Costs Among Patients With Endometrial Cancer Receiving Postoperative Hemoglobin Level Testing Following Robotic-assisted Hysterectomy

Blood loss after robotic hysterectomy for endometrial cancer is low. Nevertheless, to ensure the absence of internal bleeding before discharge, hemoglobin level is often checked after hysterectomy for endometrial cancer regardless of the surgical approach used. “This is probably based on historical practice rather than evidence-based guidelines,” wrote Joel Cardenas-Goicoechea, MD, Division of Gynecologic Oncology, Cleveland Clinic Florida, Weston, FL, and colleagues. 

To assess the clinical utility of postoperative hemoglobin testing after hysterectomy, these researchers retrospectively studied patients with endometrial cancer who had robotic surgery at an academic center from April 2016 to December 2019 (Anticancer Res. 2022;42(4):1893-1898. doi:10.21873/anticanres. 15665). To do so, they extracted data from the patients’ electronic medical records in Epic and evaluated the mean postoperative decrease in hemoglobin level by using numerical and categorical variables. A secondary objective of their study was to assess perioperative outcomes and costs.

The study cohort included 201 women, and the mean age was 63 years. Symptoms of hemodynamic compromise developed in 45 of these women, or 22.4%. Compared with asymptomatic patients, these patients did not differ in operative time, estimated blood loss, pre- and post-operative hemoglobin levels, or change in hemoglobin level. However, symptomatic patients did receive less fluid during surgery (1.2 L vs. 1.5 L, P<0.0001). 

“It is possible that their symptoms were due to dehydration at the time of surgery since almost half of the cases were performed after 12:00 pm (42.3%),” the researchers noted, adding, “Adequate hydration during and after surgery may help avoid unnecessary measures, such as repeat blood testing or more active monitoring.”

Although the researchers found that perioperative outcomes were not associated with a greater decrease in hemoglobin level after surgery, they did note that postoperative anemia was associated with preoperative anemia (0% vs. 45%, P<0.0001). Moreover, patients with postoperative anemia were more likely to be re-admitted within 30 days after surgery (7% vs. 23%, P=0.025). 

Of the 3 patients who received blood transfusions after surgery, all had a preoperative hemoglobin level <9.5 g/dL. In contrast, only 2.5% of those who did not receive a blood transfusion after surgery had a preoperative hemoglobin level <9.5 g/dL.

“Our findings suggest that routine hemoglobin testing has little clinical benefit following robotic hysterectomy and should be reserved for patients with a preoperative hemoglobin of less than 10 g/dl,” Dr. Cardenas-Goicoechea and team concluded. “We recommend judicious use of postoperative hemoglobin level testing following robotic hysterectomy and to consider checking the postoperative hemoglobin level for patients with anemia preoperatively. Patients with perioperative iron deficiency anemia should be medically optimized before surgery with oral iron without delaying cancer treatment.”

In addition, the team estimated that avoiding routine hemoglobin testing after hysterectomy for the study patients could have saved $3,629 in institutional charges and $1,236 in Medicare charges during the study period.

“Substantial cost savings would result from judicious use of hemoglobin level testing following robotic hysterectomy,” the researchers concluded, adding, “Clinical practice change can reduce healthcare costs without hindering patient care.”