Original Research
Same-Day Discharge After Minimally
Invasive Myomectomy
Katie Alton, MD, Shannon Sullivan, MD, Natalia Udaltsova,
and Eve Zaritsky, MD
OBJECTIVE: To estimate readmission rates of patients
discharged home the same day after a minimally invasive
myomectomy.
METHODS: This is a retrospective case series of patients
who underwent minimally invasive myomectomy and were
discharged the same day, which examines the feasibility and
safety by rates of readmission within Kaiser Permanente
Northern California. Chart review was performed for out-
comes of interest including readmission rates, emergency
department, and urgent clinic visits within 48 hours, 7 days,
and up to 3 months along with surgical and demographic
characteristics.
RESULTS: Of the 403 minimally invasive myomecto-
mies performed during the study period, 88% (N5356)
of patients were discharged home the same day. No read-
missions required reoperation or were life-threatening. Two
patients (0.6%) were readmitted within 48 hours for post-
operative fever. A cumulative total of five patients (1.4%)
were readmitted within 3 months. Urgent care and emer-
gency department visits occurred in zero and seven patients
(2.0%) within 48 hours of discharge, most commonly for pain
and urinary retention. Median leiomyoma weight was 204 g,
median body mass index was 26, median blood loss was 75
mL, and median surgical time was 157 minutes.
From the Department of Obstetrics and Gynecology and the Division of Research,
Kaiser Permanente Northern California, Oakland, and the Department of
Obstetrics and Gynecology, Kaiser Permanente, San Leandro, California.
Supported by Kaiser Permanente Northern California Graduate Medical Edu-
cation, Kaiser Foundation Hospitals.
Presented at the American Association of Gynecologic Laparoscopists Annual
Meeting, November 17–21, 2014, Vancouver, Canada, and presented as a poster
at the American College of Obstetricians and Gynecologists Annual Meeting, May
2–6, 2015, San Francisco, California.
Corresponding author: Eve Zaritsky, MD, Department of Obstetrics and
Gynecology, Kaiser Permanente Northern California, 3600 Broadway, Oakland,
CA 94611; e-mail: eve.f.zaritsky@kp.org.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2016 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/16
VOL. 127, NO. 3, MARCH 2016
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
PhD, Miya Yamamoto, MD,
CONCLUSION: Same-day discharge after minimally
invasive myomectomy was found to have a low readmis-
sion rate and low health care utilization in the immediate
postoperative period. Same-day discharge appears to
be a safe option for healthy patients after undergoing an
uncomplicated minimally invasive myomectomy.
(Obstet Gynecol 2016;127:539–44)
DOI: 10.1097/AOG.0000000000001291
M yomas are common, with a lifetime risk for
women of up to 70–80% and clinically appar-
ent in 12–25% of reproductive aged women.1,2 A
national survey of reproductive-aged women with
symptomatic leiomyoma found that 43% of women
desired fertility-preserving treatment, and 51% expressed
interest in preserving the uterus.3 Myomectomies are
increasingly performed using minimally invasive techni-
ques.4 Traditionally many patients stay 24–48 hours after
surgery as a result of postoperative concerns.5
Approximately 300–400 myomectomies are per-
formed every year within the study service area and
approximately 60% are performed laparoscopically or
robotically. From our chart review, close to 90% of these
patients are discharged the same day as their surgery. The
benefits of minimally invasive myomectomy include
reduced postoperative pain, shorter hospital stay, reduced
adhesions, and fewer postoperative fevers.4–7
We performed a literature search using PubMed
and MEDLINE databases from inception of the
database until January 2015 searching “leiomyoma/
surgery,” “uterine myomectomy,” and “postoperative
complications.” To date, no large studies have evalu-
ated same-day discharge after minimally invasive
myomectomy; the studies that looked at same-day
discharge as a secondary outcome had no more than
100 patients. Readmission rates for laparoscopic my-
omectomies were noted to be approximately 1%.8,9
Perron-Burdick et al10 assessed same-day discharge
in laparoscopic hysterectomy and found a similar
low readmission rate.
OBSTETRICS & GYNECOLOGY 539
 This study used a retrospective case series to
examine the safety of same-day discharge
after minimally invasive myomectomy in Kaiser
Permanente Northern California. Our primary objec-
tive was to evaluate readmission rates of patients
discharged home the same day after minimally inva-
sive myomectomy within 48 hours. Secondary objec-
tives included patient and operative characteristics
along with postoperative urgent care or emergency
visits and admissions.

MATERIALS AND METHODS

This study was approved by the Kaiser Permanente
Northern California institutional review board for the
protection of human participants. The source popula-
tion for the study was derived from Kaiser Permanente
Northern California, a large, integrated health care
delivery system providing comprehensive care for
Fig. 1. Study flowchart.
approximately 3.5 million members across Northern
Alton. Same-Day Myomectomy Discharge. Obstet Gynecol 2016.
California.
We conducted a retrospective case series that patient and surgical characteristics including frequen-
captured female patients aged 18 years and older who cies, proportions, means, and medians. We estimated
underwent a minimally invasive myomectomy for hospital readmission rates in 48 hours, 7 days, and up
leiomyoma(s) and were discharged home the same to 3 months. We also estimated rates of subsequent
day. Minimally invasive includes both laparoscopic emergency or urgent clinic visits within 48 hours, 7
and robotic abdominal myomectomy. Current Pro- days, and up to 1 month of surgery. The threshold for
cedural Terminology and International Statistical Clas- interference was defined as P,.05. We used x2 test or
sification of Diseases and Related Health Problems, 9th Fisher exact test for frequencies and proportions of
Revision codes were used to identify all patients with
leiomyoma who underwent minimally invasive myo- Table 1. Patient Characteristics
mectomy from January 2011 to December 2013 and
were discharged home the same day or within 12 hours Characteristic Total (N5356)
of admission. Admission was defined as the time at
Median age (y) 38 (19–70)
which the patient’s surgery started. Patients were consid-
BMI (kg/m2) 26 (17–47)
ered “same-day” discharge if they were discharged Higher than 30 185 (35)
within the same calendar date as the myomectomy pro- Race
cedure or if the time interval between procedure close White 104 (29)
time and discharge time was less than 12 hours. Hispanic 65 (18)
Black 101 (28)
Exclusion criteria included women younger than age
Asian 73 (21)
18 years, myomectomy through laparotomy or conver- Other 13 (4)
sion to laparotomy, hysteroscopy or vaginal approach, Previous laparotomy or laparoscopy 68 (19)
conversion to hysterectomy, and gynecologic malig- Myomectomy indication
nancy. See Figure 1 for a study participant flowsheet. Pain 249 (70)
Bleeding 162 (46)
Patients with identified minimally invasive myo-
Anemia 52 (15)
mectomy for leiomyoma underwent chart review of Infertility 98 (28)
electronic medical records to confirm minimally inva- No. of leiomyomas
sive myomectomies and same-day discharge. Patients 1–4 298 (84)
with minimally invasive myomectomy and same-day 5 or more 58 (16)
Surgery characteristics
discharge after surgery underwent a more comprehen-
Operation time (min) 157 (27–485)
sive chart review of electronic medical records to assess EBL (mL) 75 (2–1,300)
study eligibility, ensure accuracy of coding, and perform Myoma weight (g) 204 (2–4,785)
data collection. For data variables extracted, refer to BMI, body mass index; EBL, estimated blood loss.
Tables 1–3. Descriptive statistics were calculated for Data are n [median (range)] or n (%).

540 Alton et al Same-Day Myomectomy Discharge OBSTETRICS & GYNECOLOGY

Copyright ª by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 2. Rates of Readmission and Emergency
Department and Urgent Clinic Visits
Emergency
Time After Department
Surgery Readmissions Visits
48 h 2 (0.6) 7 (2.0)
7d 3 (0.8) 12 (3.4)
1 mo 3 (0.8) 17 (5.0)
3 mo 5 (1.4) — —
Data are n (%).
Total N5356.
Counts and rates are cumulative.
categorical variables and t test for mean values of con-
tinuously measured variables. Statistical analyses were
performed using SAS 9.3.
The minimally invasive myomectomies in this study
were performed predominantly by minimally invasive
gynecologic surgeons at Kaiser Permanente hospitals
throughout Northern California. Many facilities had or
were affiliated with residency training programs in
obstetrics and gynecology approved by the Accreditation
Council for Graduate Medical Education, and there was
resident participation in cases done at those centers.
Preoperative evaluation often included magnetic reso-
nance imaging for improved assessment of number and
location of leiomyomas along with improved diagnosis of
adenomyosis compared with pelvic ultrasonography.
Surgeries varied by uterine manipulator type, num-
ber of port sites, vessel sealing device type, use of
preoperative gonadotropin-releasing hormone ago-
nist, and morcellation technique. For the majority of
patients, four or five port sites were used, either three
or four 5- to 8-mm ports and one to two 10-mm
ports. Of note, the study period concluded before the
removal of power morcellators from Kaiser Perma-
nente Northern California operating rooms in May
2014.
Intraoperative steps for minimally invasive myo-
mectomies typically included patient positioned with
arms tucked in the dorsal lithotomy position, use of
Urgent a uterine manipulator, rectal misoprostol, and dilute
Clinic
Visits
vasopressin injected into the serosa above the leiomyo-
mas. Injection of local anesthetic was standard before
0 incision for postoperative incisional pain reduction.
0 Dexamethasone and ondansetron were commonly
1 (0.3)
administered at the beginning of the procedure and
ketorolac was often administered on completion for
reduced postoperative nausea and pain control.
Patients undergoing a minimally invasive myo-
mectomy were educated at their preoperative consul-
tation that same-day discharge is routine for all
uncomplicated cases. Patients were required to have
home support, access to a telephone, and immediate
transportation if needed. Patients and caregivers were
counseled on the appropriate postoperative recovery
course and given strict precautions on when to return
to the clinic or hospital. Preoperative bowel prepara-
tions were not performed.
Discharge requirements included the ability to
ambulate, tolerate oral liquids, and adequate pain control
before discharge. Patients were not routinely required to
void before discharge and specific postoperative voiding
management varied between surgeons. Discharge in-
structions are routinely given to surgical patients before
discharge and include postoperative instructions, medi-
cation list and dosing, and advice line numbers. Dis-
charge medications included an anti-inflammatory,
a narcotic, an antiemetic, and a stool softener.
RESULTS
Of the 403 minimally invasive myomectomies per-
formed during the study period, 356 (88%) patients were
sent home the same day and met criteria for inclusion in
this study. Cumulative readmission rates were 0.6% and
1.4% at 48 hours and 3 months (Table 2).

Table 3. Emergency Department and Urgent Clinic Visit Diagnoses

Time After Surgery

Emergency Department Visits Urgent Clinic Visits
Reason for Visit or Diagnosis 48 h 7d 1 mo 1 mo

Postprocedural visit 0 1 2 1
Pain 1 3 5 0
Constipation 1 2 3 0
Fever 1 1 2 0
Urinary retention 3 3 3 0
Bleeding 1 2 2 0
Total 7 (2.0) 12 (3.4) 17 (5) 1 (0.3)
Data are n (%).
Counts and rates are cumulative.

VOL. 127, NO. 3, MARCH 2016 Alton et al Same-Day Myomectomy Discharge 541

Copyright ª by The American College of Obstetricians

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Unauthorized reproduction of this article is prohibited.
 Of the total procedures, 334 (83%) were performed
laparoscopically and 69 (17%) were performed roboti-
cally (Fig. 1). Two patients were readmitted within 48
hours for postoperative fever. Three additional patients
were readmitted after 48 hours but within 3 months
for an inferior epigastric hematoma, ileus, and acute
pyelonephritis.
Urgent care and emergency department visits
after same-day discharge were also uncommon. Of
the 356 patients discharged home the same day, no
patients presented to the urgent care clinic within
7 days and 3.4% (n512) presented to the emergency
department within 7 days for postoperative-related
issues. The most common reasons for emergency depart-
ment visits were pain or urinary retention (n53 and 3,
respectively). Other reasons for emergency department
visits included constipation, bleeding, and fever. Table 3
describes diagnoses for emergency department and
urgent clinic visits.
The study population was diverse with 71% of
patients being nonwhite. Twenty-two percent of patients
who were discharged home the same day were obese,
with body mass indexes (calculated as weight (kg)/[height
(m)]2) greater than 30, and approximately 19% had a his-
tory of a previous abdominal surgery. Menopausal status
data were not collected; however, five women (1.4%)
were older than 51 years of age. One patient desired to
preserve fertility and two patients refused hysterectomy
despite counseling. Two had pedunculated leiomyomas
with a preoperative diagnosis of an adnexal mass. Patient
characteristics are shown in Table 1.
The most common indications for myomectomy
among patients undergoing minimally invasive pro-
cedures included pain and pressure (70%), bleeding
(46%), infertility (28%), and anemia (15%). The
median estimated blood loss was 75 mL (mean 129
mL, range 2–1,300 mL) and the median leiomyoma
weight was 204 g (mean 280 g, range 2–4,785 g). The
median surgical time was 157 minutes (mean 167 mi-
nutes, range 27–485 minutes). No intraoperative
blood transfusions were required for any patients
(Table 1). Figure 2 histograms show the distribution

Fig. 2. Histograms. A. Distribution of myoma weight. B. Distribution of estimated blood loss. C. Distribution of operative time.
Alton. Same-Day Myomectomy Discharge. Obstet Gynecol 2016.

542 Alton et al Same-Day Myomectomy Discharge OBSTETRICS & GYNECOLOGY

Copyright ª by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
of myoma weight, estimated blood loss, and operative
time.
Forty-seven (12%) procedures were excluded as
a result of admission after the procedure. Reason for
postoperative admission included surgeon prefer-
ence (49%), intraoperative blood loss or anemia
(19%), urinary retention (9%), pain control (6%), or
nausea (4%), Initially there were three surgeons who
had traditionally admitted patients overnight but
changed their practices during the study period.
DISCUSSION
The benefits of minimally invasive myomectomy
include reduced postoperative pain, time to return
to normal function, and blood loss.6–8 This is a large
study evaluating same-day discharge after minimally
invasive myomectomy in a relatively healthy patient
population. None of the readmissions, visits to the
emergency department, or urgent care were surgical
or life-threatening events.
Minimally invasive myomectomies within Kaiser
Northern California are predominantly performed
by minimally invasive gynecologic specialists. At the
time of this study, there were 11 surgeons who performed
the majority of minimally invasive myomectomies in the
region, only four of whom were fellowship-trained.
As a result of the U.S. Food and Drug Administra-
tion statement on the use of the power morcellator, in
May of 2014, the device was removed from operating
rooms in Kaiser Permanente Hospitals in Northern
California.
A particular strength of this study includes
comprehensive documentation of the postoperative
course as a result of the use of electronic medical
records. The large patient population and detailed
electronic medical records allowed for detailed data
extraction. The Kaiser Permanente Northern Califor-
nia region provides health care to approximately one
third of the overall population in Northern California.
Because of the extensive network of Kaiser clinics and
hospitals in this region, very few patients seek care for
postoperative issues outside of the Kaiser network.
However, because the Kaiser system does not always
have access to outside hospital records, it is possible
that additional data were missed if the patient pre-
sented to a non-Kaiser facility. The diversity of the
patient population is reflective of Northern California,
which is another asset of the study.11
Limitations of the study include the very low
readmission rate, which could be addressed by
a larger sample size. Additionally, this study did
not have a nonsame-day discharge comparison
group because same-day discharge for minimally
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Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
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invasive myomectomies have become routine. As
a result of this shift in the standard of care, it would
have been difficult to find an appropriate compari-
son group. In addition, the specialized group of
gynecologic surgeons who performed the surgeries,
the multimodal care model, and the extent of
resources may limit generalizability.
To facilitate same-day discharge, it is important that
the surgeon’s clinic staff, anesthesiology department,
and preoperative and postoperative nursing care teams
all understand the expectation of same-day discharge.
Having a team of anesthesiologists that provides specific
antiemetic protocols has been shown to reduce postop-
erative nausea.12 Providing patients and their families
with a detailed written version of postoperative instruc-
tions, including pain expectation and management,
along with nausea prevention, is a central step in post-
operative management in addition to traditional verbal
counseling.
Emphasizing resources such as telephone advice
lines and the surgeon availability by e-mail can also help
patients with less acute access information and obtain
Box 1. Guidelines for Same-Day Discharge for
Minimally Invasive Myomectomy*
Preoperative
 Mental capacity and reasoning ability
 Access to ancillary care including phone advice
nurse and outpatient clinic numbers
 Access to emergency services
 Reliable caretaker at home for at least 24 h
Operative
 Enhanced Recovery After Surgery (ERAS): preoperative
scopolamine patch, intravenous dexamethasone, intra-
venous acetaminophen, ketorolac, ondansetron
 Use of intraoperative vasopressin, rectal misoprostol
Postoperative
 Ability to tolerate oral fluids and medication
 Sent home and instructed to use around-the-clock
nonsteroidal anti-inflammatory drugs and narcotics
as needed for approximately 48 h
 Sent home with oral antiemetics and stool softener to
use as needed
 Use of abdominal binder for reduced postoperative
pain
 Patients are usually called by the registered nurses,
medical doctors, or both the next day
Of note, there is health care provider variation and practice
within our medical group.
*Similar guideline for same-day hysterectomy discharge.
Alton et al Same-Day Myomectomy Discharge 543
reassurance. Routine follow-up by telephone or video
visits within 24–48 hours of surgery can also help ame-
liorate patient anxiety, which may prevent unnecessary
urgent visits.13,14 Many urgent visits can be resolved with
reassurance and supportive care. Safety and feasibility
are only one component of this practice; future studies
should investigate patient satisfaction of this practice.
In conclusion, this study demonstrates that same-
day discharge after a minimally invasive myomec-
tomy performed in a healthy patient population has
a very low readmission rate. Same-day discharge
reduces the health care burden for hospital stay and
nosocomial infections. Readmission rates are low and
optimized when guidelines include detailed preoper-
ative counseling, expectation management, standard-
ized intraoperative and postoperative medication
procedure as well as patient follow-up (Box 1). This
study is an important example of reduction in health
care cost without compromising patient care.
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