see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). 8.9% underwent SDD. SDD patients had no early post-operative complications or hospital readmissions. It was concluded the elderly patients presenting objective criteria for frailty represent a more vulnerable population not suitable for SDD.\u003c/p\u003e \u003cp\u003eTo follow-up on the SDD success of their quality improvement program (Kim et al. 2021) complication rates and negative predictive factors of the 102 intervention cohort (IC) in 2020 was compared to 100 post-intervention cohort (PIC) in 2021 (McCracken et al., 2024)(see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). SDD rate remained 72%. PIC were operated longer. 30-day complications, readmission, reoperation, or emergency room visits were not significantly different between IC and PIC. 30-day post-operative clinic visits decreased from 18% to 5% in the PIC. Overnight stay was significantly associated with second OR case and postoperative narcotic use in the ward. It is concluded that being first case of the day receiving no post-operative narcotics will bring a high likelihood of SDD success.\u003c/p\u003e \u003cp\u003eWith respect to SDD and cost savings in a study from the US data from 128,634 women who underwent laparoscopic hysterectomy between 2000 and 2010 were analysed: same-day discharge was associated with reduced costs compared to longer hospital stays (Schiavone et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). For patients discharged on postoperative day 1 costs were \u003cspan\u003e$\u003c/span\u003e207 higher compared to patients with SDD.\u003c/p\u003e \u003cp\u003eIn another study from the US 215 patients underwent complex robotic assisted hysterectomy in 2018 and 41 (19%) underwent SDD (McAlarnen et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). \u003cspan\u003e$\u003c/span\u003e1,975 were saved per SDD per patients with no increase to readmission or emergency room visits within 30 days post surgery.\u003c/p\u003e \u003cp\u003eAll referenced studies are either from Canada or the USA. In these countries outpatient surgery has a long tradition and an excellent infrastructure to secure the safety of patients post ambulatory surgery. This tradition is mainly based on a reimbursement system which differs from the European and especially German standards.\u003c/p\u003e \u003cp\u003eOur first experience with surgical procedures of intermediate to high complexity in gynecological cancer patients is similar to the results reported in the literature. There was no intra- or postoperative complication and no readmission within 30 days.\u003c/p\u003e \u003cp\u003e35 patients with laparoscopically based surgery and 15 patients with advanced vulvar surgery is a small number and our case series will be expanded and prospective follow-up will be performed.\u003c/p\u003e \u003cp\u003eHowever, this case-series allows already a preliminary answer to our initial question \u0026bdquo; Does lack of surgical skills of gynecologic oncologists explain the phenomenon that ambulatory surgery is not offered to German women diagnosed with gynecologic cancer?\u0026ldquo; The answer is \u0026bdquo;No\u0026ldquo;.\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 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCost-utility analysis for LAVH \u0026amp; bilateral SO \u0026amp; pelvic \u0026amp; paraaortic Sentinel LNE\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=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCost category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperating theatre \u0026amp; Recovery room\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEBM Reimbursement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDeficit\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkforce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR nurse: 35 \u0026euro; \u0026times; 2 hours\u0026thinsp;=\u0026thinsp;70 \u0026euro;\u003c/p\u003e \u003cp\u003eStandby nurse: 30 \u0026euro; \u0026times; 2 hours\u0026thinsp;=\u0026thinsp;60 \u0026euro;\u003c/p\u003e \u003cp\u003eSurgeon:\u003c/p\u003e \u003cp\u003e100 \u0026euro;/2 hours\u0026thinsp;=\u0026thinsp;200 \u0026euro; Assistant surgeon:\u003c/p\u003e \u003cp\u003e100 \u0026euro;/2 hours\u0026thinsp;=\u0026thinsp;200 \u0026euro;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgeon:\u003c/p\u003e \u003cp\u003e100 \u0026euro;/hour\u0026thinsp;=\u0026thinsp;100 \u0026euro;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e660,00\u0026nbsp;\u0026euro;\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsumables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e482,91\u0026nbsp;\u0026euro;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e482,91\u0026nbsp;\u0026euro;\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisposable instruments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e604,04\u0026nbsp;\u0026euro;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e604,04\u0026nbsp;\u0026euro;\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOR infrastructure\u0026amp;\u003c/p\u003e \u003cp\u003eEquipment \u0026amp; Instruments *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211,22\u0026nbsp;\u0026euro;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e211,22\u0026nbsp;\u0026euro;\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSterilsation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92,00\u0026nbsp;\u0026euro;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92,00\u0026nbsp;\u0026euro;\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12,93\u0026nbsp;\u0026euro;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12,93\u0026nbsp;\u0026euro;\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCodierung \u003c/p\u003e \u003cp\u003eBei 100 \u0026euro;/Stunde: 100 \u0026euro; \u0026times; 0.5\u0026thinsp;=\u0026thinsp;50 \u0026euro;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50,00\u0026nbsp;\u0026euro;\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66,67\u0026nbsp;\u0026euro;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66,67\u0026nbsp;\u0026euro;\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2179,77\u0026nbsp;\u0026euro;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e616,19\u0026nbsp;\u0026euro;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e-1.563,58\u0026nbsp;\u0026euro;\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 \u003cp\u003e*Cost Calculation for OR Equipment, Devices \u0026amp; Instruments\u003c/p\u003e\n\u003cp\u003eCost calculation for OR equipment (\u0026euro;289,468) \u0026amp; devices \u0026amp; instruments (\u0026euro;222,150):\u003cbr\u003e\u0026nbsp;the investment of \u0026euro;511,618 is depreciated over 5 years and operations are performed for 1,550 hours per year (8 hours per working day)\u003c/p\u003e\n\u003cp\u003eRepair and maintenance costs amount to approximately 12% of the investment sum per year.\u0026nbsp;\u003cbr\u003e\u0026nbsp;Annual repair and maintenance costs: \u0026euro;511,618 \u0026times; 12% = \u0026euro;61,394 per year\u003cbr\u003e\u0026nbsp;Total costs over 5 years: \u0026euro;61,394 \u0026times; 5 = \u0026euro;306,970\u003cbr\u003e\u0026nbsp;Additional costs per hour: \u0026euro;306,970 \u0026divide; 7,750 hours = \u0026euro;39.58 per hour\u003c/p\u003e\n\u003cp\u003eTotal Cost per OR Hour:\u003c/p\u003e\n\u003cp\u003eDepreciation per year:\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026euro;511,618 \u0026divide; 5 years = \u0026euro;102,324 per year\u003c/p\u003e\n\u003cp\u003e\u0026euro;102,324 \u0026divide; 1,550 hours = \u0026euro;66.03 per hour\u003cbr\u003e\u0026nbsp;Total hourly cost:\u003cbr\u003e\u0026nbsp;Depreciation (\u0026euro;66.03) + Maintenance (\u0026euro;39.58) = \u0026euro;105.61 per hour\u003cbr\u003e\u0026nbsp;Cost for a 2-hour operation: \u0026euro;105.61 \u0026times; 2 = \u0026euro;211.22\u003c/p\u003e\n\u003cp\u003eThe cost for a 2-hour operation is \u0026euro;211.22 (assuming even usage and an annual repair rate of 12% of the investment sum).\u003c/p\u003e\u003cp\u003eThe referenced literature is empty with respect to a detailed cost-utility analysis of SDD.\u003c/p\u003e \u003cp\u003eOur cost-utility analysis using the actual German reimbursement system showed a deficit of 1564 Euros for the surgical part of LAVH \u0026amp; BSO \u0026amp; LNE. (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThus, in the current German health care system outpatient surgery is clearly underfinanced and therefore there is no economic incentive for offering patients SDD for the providers. This is the main reason that SDD based surgery is not offered to German patients so far.\u003c/p\u003e \u003cp\u003eSince we showed that the surgical quality standards established in Canada and the US can be met, the German reimbursement system must be changed as next major step. Only then also women in Germany will have the option for a treatment modality which is more patient oriented. In addition to the personal benefit for the patient potential economic benefits are savings of inpatient stay charges (room fees, nursing care, meals), freeing of hospital beds and staff and minimizing risk of hospital-acquired infections (HAIs).\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.S. wrote the manuscript and performed the majority of operations. All authors reviewed the manuscript. A.P performed surgeries and provided data for cost-utility analysis. H.J. performed macro- and histopathologic evaluation of surgical specimen. H.V., N.E., N.R. performed anaesthesia of all patients. T.W. initiated, planned and funded the ambulatory surgical unit and all colposcopy clinics.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWithout the support of our lab technicians, clinic nurses and OP staff the effort of introducing laparoscopic procedures of high complexity and SDD would not have been possible.We thankfully acknowledge the help with surgical expertise by Christhardt K\u0026ouml;hler M.D. and Martin Voss M.D. and with technical support by Viola Schneider M.D..We appreciate the support by Peter Oppelt M.D. for literature review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLiu J, Chen Y, Tan X, Chen H (2024) Factors influencing same-day discharge after minimally invasive hysterectomy for malignant and non-malignant gynecological diseases: a systematic review and meta-analysis. 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Int J Gynecol Cancer. ;32(4):457\u0026ndash;465. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/ijgc-2021-003065\u003c/span\u003e\u003cspan address=\"10.1136/ijgc-2021-003065\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34987097\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaight PJ, Piver RN, Barrington DA, Baek J, Graves SM, Ardizzone M, Akinduro JA, Busho AC, Fadoju D, Pandit R, Stephens R, Strowder LM, Tadepalli S, VanNoy B, Sriram B, McLaughlin EM, Ds Lightfoot M, Chambers LM, Bixel KL, Cohn DE, Cosgrove CM, O'Malley D, Salani R, Backes FJ, Nagel I (2023) Assessment of the feasibility of same-day discharge following minimally invasive hysterectomy in the elderly population. 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Gynecol Oncol Rep 48:101227. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.gore.2023.101227\u003c/span\u003e\u003cspan address=\"10.1016/j.gore.2023.101227\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 37415961; PMCID: PMC10320489\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelamed A, Katz Eriksen JL, Hinchcliff EM, Worley MJ Jr, Berkowitz RS, Horowitz NS, Muto MG, Urman RD, Feltmate CM (2016) Same-Day Discharge After Laparoscopic Hysterectomy for Endometrial Cancer. Ann Surg Oncol 23(1):178\u0026ndash;185. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1245/s10434-015-4582-4\u003c/span\u003e\u003cspan address=\"10.1245/s10434-015-4582-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2015 May 9. PMID: 25956576\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanabria D, Rodriguez J, Pecci P, Ardila E, Pareja R (2020 May-Jun) Same-Day Discharge in Minimally Invasive Surgery Performed by Gynecologic Oncologists: A Review of Patient Selection. J Minim Invasive Gynecol 27(4):816\u0026ndash;825. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jmig.2019.10.023\u003c/span\u003e\u003cspan address=\"10.1016/j.jmig.2019.10.023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2019 Nov 9. PMID: 31715304\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu H, Zhang J, Zhao S, He N (2023) Survival outcomes of robotic-assisted laparoscopy versus conventional laparoscopy and laparotomy for endometrial cancer: A systematic review and meta-analysis. Gynecol Oncol 174:55\u0026ndash;67 Epub 2023 May 5. PMID: 37149906\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchiavone MB, Herzog TJ, Ananth CV, Wilde ET, Lewin SN, Burke WM, Lu YS, Neugut AI, Hershman DL, Wright JD (2012) Feasibility and economic impact of same-day discharge for women who undergo laparoscopic hysterectomy. Am J Obstet Gynecol. ;207(5):382.e1-9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2012.09.014\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2012.09.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2012 Sep 17. PMID: 23107080\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcAlarnen L, Monroe A, Erin E, Hopp E, Rader J, Bradley W, Streitenberger K, Uyar D (2021) Same-day discharge after robotic hysterectomy for gynecologic malignancy: a study of cost analysis and resource utilization. Gynecol Oncol 162:S270\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-research-and-clinical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jocr","sideBox":"Learn more about [Journal of Cancer Research and Clinical Oncology](https://www.springer.com/journal/432)","snPcode":"432","submissionUrl":"https://submission.nature.com/new-submission/432/3","title":"Journal of Cancer Research and Clinical Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8768631/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8768631/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmbulatory surgery is well established outside Europe for women diagnosed with gynecologic cancer. Overstrained hospital staff, multi-resistant nosocomial hospital germs and pending pandemics are arguments for same day discharge (SDD).\u003cbr\u003e\nWhat is the reason that this option is not offered to patients in Germany? Does lack of surgical skills of gynecologic oncologists explain this phenomenon?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween April 2024 and December 2025 83 consecutive cancer patients underwent outpatient surgery at Eviamed Oncology Center. The majority of patients were diagnosed with cervical cancer (n=41), followed by cancer of vulva (n=27), corpus uteri (n=8), vagina (n=5) or ovary (n=1). Major surgery was performed laparoscopically in 35 patients by lymphadenectomy (LNE) alone or vaginal-assisted simple (LAVH) or radical hysterectomy (VALRH) and in 15 patients by inguinal LNE combined with vulvectomy. Pre- and postoperative findings were presented and discussed in an interdisciplinary tumor board.\u003c/p\u003e\n\u003cp\u003ePostoperatively all patients were contacted by phone for their well-being and received a check-up examination by the responsible surgeon. We made sure that the patients had family support up to postoperative day 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the laparoscopy group mean age of was 49 (24 - 87)years, mean BMI 27.3 (18.8-43.8), interval between incision and suture 147 (70-288) min, duration of narcosis 183 (90-338) minand of postoperative observation 151 (83-260) min. Vulva patients were on average 18 years older with similar BMI and up to 40% shorter time intervals.\u003cbr\u003e\n There were no intraoperative complications, no conversion to laparotomy and no hospital admission within 30 days post surgery. One ureter leakage, 3 symptomatic lymphoceles and one urinary tract infection had to be treated in the laparoscopy group and 1 symptomatic lymphocele in the vulva group.\u003c/p\u003e\n\u003cp\u003eA cost-utility analysis using the actual German reimbursement system showed a considerable deficit for the surgical part of LAVH \u0026amp; LNE.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe reason that SDD is not offered to patients in Germany is not incompetence of the gynecologic oncologists but inadequate reimbursement by the health insurance providers.\u003c/p\u003e","manuscriptTitle":"Same day discharge (SDD) after surgery for gynecologic cancer patients in Germany ?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-15 16:50:33","doi":"10.21203/rs.3.rs-8768631/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-21T15:38:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-19T12:54:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-19T07:06:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T19:33:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193854993552347957454959792499555847061","date":"2026-03-18T09:49:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-15T10:10:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126113687404566831069657443260562751774","date":"2026-03-14T19:14:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20798065359815399165864358833579932110","date":"2026-03-14T08:27:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"111561118096199185358517610853009018235","date":"2026-03-14T07:15:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325973946618579712508594011051597484867","date":"2026-03-14T07:10:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37148365419709179624826136579000854494","date":"2026-03-14T03:59:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254574478639749379056312123062044908924","date":"2026-03-14T03:03:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217212197483238096767131887742696471864","date":"2026-03-10T06:32:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-10T04:32:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-09T13:54:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-06T02:45:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cancer Research and Clinical Oncology","date":"2026-03-05T05:53:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-research-and-clinical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jocr","sideBox":"Learn more about [Journal of Cancer Research and Clinical Oncology](https://www.springer.com/journal/432)","snPcode":"432","submissionUrl":"https://submission.nature.com/new-submission/432/3","title":"Journal of Cancer Research and Clinical Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d5bbb8c4-5336-432c-9dd4-173ff814b1ed","owner":[],"postedDate":"March 15th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:08:52+00:00","versionOfRecord":{"articleIdentity":"rs-8768631","link":"https://doi.org/10.1007/s00432-026-06475-z","journal":{"identity":"journal-of-cancer-research-and-clinical-oncology","isVorOnly":false,"title":"Journal of Cancer Research and Clinical Oncology"},"publishedOn":"2026-04-21 15:58:14","publishedOnDateReadable":"April 21st, 2026"},"versionCreatedAt":"2026-03-15 16:50:33","video":"","vorDoi":"10.1007/s00432-026-06475-z","vorDoiUrl":"https://doi.org/10.1007/s00432-026-06475-z","workflowStages":[]},"version":"v1","identity":"rs-8768631","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8768631","identity":"rs-8768631","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}