Predicting postoperative day 1 hematocrit levels after hysterectomy for malignant indication: Validating a previously published model.

OBJECTIVE: To determine whether the Swenson model of postoperative day 1 (POD1) hematocrit after benign hysterectomy is applicable to gynecologic oncology hysterectomies. METHODS: Data were retrospectively collected from cases of hysterectomy with malignant pathology in Hartford, USA, from 2014 to 2016. Predicted POD1 hematocrit was compared with actual hematocrit. ROC curve analysis was used to determine the optimal cut-off point for predicting hematocrit levels of 30% or less. RESULTS: Among 107 women, mean age was 62.9 years and body mass index was 34.0. Most underwent robotic (44.9%) or abdominal (43.9%) hysterectomy. The published equation correctly predicted hematocrit to within ±5% for 83.2% of women, which was less accurate than observed in the original validation set. The equation was more likely to underestimate lower hematocrit levels, adding safety to its use. By ROC curve analysis, the best cut-off point for predicting actual hematocrit above 30% was predicted hematocrit 32.3% (100% specificity). CONCLUSION: The Swenson equation predicted POD1 hematocrit less accurately in the current dataset. As a screening tool for hematocrit below 30%, however, ordering postoperative hematocrit is probably unnecessary if the predicted value is 32.3% or higher. This equation should be used as a screening tool to reduce unnecessary laboratory tests.

Predicting postoperative day 1 hematocrit levels after hysterectomy.

BACKGROUND: The Swenson model was developed as a linear regression model to estimate postoperative day 1 hematocrit levels after benign hysterectomy. Predictive variables included preoperative hematocrit level, patient weight, estimated blood loss, intraoperative crystalloid volume, preoperative platelet count, and hysterectomy route that predicted postoperative day 1 hematocrit level at ±5% for 100% of patients who used an internal validation set. OBJECTIVE: We aimed to validate externally the Swenson model using our hysterectomy population and to further validate the model in a cohort that included robotic-assisted cases. STUDY DESIGN: In a retrospective cohort, data were collected from benign hysterectomies from April 2014 through May 2016. Predicted postoperative day 1 hematocrit level was calculated with the use of the Swenson equation and compared with measured hematocrit values. We compared our results to the Swenson model results using chi-square or Fisher's exact test. We then restricted our analysis to those with actual postoperative day 1 hematocrit level of ≤30%, to determine whether the model performed accurately in this subgroup that may need intervention. We generated a receiver-operating characteristic curve with Louden Index to determine the best cut-point from the Swenson hematocrit level projections for the prediction of an actual hematocrit level of ≤30%. Furthermore, we stratified the Swenson model predicted hematocrit level into 4 ranges: <32%, 32-35%, 35-38%, and >38%. This stratification allowed us to assess the differential accuracy of the Swenson model across hematocrit level ranges. RESULTS: Of 602 hysterectomies, 478 patients had all the variables that were needed for the Swenson model and postoperative day 1 hematocrit level for comparison. The Swenson model was significantly less accurate in our data compared with their validation set with fewer patients whose predicted hematocrit level was accurate at different thresholds from ±1% through ±5% of actual hematocrit level (all P<.001). Only 76.8% of the predicted hematocrits were accurate within ±5%. Analysis of variance showed accuracy that was similar among different surgical routes (P=.193). A quadratic best-fit curve showed accuracy was maximized when hematocrit level of 36.2%. Projected hematocrit level was ±2.5% of actual but deteriorated at higher and lower hematocrit level values. When the analysis was restricted to those patients with postoperative day 1 hematocrit levels of ≤30%, accuracy was worse, with only 55.3% of predicted hematocrit level values within ±5%. In this subset, the Swenson equation was more likely to overestimate hematocrit level and give false reassurance. A receiver-operating characteristic curve analysis showed that the best Swenson cut-point for the prediction of an actual hematocrit level of ≤30% was 31.9% (sensitivity, 75.5%; specificity, 64.0%). Finally, predicted hematocrit level was divided into 4 groups: <32%, 32-35%, 35-38%, and >38%. When predicted hematocrit level was <32% (n=164), the model was more likely to under-predict hematocrit level and was least accurate in the subset of patients who were most likely to need intervention. When predicted hematocrit level was 32-35% (n=192), 17.2% of the patients (approximately 1 in 6) had an actual postoperative day 1 hematocrit level of ≤30%. When a predicted hematocrit level of ≥35% was used as a cut-off point, the percentage of patients who had an actual postoperative day 1 hematocrit level of ≤30% dropped to 8.2%. No patients had an actual hematocrit level of <24%, which makes this a reasonable choice for screening for anemia. CONCLUSION: Although the Swenson model was reliable for the prediction of postoperative day 1 hematocrit level in their internal validation set, it did not perform as well in our hysterectomy population. It may have utility as a screening tool if the projected hematocrit level was ≥35%. Further research is needed to create a model for the prediction of postoperative day 1 hematocrit level that can be incorporated into standard practice.

Effects of Endometrial Ablation on Treatment Planning in Women With Endometrial Cancer.

To evaluate effects of endometrial ablation on the staging and treatment planning of postablation endometrial cancer. After authorization from the institutional review board, we performed a retrospective chart review of patients with a history of endometrial ablation and a subsequent diagnosis of endometrial cancer from July 2006 to December 2013. The information obtained included patient's age at time of cancer diagnosis, pre-ablation endometrial biopsy histology, dilation and curettage histology at time of ablation, endometrial biopsy-to-ablation interval, ablation-to-hysterectomy interval, final pathologic diagnosis, Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) staging, and treatment recommendations for adjuvant therapy. The histopathology was examined by a gynecologic pathologist. The National Comprehensive Cancer Network guidelines were applied to determine need for adjuvant therapy. Six of 490 (1.2%) patients with endometrial cancer were identified to have an antecedent ablation. Mean patient age was 48.2 years (range: 40-53). The time interval from office pre-ablation endometrial sampling to ablation ranged from 1 to 17 months. Four patients (67%) had an undetected endometrial cancer at the time of ablation, despite having benign pre-ablation histology. Following surgical staging, 4 patients (67%) had no evidence of residual carcinoma, and 2 (33%) had evidence of endometrial adenocarcinoma grades 1 to 2. There was no evidence of myometrial invasion in all cases, and a FIGO stage of IA was assigned. No adjuvant therapies were indicated. There have been no documented cancer recurrences, with a follow-up range from 16 to 52 months (average 30.2). Endometrial ablation artifact does not appear to hinder evaluation and treatment planning in the presence of endometrial cancer.

Robotic Surgery Training in an OB/GYN Residency Program: A Survey Investigating the Optimal Training and Credentialing of OB/GYN Residents.

OBJECTIVE: Many community hospital gynecologic surgery training programs now include robotics.At St. Francis Hospital and Medical Center, we have integrated robotic surgical training since 2006. This study is designed to assess the success in training gynecology residents in robotic surgery. DESIGN: An anonymous web-based survey tool (www. survey monkey. com) was sent to all Ob/Gyn residency graduates from 2007-2010 (n = 17). From 2011-2014, we emailed three reevaluation questions to all 2007-2014 graduates (N = 32). Design Classification: II-3. RESULTS: The response rate was 95%, and 11 of 17 initial graduates (65%) indicated that they had received adequate robotic training. Currently, 24 of 32 (75%) graduates practice in hospitals with robotic availability. Twenty of the 32 graduates (63%) are using robotics in their surgical practices. Nine of these 20 graduates (45%) were fully credentialed following their residency. The other 11 graduates (55%)required further proctoring to obtain full robotic credentials. CONCLUSION: Robotic surgical training is a component of modern gynecologic surgical training. Postresidency robotic credentialing is a realistic graduation goal for residents who plan to practice gynecologic surgery.

Adjuvant treatment for early ovarian cancer: a randomized phase III trial of intraperitoneal 32P or intravenous cyclophosphamide and cisplatin--a gynecologic oncology group study.

PURPOSE: To conduct a prospective study of intraperitoneal radioactive chromic phosphate (32P) versus cyclophosphamide-cisplatin (CP) in women with early ovarian cancer at high risk for recurrence (International Federation of Gynecology and Obstetrics stage Ia or Ib grade 3 or Ic or stage II, no macroscopic residual disease) and to compare cumulative incidence of recurrence, overall survival, and relative toxicity. MATERIALS AND METHODS: A total of 251 patients were randomly assigned to treatment with 32P or CP. Twenty-two (8.7%) were ineligible following centralized pathology review. Of the 229 patients included in the analysis, 110 received 32P, and 119 received CP. RESULTS: The cumulative incidence of recurrence at 10 years was 35% (95% CI, 27% to 45%) for patients receiving 32P and 28% (95% CI, 21% to 38%) for those receiving CP. Patients receiving CP had a recurrence rate 29% lower than that of those receiving 32P (P =.15, two-tail test). The death rate for patients treated with CP was 17% lower than that for patients treated with 32P (difference not significant). Combining both arms, the 10-year cumulative incidence of recurrence for all stage I patients was 27% (95% CI, 20% to 34%) compared with 44% (95% CI, 32% to 56%) for stage II patients (P =.01). Both regimens were reasonably well tolerated, but problems with inadequate distribution (7%) and small-bowel perforation (3%) make the otherwise less toxic 32P less acceptable. CONCLUSION: Although there are no statistically significant differences in survival, the lower cumulative recurrence seen with CP and complications of 32P administration make platinum-based combinations the preferred adjuvant therapy for early ovarian cancer patients at high-risk for recurrence.