A retrospective evaluation of the perioperative drug use and comparison of its cost in robotic vs open surgery for endometrial cancer

  • Reshu Agarwal
  • Anupama Rajanbabu
  • U. G. Unnikrishnan
Original Article


To compare the usage and cost of analgesics (opioid and non-opioids), antiemetics, and IV fluids and its associated costs in robotic vs open staging surgery for endometrial cancer (EC). This retrospective study was performed at a single academic institution from January 2014 to June 2017 in the department of Gynecology Oncology at Amrita Institute of Medical Science, Kerala, India. The study included women with biopsy confirmed clinically early stage endometrial cancer or atypical hyperplasia, who underwent robotic-assisted or open staging surgery. Data on surgical time, blood loss, post-anaesthesia care unit (PACU) stay, and length of hospital (LOH) stay; analgesic, antiemetic, and IV fluid use were collected for three distinct periods: intra-operative, PACU, and ward. Direct medicine and material costs associated with the administration of intravenous (IV) fluids, analgesics, and antiemetics were collected. All parameters were compared between two surgical groups. The study included 133 (54 open and 79 robotic-assisted) patients. As compared to open surgery, robotic-assisted surgery was associated with significantly reduced: surgical time (p = 0.007), estimated blood loss (p < 0.001), PACU stay (p < 0.001), LOH stay (p < 0.001); IV fluids (crystalloid and colloid; p < 0.001); opioids (p < 0.001), non-opioids (intravenous acetaminophen, oral acetaminophen, diclofenac; all p < 0.001); incidence of post-operative nausea and vomiting and the requirement of rescue antiemetics (p < 0.001). EC staging using robotic-assisted surgery was associated with significantly lower medicine and material costs attributed to IV fluids, analgesia, and antiemetics (p < 0.001). As compared to open surgery, robotic surgery was associated with the total saving of $107.7 ($19.5 in IV fluids, $49.2 in analgesics, $1.33 in antiemetics, and $37.8 in material). Robotic-assisted surgical staging for endometrial cancer is associated with decreased requirement and expenditure attributable to post-operative pain, post-operative nausea and vomiting, and maintenance and replacement fluid therapy.


Endometrial cancer Open surgery Robotic-assisted surgery Intravenous fluids Analgesics Antiemetics Costs 


Compliance with ethical standards

Conflict of interest

Authors Reshu Agarwal and Unnikrishnan U G declare that they have no conflict of interest. Author Anupama Rajanbabu is a proctor and advanced trainer for Robotic surgery.

Ethical approval

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000.

Informed consent

Informed consent was obtained from all patients for being included in the study.


  1. 1.
    van den Beuken-van Everdingen MHJ, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J (2007) Prevalance of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol 18:1437–1449CrossRefPubMedGoogle Scholar
  2. 2.
    World Health Organization (1986) Cancer Pain Relief. World Health Organization, GenevaGoogle Scholar
  3. 3.
    World health organisation (1996) Cancer pain relief: with a guide to opioid availability, 2nd edn. World Health Organization, GenevaGoogle Scholar
  4. 4.
    Deandrea S, Montanari M, Moja L, Apolone G (2008) Prevelance of undertreatment in cancer pain, A review of published literature. Ann Oncol 19(12):1985–1991CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J (2007) High prevalence of pain in patients with cancer in a large population-based study in The Netherlands. Pain 132(3):312–320CrossRefPubMedGoogle Scholar
  6. 6.
    Thomas MA (2003) Pain management—the challenge. Ochsner J 5:15–21PubMedPubMedCentralGoogle Scholar
  7. 7.
    Wells N, Pasero C, McCaffery M (2008) Improving the quality of care through pain assessment and management. In: Hughes RG (ed) Patient safety and quality: an evidence-based handbook for nurses. Agency for Healthcare Research and Quality, RockvilleGoogle Scholar
  8. 8.
    Vadivelu N, Mitra S, Narayan D (2010) Recent advances in postoperative pain management. Yale J Biol Med 83:11–25PubMedPubMedCentralGoogle Scholar
  9. 9.
    Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N (1999) A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 91:693–700CrossRefPubMedGoogle Scholar
  10. 10.
    Koivuranta M, Läärä E, Snåre L, Alahuhta S (1997) A survey of postoperative nausea and vomiting. Anaesthesia 52:443–449CrossRefPubMedGoogle Scholar
  11. 11.
    Sinclair DR, Chung F, Mezei G (1999) Can postoperative nausea and vomiting be predicted? Anesthesiology 91:109–118CrossRefPubMedGoogle Scholar
  12. 12.
    Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS et al (2009) Laparoscopy compared with laparotomy for comprehensive surgical staging for uterine cancer: gynecologic oncology group LAP2 study. J Clin Oncol 27(32):5331–5336CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS et al (2012) Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging for uterine cancer: gynecologic oncology group LAP2 study. J Clin Oncol 30(7):695–700CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Lau S, Vaknin Z, Ramana-Kumar AV, Halliday D, Franco EL, Gotlieb WH (2012) Outcomes and cost comparisons after introducing a robotics program for endometrial cancer surgery. Obstet Gynecol 119(4):717–724CrossRefPubMedGoogle Scholar
  15. 15.
    Barnett JC, Judd JP, Wu JM, Scales CD Jr, Myers ER, Havrilesky LJ (2010) Cost comparison among robotic, laparoscopic, and open hysterectomy for endometrial cancer. Obstet Gynecol 116(3):685–693CrossRefPubMedGoogle Scholar
  16. 16.
    Wright JD, Ananth CV, Tergas AI, Herzog TJ, Burke WM, Lewin SN et al (2014) An economic analysis of robotic assisted hysterectomy. Obstet Gynecol 123(5):1038–1048CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Leitao MM Jr, Bartashnik A, Wagner I, Lee SJ, Caroline A, Hoskins WJ et al (2014) Cost effective analysis of robotically assisted laparoscopy for newly diagnosed uterine cancers. Obstet Gynecol 123(5):1031–1037CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Venkat P, Chen LM, Young-Lin N, Kiet TK, Young G, Amatori D et al (2012) An economic analysis of robotic versus laparoscopic surgery for endometrial cancer: costs, charges and reimbursements to hospitals and professionals. Gynecol Oncol 125(1):237–240CrossRefPubMedGoogle Scholar
  19. 19.
    Abitbol J, Cohn R, Hunter S, Rombaldi M, Cohen E, Kessous R et al (2017) Minimizing pain medication use and its associated costs following robotic surgery. Gynec Oncol 144:187–192CrossRefGoogle Scholar
  20. 20.
    Bell MC, Torgerson J, Seshadri-Kreaden U, Suttle AW, Hunt S (2008) Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecol Oncol 111:407–411CrossRefPubMedGoogle Scholar
  21. 21.
    Leitao MM Jr, Malhotra V, Briscoe G, Suidan R, Dholakiya P, Santos K et al (2013) Postoperative pain medication requirements in patients undergoing computer-assisted (“robotic”) and standard laparocopic procedures for newly diagnosed endometrial cancer. Ann Surg Oncol 20:3561–3567CrossRefPubMedGoogle Scholar
  22. 22.
    Turner TB, Habib AS, Broadwater G, Valea FA, Fleming ND, Ehrisman JA et al (2015) Postoperative pain scores and narcotic use in robotic-assisted versus laparoscopic hysterectomy for endometrial cancer staging. JMIG 22:1004–1010Google Scholar
  23. 23.
    Gower ST, Quigg CA, Hunt JO, Wallace SK, Myles PS (2006) A comparison of patient self-administered and investigator-administered measurement of quality of recovery using the QoR-40. Anaesth Intensive Care 34:634–638PubMedGoogle Scholar
  24. 24.
    DeNardis SA, Holloway RW, Bigsby GE 4th, Pikaart DP, Ahmad S, Finkler NJ (2008) Robotically assisted laparoscopic hysterectomy versus total abdominal hysterectomy and lymphadenectomy for endometrial cancer. Gynecol Oncol 111:407–411CrossRefGoogle Scholar
  25. 25.
    Cohn DE, Castellon-Larios K, Huffman L, Salani R, Fowler JM, Copeland LJ et al (2016) A Prospective comparative study for the evaluation of postoperative pain and quality of recovery in patients undergoing robotic versus open hysterectomy for staging of endometrial cancer. JMIG 23:429–434Google Scholar
  26. 26.
    Kornblith AB, Huang HQ, Walker JL, Spirtos NM, Rotmensch J, Cella D (2009) Quality of life of patients with endometrial cancer undergoing laparoscopic International Federation of Gynecology and Obstetrics Staging compared with Laparotomy: a gynecologic oncology group study. J Clin Oncol 27(32):5337–5342CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Eltabbakh GH, Shamonki MI, Moody JM, Garafano LL (2000) Hysterectomy for obese women with endometrial cancer: laparoscopy or laparotomy? Gynecol Oncol 78(3 Pt 1):329–335CrossRefPubMedGoogle Scholar
  28. 28.
    Schwenk W, Bohm B, Muller JM (1998) Postoperative pain and fatigue after laparoscopic or conventional colorectal resections. A prospective randomized trial. Sur Endosc 12(9):1131–1136CrossRefGoogle Scholar
  29. 29.
    Soliman PT, Langley G, Munsell MF, Vaniya HA, Frumovitz M, Ramirez PT (2013) Analgesic and antiemetic requirement after minimally invasive surgery for early cervical cancer: a comparison between Laparoscopy and Robotic surgery. Ann Surg Oncol 20:1355–1359CrossRefPubMedGoogle Scholar
  30. 30.
    Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C et al (2016) Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: enhanced recovery after surgery (ERAS) society recommendations—part I. Gynecol Oncol 140:313–322CrossRefPubMedGoogle Scholar
  31. 31.
    Bogani G, Multinu F, Dowdy SC, Cliby WA, Wilson TO, Gostout BS et al (2016) Incorporating robotic-assisted surgery for endometrial cancer staging: analysis of morbidity and costs. Gynecol Oncol 141:218–224CrossRefPubMedGoogle Scholar
  32. 32.
    Klein JR, Heaton JP, Thompson JP, Cotton BR, Davidson AC, Smith G (2000) Infiltration of the abdominal wall with local anaesthetic after total abdominal hysterectomy has no opioid sparing effect. Br J Anaesth 84:248–249CrossRefPubMedGoogle Scholar
  33. 33.
    Fong SY, Pavy TJ, Yeo ST, Paech MJ, Gurrin LC (2001) Assessment of wound infiltration with bupivacaine in women undergoing day-case gynaecological laparoscopy. Reg Anesth Pain Med 26:131–136CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag London Ltd., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Gynecologic OncologyAmrita Institute of Medical Sciences, Amrita UniversityKochiIndia
  2. 2.Department of BiostatisticsAmrita Institute of Medical Sciences, Amrita UniversityKochiIndia

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