Abstract
Objective
To describe patient-reported postoperative symptoms and to evaluate the use of digital symptom tracking and alerts to detect postoperative complications.
Methods
We retrospectively reviewed patients who underwent a minimally invasive hysterectomy and enrolled in our Recovery Tracker program from 4/5/17–12/31/21. The Recovery Tracker is an at-home virtual tool used to track patient-reported postoperative symptoms for 10 days. Predefined thresholds for “red” and “yellow” alerts are based on symptom severity and timing. Data on patient demographics, surgery, and postoperative course were collected to evaluate the association of alerts with complications and compare outcomes of patients who did/did not enroll in the program.
Results
Of 2362 eligible patients, 1694 (71.7%) enrolled in the Recovery Tracker program. Pain was the most severe symptom, followed by fatigue. Eighty-seven patients experienced 102 complications (5.1% complication rate) and 32 experienced 39 grade ≥2 complications (1.9% severe complication rate).
Excluding complications that occurred prior to Recovery Tracker use, 1673 patients experienced 28 grade ≥2 complications. Of 345 patients (20.6%) who triggered a red alert, 13 (3.8%) had a grade ≥2 complication. Of 1328 patients (79.4%) with no red alerts, 15 (1.13%) had a grade ≥2 complication. Relative risk of a grade ≥2 complication if a red alert was triggered was 3.25 (95% CI: 1.6–6.9, P=.002). Rate of severe complications was significantly higher among patients who did not use the tool (3.3% vs 1.9%; P=.04).
Conclusions
The Recovery Tracker tool may assist in early identification of postoperative symptoms after minimally invasive hysterectomy.
Keywords: digital health, minimally invasive hysterectomy, patient-reported symptoms, postoperative complications, postoperative recovery, Recovery Tracker
Introduction
Approximately 600,000 women in the United States undergo a hysterectomy each year.1 An increasing number of these procedures are performed with minimally invasive surgical (MIS) techniques and use enhanced surgical recovery pathways. Same-day discharge and enhanced recovery pathways have been shown to improve patient outcomes and satisfaction and decrease costs, with no increase in complication rates, for various surgical procedures, including minimally invasive hysterectomy.2–6 As a function of these improvements, more patients complete the majority of their acute surgical recovery at home,7–9 which necessitates new models of postoperative follow-up. Many gynecologic surgeons and hospital systems have created digital tools to connect with patients during the postoperative period. Tools include text messages with discharge instructions, symptom surveys, and phone calls with automated alerts, all of which have been shown to improve patient connectedness and satisfaction, as well as postoperative outcomes.10–16
Our gynecologic surgery group piloted a web-based model of symptom tracking, which demonstrated feasibility with once-weekly patient evaluations. This led to a pilot study of a daily postoperative tracking tool, which also demonstrated feasibility, with patients reporting high satisfaction with the tool.13,17 Increased recovery time at home in patients who undergo minimally invasive hysterectomy may influence patients’ desire to communicate their personal experience with surgical recovery; for example, patients may engage with others on online platforms to compare experiences, understand what to expect in advance of surgery, and ascertain whether their postoperative experiences are “typical.”18
Despite increased efforts to engage with patients following discharge, large series of patient-reported symptoms after a minimally invasive hysterectomy are lacking in the literature. Thus, patient counseling is based on smaller patient series or anecdotal experience.
We previously demonstrated a decrease in urgent care and emergency room visits after implementation of the Recovery Tracker, an at-home symptom monitoring tool, for patients who underwent outpatient surgery.11 Additionally, the urologic group at our institution demonstrated an association between automatically generated alerts and postoperative complications.12 We have not, however, assessed the extent to which the Recovery Tracker can aid in the identification of potential complications in patients after a minimally invasive hysterectomy.
The primary objective of this study was to describe the typical postoperative course following a minimally invasive hysterectomy. Our secondary objective was to use symptom reporting to aid in the prediction and early detection of complications. We sought to evaluate the utility of the Recovery Tracker and its alert systems to identify complications by assessing the association between symptoms after a minimally invasive hysterectomy and reported complications. We discuss broader findings and implications for using patient-reported symptoms to identify potential surgical complications. This information can be used for more accurate patient counseling, which can improve patient expectations and normalize the experience of an uncomplicated surgical recovery.
Materials and Methods
We performed a retrospective cross-sectional study of all patients who underwent a minimally invasive hysterectomy, were booked for 23-hour stay at our institution between April 5, 2017, and December 31, 2021, and who were offered enrollment into the Recovery Tracker program. The Recovery Tracker was implemented at our institution in 2016 and introduced to patients undergoing hysterectomy in 2017.12
Patients are offered enrollment into the Recovery Tracker program in their discharge paperwork and via the patient portal. The tool is designed to capture patient-reported postoperative symptoms daily for 10 days after surgery during at-home recovery. Patients receive daily emails with questions about postoperative symptoms based on items adapted from the National Cancer Institute’s Patient-Reported Outcomes version of the Common Terminology for Adverse Events. Symptoms assessed include pain, fatigue, nausea, vomiting, swelling, bruising, chills, and shortness of breath. Symptoms are reported by patients on a Likert Scale of 0–4, with 0 indicating no symptoms, 1 indicating mild symptoms, 2 indicating moderate symptoms, 3 indicating severe symptoms, and 4 indicating very severe symptoms. Predefined thresholds, defined as “yellow alerts” and “red alerts,” are based on symptom severity and timing postoperatively; the thresholds were created by our institution based on expert opinion (Supplementary Table S1). A red alert notifies the patient to contact the doctor’s office immediately and also notifies the surgical team to call the patient. A yellow alert notifies the surgical team that the patient should be assessed by telephone or secure message during regular office hours.
During the early part of the study period (September 2017- September 2019), 90 of the included patients were also enrolled in an “Enhanced Feedback” study for yellow alerts. Instead of notifying the surgical team, these patients received written explanations regarding their reported symptoms. On February 16, 2021, the “Enhanced Feedback” tool was incorporated for all Recovery Tracker users. Complications are collected in real time based on monthly chart reviews and graded using the Memorial Sloan Kettering Cancer Center Secondary Events Grading System, which is a modification of the Clavien-Dindo classification, as previously described.19
First, we examined the trend of symptoms over the 10-day postoperative period. Additionally, we described the number of patients reporting symptoms by severity level on each postoperative day (POD). Next, we evaluated the association between red alerts and grade ≥2 complications and grade 3 complications using a univariate analysis. We then performed the same analysis between any alert (yellow or red) and grade ≥2 complications and grade 3 complications. Patients with complications who did not use the Recovery Tracker prior to onset of their complications were excluded from this analysis. Lastly, we compared patients who did and did not use the tool, including characteristics of surgery and complications.
Data description and analyses were performed using R, ggplot, and CompareGroups packages. Institutional Review Board exemption was obtained for this retrospective study (IRB #17–544).
Results
A total of 2362 patients were eligible and invited to participate in the Recovery Tracker program. Of those invited, 1694 patients (71.7%) completed at least 1 survey in the postoperative period. Enrolled patients completed a median of 7 surveys. Table 1 details the clinical characteristics of Recovery Tracker responders. Overall, 989 patients (58.4%) had a cancer diagnosis and 185 (10.9%) had a diagnosis of cervical carcinoma in situ or endometrial intraepithelial neoplasia. Forty patients (2.4%) had a procedure coded as a radical hysterectomy, and 990 patients (58.4%) underwent lymph node dissection, including sentinel lymph node biopsy, as part of their surgery. The median length of surgery was 117 minutes (range, 95–146 minutes), and the median length of postoperative stay was 15.7 hours (range, 6.4–20.3 hours); 639 patients (38%) were discharged on the day of surgery.
Table 1 –
Patient characteristics.
| Characteristic | No. of patients (N = 1694) |
|---|---|
|
| |
| Median age, years (interquartile range) | 56 (47–64) |
| Diagnoses | |
| Benign | 520 |
| Cancer | 989 |
| Uterine | 842 |
| Cervical | 47 |
| Ovarian | 52 |
| Other | 48 |
| Carcinoma in situ | 185 |
| Endometrial intraepithelial neoplasia | 154 |
| Cervical carcinoma in situ | 31 |
| Surgery | |
| TLH | 697 |
| TLH with LND | 957 |
| Laparoscopic radical hysterectomy | 7 |
| Laparoscopic radical hysterectomy with LND | 33 |
| Median length of surgery, minutes (interquartile range) | 117 (95–146) |
| Median length of stay, hours (interquartile range) | 15.7 (6.4–20.3) |
| Median # of postop surveys completed (interquartile range) | 7 (4–9) |
| Number of complications (# of pts, complication rate) | 102 (87 patients, 5.1%) |
| # of grade 3 complications | 17 (16 patients, 0.9%) |
| # of grade 2 complications | 22 (18 patients, 1.1%) |
TLH = total laparoscopic hysterectomy, with or without robot assistance; LND = lymph node dissection, sentinel or complete; Postop = postoperative; pts, patients
Average symptom scores by day are shown in Figure 1 as a linear regression with 95% confidence intervals (CIs). Pain was the most severe reported symptom, with an average score of 1.77 on POD 1, which decreased to <1 by POD 7. The second most severe symptom was fatigue, with an average score of 1.44 on POD 1, which decreased to <1 by POD 8. Bruising increased from an average score of 0.67 on POD 1 to a peak of 0.92 on POD 5, after which it decreased again. Patients reported an average score of 0.25 for shortness of breath on POD 1, which increased slightly to 0.39 on POD 2 before decreasing again. For swelling, patients had an average score of 0.74 on POD 1, which increased to 0.79 on POD 2 and subsequently decreased. Other symptoms monitored (nausea, vomiting, chills) indicated initial average scores in the mild range (≤1) before decreasing on subsequent days.
Figure 1 –
Average scores of each symptom, by postoperative day.
Figure 2 displays the percentage of patients who experienced symptoms by severity on each POD. Nearly 100% of patients reported some level of postoperative pain. Approximately 13% of patients had severe pain on PODs 1 and 2, which decreased to 5% on POD 3 and continued to decrease thereafter. Eighty percent of patients had mild or moderate pain over PODs 1–3, with an increasing proportion of patients with mild pain on each subsequent day. On POD 1, 85% of patients reported fatigue, with approximately 10% of patients reporting severe fatigue. The fatigue score improved on POD 2 and continued to improve thereafter. By POD 7, 70% of patients reported any fatigue and <2% of patients reported severe fatigue. Approximately 30% of patients experienced shortness of breath on POD 2, with <1% reporting severe shortness of breath, both of which decreased on each subsequent day. Greater than 70% of patients reported no nausea after surgery and <2% of patients had severe nausea on POD 1. Nausea improved for all patients each POD. Approximately 3% of patients reported any vomiting after surgery. Twenty percent of patients reported chills, with the highest levels reported on POD 1, which improved on each subsequent POD. Bruising increased from more than half of patients with bruising on POD 1 to a peak of >70% of patients with bruising on POD 5, which decreased thereafter. More than half of patients reported swelling on POD 1; just under half of patients reported swelling by POD 5.
Figure 2 –
Percentages of reported symptom severity, by postoperative day.
There were 102 total complications in 87 patients (5.1% complication rate), with 39 grade ≥2 complications in 32 patients (1.9% severe complication rate). Grade 2 and 3 complications are summarized in Table 2. There were 17 grade 3 complications in 16 patients. Of the patients with grade 3 complications, 3 did not fill out Recovery Tracker surveys until after they experienced a complication. The most common grade 3 complications were infection related; there were 9 intrabdominal collections or infections and 4 wound infections or abscesses. Additional grade 3 complications included bleeding, urinary tract injury, and cardiac complications (ie, acute myocardial infarction). There were 22 grade 2 complications reported in 18 patients; 4 patients did not fill out Recovery Tracker surveys until after they experienced a complication. There were 7 infection-related complications (5 intrabdominal collections or infections and 2 wound infections or abscesses) and 7 episodes of venous thromboembolism. There were 2 bleeding complications, 2 urinary tract infections (UTIs), 1 cardiac complication, and 1 small bowel obstruction. No grade 4 or grade 5 complications were reported.
Table 2 –
Description of all grade 2 and 3 complications.
| Complication | G2 complications (n=22) | G3 complications (n=17) |
|---|---|---|
|
| ||
| Intra-abdominal collection or infection | 5 (22.7%) | 9 (52.9%) |
| Wound infection or abscess | 2 (9.1%) | 4 (23.5%) |
| DVT/PE | 7 (31.8%) | 0 |
| Bleeding | 2 (9.1%) | 2 (11.8%) |
| UTI | 2 (9.1%) | 0 |
| Urinary tract injury | 0 | 1 (5.9%) |
| Cardiac | 1 (4.55%) | 1 (5.9%) |
| Small bowel obstruction | 1 (4.55%) | 0 |
| Prolonged intubation | 1 (4.55%) | 0 |
| Clostridium difficile infection | 1 (4.55%) | 0 |
G2 = grade 2; G3 = grade 3; DVT = deep vein thrombosis; PE = pulmonary embolism; UTI = urinary tract infection
After excluding all complications that occurred prior to Recovery Tracker use (n=21 patients), there were 28 patients with grade ≥2 complications among 1673 patients. The association between red alerts and complications is reported in Table 3. A total of 345 patients (20.6%) experienced a red alert. Of these patients, 13 had a grade ≥2 complication (3.77%). There were 1328 patients (79.4%) with no red alerts on their surveys. Of these patients, 15 (1.13%) had a grade ≥2 complication. The relative risk of grade ≥2 complication if a red alert was triggered was 3.25 (95% CI: 1.6–6.9, P=.002). Red alerts identified 13 (46.4%) of 28 patients who had a grade ≥2 complication. With respect to the red alert as a threshold test for complications, we report 46% sensitivity, 79.8% specificity, 3.8% positive predictive value, and 98.9% negative predictive value.
Table 3 –
Red alerts and complications.
| Complication Grade | Red Alert | No Red Alert | P value |
|---|---|---|---|
| No. of patients (n=345) | No. of patients (n=1328) | ||
|
| |||
| ≥G2 complications | 13 (3.77%) | 15 (1.13%) | .002 |
| G3 complications | 5 (1.45%) | 10 (0.75%) | .211 |
G2 = grade 2; G3 = grade 3
A total of 668 patients were offered enrollment in the Recovery Tracker program but did not use the tool. Twenty-eight patients were excluded from analysis (n=22 converted to open surgery and thus were not eligible for Recovery Tracker enrollment, and n=6 had minimally invasive non-hysterectomy procedures). Supplementary Table S2 compares patients who did and did not enroll in the Recovery Tracker program. Patients had similar rates of benign versus oncologic procedures (56.9% of non-Recovery Tracker users and 58.4% of Recovery Tracker users underwent an oncologic procedure). Patients who did not use Recovery Tracker had a higher rate of radical hysterectomy with lymph node dissection (4.4% versus 1.9%), while patients who used Recovery Tracker had a higher rate of total laparoscopic hysterectomy with lymph node dissection (50.6% versus 56.5%, P=.002). Patients who did not use Recovery Tracker also had a longer length of surgery (131 minutes versus 126 minutes, P=.02) and a longer length of stay (25 hours versus 14.4 hours, P<.001). Among the group of 640 patients, there were 48 total complications in 40 patients (7.5% complication rate) and 25 grade ≥2 complications in 21 patients (3.3% severe complication rate; grade ≥2 complications are detailed in Supplementary Table S3). The grade ≥2 complication rate was significantly higher in patients who did not use the Recovery Tracker compared to those who did (1.9% severe complication rate; P=.04).
Discussion
In this study, we describe patient-reported symptoms for 10 consecutive days of at-home recovery following minimally invasive hysterectomies for benign or oncologic indications across 1694 patients. We found that red alerts triggered by patient-reported symptoms were associated with a statistically significant increase in the rate of grade ≥2 complications, and that use of the Recovery Tracker was associated with a decreased rate of severe complications. Thus, during postoperative recovery, it is possible to identify patients at a higher risk for complications based on reported symptoms, and potentially to avoid severe complications. Overall, most patients reported mild to moderate symptoms. As displayed in Table 1, the confidence intervals are very narrow for our patient-reported symptoms, suggesting the average is representative of most patients’ experience and has broad utility for counseling of future patients. The most common symptoms reported were pain and fatigue. Most patients also reported mild bruising and swelling. A small but significant portion of patients reported nausea, shortness of breath, and chills, but very few experienced vomiting.
Prior studies have described postoperative trajectories in smaller groups of patients who underwent minimally invasive or open hysterectomies.13,20 For example, one prior study evaluated 97 patients who underwent a minimally invasive hysterectomy. Similar to our current study, most patients reported mild to moderate symptoms, with pain and swelling being the most common symptoms reported; although, fatigue was not evaluated and there was a higher percentage of patients who reported severe pain in the first 2 days postoperatively. In a pilot study of perioperative trajectory by Meyer et al, 29 patients were evaluated, 22 of whom were diagnosed with ovarian cancer and underwent debulking surgery. The authors found that the symptoms with the highest postoperative burden were pain, abdominal pain, fatigue, dry mouth, and drowsiness; the highest symptom burdens were found on days 1 and 6.
Using symptoms to predict complications is an area of great interest, given the high volume of minimally invasive hysterectomies performed nationally. Patients with red alerts had a relative risk of 3.25 for severe complications, and the alerts detected approximately half of the complications. The alerts, however, did not identify the other half of patients with complications and only had a 3.8% positive predictive value. The red alerts did, however, have a negative predictive value of 98.9%, which highlights its potential as a threshold test to rule-out complications (ie, if someone does not generate a red alert, they are very unlikely to have a grade ≥2 complication). Similar to our findings, the urologic group at our institution found an association between alerts and high-grade complications in patients who underwent a radical prostatectomy. They found a 1.3% increase in detection of complications in patients with no red or yellow alerts and a 3.0% increase in patients with a red or yellow alert (P=.026).14
When comparing patients who chose not to enroll in the Recovery Tracker to those who did, we found a similar overall complication rate between the two groups, but a longer length of stay and a significantly higher rate of grade ≥2 complications among the 640 patients who were offered enrollment but did not enroll. This finding warrants future investigation into the role of the Recovery Tracker and understanding of which patients choose to enroll. Selection bias may have influenced these findings, as patients who are at risk for complications (eg, patients with more complex surgery, patients without access to regular phone/portal use, or patients with lower health literacy) self-selected into the group that did not enroll in the Recovery Tracker program. We seek to improve enrollment in the Recovery Tracker program among these patients, and study prospectively as we hypothesize that the Recovery Tracker may lead enrolled patients to earlier care and enable them to receive an intervention prior to the development of a grade ≥2 complication.
This study has widely applicable findings for patients who undergo and surgeons who perform minimally invasive hysterectomies. During preoperative counseling, our findings can help establish patient expectations for surgical recovery and prepare patients for the postoperative period. Further, during postoperative recovery, these data can help patients normalize their experience in the context of typical recovery trajectories, which may help mitigate stress and fear for some patients during their recovery process and potentially prevent them from seeking anecdotal answers via online communities.
Our findings indicate that patient-reported symptoms may be an early predictor of complications, although additional research is needed. One reason the alert system may have a statistically significant increase in complication prediction but a low positive predictive value is due to low prevalence of complications in patients who undergo a minimally invasive hysterectomy. The Recovery Tracker may have a stronger positive predictive value if used by patients who undergo surgeries with higher rates of complications (eg, open gynecologic surgery requiring inpatient admission).
Our work may also be improved by evaluating the symptoms tracked within the Recovery Tracker. For example, one group at the MD Anderson Cancer Center has worked to define and standardize perioperative symptom burden in patients with gynecologic cancer.21 In their study, they identified nine symptoms – bloating, abdominal cramping, constipation, diarrhea, dizziness, grogginess/confusion, urinary pain, inability to urinate/difficulty urinating, and hot flashes – to measure interference with functioning during perioperative care for benign or oncologic gynecologic surgery. In future developments of the Recovery Tracker, gynecology-specific tools may help to better track postoperative trajectories and perhaps aid in the early detection of complications.
Our study is the largest of its kind to date, with the evaluation of patient-reported symptoms after a hysterectomy in almost 1700 patients. This study is limited, however, by its retrospective nature. It was also performed at a single institution, which may increase selection bias and decrease population diversity. As noted, because complication events are rare, our ability to evaluate its association with symptom severity is limited.
In conclusion, using the Recovery Tracker to track patient outcomes following a hysterectomy enables clinicians to better describe postoperative recovery and to improve patient counseling, both before and after a minimally invasive hysterectomy. Using the Recovery Tracker early, in combination with measuring clinical outcomes, shows the potential benefit of using alert systems to improve the prediction of complications. Future work is needed to assess the Recovery Tracker in an expanded population of patients, starting with patients (after discharge) who were admitted for gynecologic surgery, and to consider the implementation of questions specific to gynecologic surgery.
Supplementary Material
Highlights.
We report patient-reported symptoms and association with complications in patients after minimally invasive hysterectomy
The most common symptoms reported by patients following minimally invasive hysterectomy were pain and fatigue
Use of the digital at-home Recovery Tracker tool was associated with a decrease in severe postoperative complications
Red alerts triggered by patient-reported symptoms were associated with a significant increase in grade ≥2 complications
The Recovery Tracker tool may aid in the early detection of complications following minimally invasive hysterectomy
Funding:
This work was supported by the National Cancer Institute at the National Institutes of Health (P30CA008748). NCI/NIH had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication.
Footnotes
Conflict of Interest Statement
D. Chi reports personal fees from Apyx Medical, Verthermia Inc., Biom ‘Up, and AstraZeneca, as well as recent or current stock/options ownership of Apyx Medical, Verthemia, Intuitive Surgical, Inc., TransEnterix, Inc., Doximity, Moderna, and BioNTech SE. N. Abu-Rustum reports grant funding from GRAIL paid to the institution. M. M. Leitao is an ad hoc speaker for Intuitive Surgical, Inc.; outside the submitted work, he is on the Advisory Board of Ethicon/Johnson & Johnson and Takeda; and reports grants paid to the institution by KCI/Acelity. E. Jewell reports personal fee from Covidien/Medtronic. J. Cracchiolo reports personal fees from Medscape for a lecture. All other authors have no potential conflicts of interest to disclose.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
References
- 1.Cohen SL, Vitonis AF, Einarsson JI. Updated hysterectomy surveillance and factors associated with minimally invasive hysterectomy. JSLS. Jul-Sep 2014;18(3). doi: 10.4293/JSLS.2014.00096 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Melamed A, Katz Eriksen JL, Hinchcliff EM, et al. Same-day discharge after laparoscopic hysterectomy for endometrial cancer. Ann Surg Oncol. Jan 2016;23(1):178–85. doi: 10.1245/s10434-015-4582-4 [DOI] [PubMed] [Google Scholar]
- 3.Bisch SP, Jago CA, Kalogera E, et al. Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology - a systematic review and meta-analysis. Gynecol Oncol. Apr 2021;161(1):46–55. doi: 10.1016/j.ygyno.2020.12.035 [DOI] [PubMed] [Google Scholar]
- 4.Smith TW Jr., Wang X, Singer MA, Godellas CV, Vaince FT. Enhanced recovery after surgery: a clinical review of implementation across multiple surgical subspecialties. Am J Surg. Mar 2020;219(3):530–4. doi: 10.1016/j.amjsurg.2019.11.009 [DOI] [PubMed] [Google Scholar]
- 5.Meyer LA, Lasala J, Iniesta MD, et al. Effect of an enhanced recovery after surgery program on opioid use and patient-reported outcomes. Obstet Gynecol. Aug 2018;132(2):281–290. doi: 10.1097/AOG.0000000000002735 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced recovery pathways for improving outcomes after minimally invasive gynecologic oncology surgery. Obstet Gynecol. Jul 2016;128(1):138–144. doi: 10.1097/AOG.0000000000001466 [DOI] [PubMed] [Google Scholar]
- 7.Cappuccio S, Li Y, Song C, et al. The shift from inpatient to outpatient hysterectomy for endometrial cancer in the United States: trends, enabling factors, cost, and safety. Int J Gynecol Cancer. May 2021;31(5):686–693. doi: 10.1136/ijgc-2020-002192 [DOI] [PubMed] [Google Scholar]
- 8.Desai VB, Xu X. An update on inpatient hysterectomy routes in the United States. Am J Obstet Gynecol. Nov 2015;213(5):742–3. doi: 10.1016/j.ajog.2015.07.038 [DOI] [PubMed] [Google Scholar]
- 9.Cohen SL, Ajao MO, Clark NV, Vitonis AF, Einarsson JI. Outpatient hysterectomy volume in the United States. Obstet Gynecol. Jul 2017;130(1):130–7. doi: 10.1097/AOG.0000000000002103 [DOI] [PubMed] [Google Scholar]
- 10.Meirte J, Hellemans N, Anthonissen M, et al. Benefits and disadvantages of electronic patient-reported outcome measures: systematic review. JMIR Perioper Med. Apr 3 2020;3(1):e15588. doi: 10.2196/15588 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Pusic AL, Temple LK, Carter J, et al. A randomized controlled trial evaluating electronic outpatient symptom monitoring after ambulatory cancer surgery. Ann Surg. Sep 1 2021;274(3):441–8. doi: 10.1097/SLA.0000000000005005 [DOI] [PubMed] [Google Scholar]
- 12.Simon BA, Assel MJ, Tin AL, et al. Association between electronic patient symptom reporting with alerts and potentially avoidable urgent care visits after ambulatory cancer surgery. JAMA Surg. Aug 1 2021;156(8):740–6. doi: 10.1001/jamasurg.2021.1798 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Zivanovic O, Chen LY, Vickers A, et al. Electronic patient-reported symptom monitoring in patients recovering from ambulatory minimally invasive gynecologic surgery: a prospective pilot study. Gynecol Oncol. Oct 2020;159(1):187–194. doi: 10.1016/j.ygyno.2020.07.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Clements MB, Tin AL, Estes CL, et al. Characterization of symptoms after radical prostatectomy and their relation to postoperative complications. J Urol. Feb 2022;207(2):367–374. doi: 10.1097/JU.0000000000002202 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Sajnani J, Swan K, Wolff S, Drummond K. Discharge instruction reminders via text messages after benign gynecologic surgery: quasi-experimental feasibility study. JMIR Perioper Med. Dec 14 2021;4(2):e22681. doi: 10.2196/22681 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Bouwsma EVA, Huirne JAF, van de Ven PM, et al. Effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: cluster controlled trial with randomised stepped-wedge implementation. BMJ Open. Jan 30 2018;8(1):e017781. doi: 10.1136/bmjopen-2017-017781 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Cowan RA, Suidan RS, Andikyan V, et al. Electronic patient-reported outcomes from home in patients recovering from major gynecologic cancer surgery: a prospective study measuring symptoms and health-related quality of life. Gynecol Oncol. Nov 2016;143(2):362–6. doi: 10.1016/j.ygyno.2016.08.335 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Dave A, Yi J, Boothe A, Brashear H, Byrne J, Gad Y. Listening to the HysterSisters: a retrospective keyword frequency analysis of conversations about hysterectomy recovery. JMIR Perioper Med. Sep 26 2019;2(2):e10728. doi: 10.2196/10728 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Strong VE, Selby LV, Sovel M, et al. Development and assessment of Memorial Sloan Kettering Cancer Center’s Surgical Secondary Events grading system. Ann Surg Oncol. Apr 2015;22(4):1061–7. doi: 10.1245/s10434-014-4141-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Meyer LA, Nick AM, Shi Q, et al. Perioperative trajectory of patient reported symptoms: a pilot study in gynecologic oncology patients. Gynecol Oncol. Mar 2015;136(3):440–5. doi: 10.1016/j.ygyno.2015.01.547 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Wang XS, Shi Q, Williams LA, et al. Validation and application of a module of the MD Anderson Symptom Inventory for measuring perioperative symptom burden in patients with gynecologic cancer (the MDASI-PeriOp-GYN). Gynecol Oncol. Mar 2019;152(3):492–500. doi: 10.1016/j.ygyno.2018.11.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.