Enhanced recovery after surgery (ERAS) for laparoscopic hysterectomy in low-risk endometrial cancer: a randomized controlled trial

Background: Enhanced Recovery After Surgery (ERAS) programs aim for early recovery and reduced hospital length of stay (LOS). Their role in specific patient groups, such as those with early-stage endometrial cancer undergoing Minimally Invasive Surgery (MIS), is not well understood. Methods: This randomized controlled trial included low-risk patients with early-stage endometrial cancer who underwent total hysterectomy and salpingo-oophorectomy by laparoscopy. Patients were assigned to an ERAS protocol or a conventional control (CC) protocol. The primary outcome was LOS, while secondary outcomes included perioperative morbidity and quality of life (QoL). Results: From June 2019 to August 2021, 92 women were recruited, with 24 exclusions. Compliance with ERAS was 87.9%. ERAS patients showed significantly reduced hospitalization, with 67.6% discharged on the first postoperative day compared with 20.6% in the CC group (p < 0.001). Median LOS was 1 day (interquartile range (IQR) 1–2) for ERAS vs. 2 days (IQR 2–2) for CC (p < 0.001). No significant differences were found in postoperative complications or readmissions. However, QoL improved significantly in the ERAS group at 10 days (p = 0.012) and 30 days (p < 0.001) post-surgery, based on the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Pain scores on the Visual Analogue Scale (VAS) were also better in the ERAS group at 3 and 10 days (p = 0.023 and p = 0.041). Conclusions: Patients with early-stage endometrial cancer benefit from ERAS protocols, achieving lower LOS and improved QoL after MIS. Clinical Trial Registration: NCT06732635, retrospectively registered.

Endometrial cancer; Quality of life; Enhanced recovery after surgery

[1] Tankou J, Pollack LM, Wilson E, Kuo I, Wang M, Eckhouse SR, et al. Cost-effectiveness of combined minimally invasive hysterectomy and bariatric surgery in women with morbid obesity and endometrial hyperplasia or early-stage endometrial cancer. Journal of Minimally Invasive Gynecology. 2026; 33: 283–290.

[2] Cucinella G, Di Donna MC, Solazzo MC, Ronsini C, Scaffa C, Chiantera V. Robotic surgery in endometrial cancer using robot da Vinci® SP. Annals of Surgical Oncology. 2026; 33: 1134.

[3] Nelson G, Fotopoulou C, Taylor J, Glaser G, Bakkum-Gamez J, Meyer LA, et al. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: addressing implementation challenges—2023 update. Gynecologic Oncology. 2023; 173: 58–67.

[4] O’Neill AM, Calpin GG, Norris L, Beirne JP. The impact of enhanced recovery after gynaecological surgery: a systematic review and meta-analysis. Gynecologic Oncology. 2023; 168: 8–16.

[5] Yi HC, Ibrahim Z, Abu Zaid Z, Mat Daud Z’, Md Yusop NB, Omar J, et al. Impact of enhanced recovery after surgery with preoperative whey protein-infused carbohydrate loading and postoperative early oral feeding among surgical gynecologic cancer patients: an open-labelled randomized controlled trial. Nutrients. 2020; 12: 264.

[6] Sánchez-Iglesias JL, Carbonell-Socias M, Pérez-Benavente MA, Monreal Clua S, Manrique-Muñoz S, García Gorriz M, et al. PROFAST: a randomised trial implementing enhanced recovery after surgery for highcomplexity advanced ovarian cancer surgery. European Journal of Cancer. 2020; 136: 149–158.

[7] Chiewhatpong P, Charoenkwan K, Smithiseth K, Lapisatepun W, Lapisatepun P, Phimphilai M, et al. Effectiveness of enhanced recovery after surgery protocol in open gynecologic oncology surgery: a randomized controlled trial. International Journal of Gynecology & Obstetrics. 2022; 159: 568–576.

[8] Colombo N, Creutzberg C, Amant F, Bosse T, González-Martín A, Ledermann J, et al. ESMO–ESGO–ESTRO consensus conference on endometrial cancer: diagnosis, treatment and follow-up. Radiotherapy and Oncology. 2015; 117: 559–581.

[9] Dindo D, Demartines N, Clavien P. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of Surgery. 2004; 240: 205–213.

[10] Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The European organization for research and treatment of cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. Journal of the National Cancer Institute. 1993; 85: 365–376.

[11] Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, et al. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery after Surgery (ERAS) Society recommendations—2019 update. International Journal of Gynecological Cancer. 2019; 29: 651–668.

[12] Mateshaytis J, Brawner M, Steed H, Pin S. Improving the rate of same-day discharge in gynecologic oncology patients with endometrial cancer undergoing minimally invasive robotic surgery: a quality improvement initiative. Journal of Minimally Invasive Gynecology. 2022; 29: 1184–1193.

[13] Miguet C, Jauffret C, Zemmour C, Boher JM, Sabiani L, Houvenaeghel G, et al. Enhanced recovery after surgery and endometrial cancers: results from an initial experience focused on elderly patients. Cancers. 2023; 15: 3244.

[14] Chen L, Yuan Q, Li J. Effect of enhanced recovery after surgery on curative effect and prognosis of patients undergoing laparoscopic hysterectomy for cervical cancer. International Journal of Clinical and Experimental Medicine. 2020; 13: 2613–2620.

[15] Ferrari F, Forte S, Sbalzer N, Zizioli V, Mauri M, Maggi C, et al. Validation of an enhanced recovery after surgery protocol in gynecologic surgery: an Italian randomized study. American Journal of Obstetrics and Gynecology. 2020; 223: 543.e1–543.e14.

[16] Minig L, Chuang L, Patrono MG, Fernandez-Chereguini M, Cárdenas-Rebollo JM, Biffi R. Clinical outcomes after fast-track care in women undergoing laparoscopic hysterectomy. International Journal of Gynecology & Obstetrics. 2015; 131: 301–304.

[17] Relph S, Bell A, Sivashanmugarajan V, Munro K, Chigwidden K, Lloyd S, et al. Cost effectiveness of enhanced recovery after surgery programme for vaginal hysterectomy: a comparison of pre and post-implementation expenditures. The International Journal of Health Planning and Management. 2014; 29: 399–406.

[18] Kilpiö O, Härkki PSM, Mentula MJ, Väänänen A, Pakarinen PI. Recovery after enhanced versus conventional care laparoscopic hysterectomy performed in the afternoon: a randomized controlled trial. International Journal of Gynecology & Obstetrics. 2020; 151: 392–398.

[19] Bahadur A, Mallick BK, Heda A, Pathak A, Heda S, Mundhra R. Comparison of the outcomes of enhanced recovery after surgery and traditional recovery pathway in robotic hysterectomy for benign indications: a randomized controlled trial. Journal of Minimally Invasive Gynecology. 2024; 31: 601–606.

[20] Wijk L, Udumyan R, Pache B, Altman AD, Williams LL, Elias KM, et al. International validation of enhanced recovery after surgery society guidelines on enhanced recovery for gynecologic surgery. American Journal of Obstetrics and Gynecology. 2019; 221: 237.e1–237.e11.

[21] Aubrey C, Nelson G. Enhanced recovery after surgery (ERAS) for minimally invasive gynecologic oncology surgery: a review. Current Oncology. 2023; 30: 9357–9366.

[22] Kim SR, Laframboise S, Nelson G, McCluskey SA, Avery L, Kujbid N, et al. Enhanced recovery after minimally invasive gynecologic oncology surgery to improve same day discharge: a quality improvement project. International Journal of Gynecological Cancer. 2022; 32: 457–465.

[23] Brancazio SN, Lehman A, Kemp EV, Brown J, Crane EK, Tait DL, et al. Factors associated with same day discharge after laparoscopic surgery in gynecologic oncology. Journal of Minimally Invasive Gynecology. 2022; 29: 114–118.

[24] Li D, Jensen C. Patient satisfaction and quality of life with enhanced recovery protocols. Clinics in Colon and Rectal Surgery. 2019; 32: 138–144.

[25] Bartels HC, Rogers AC, Janda M, Obermair A, Brennan DJ. Quality of life following minimally invasive hysterectomy compared to abdominal hysterectomy: a metanalysis. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2020; 252: 206–212.

[26] Ferrari F, Soleymani Majd H, Giannini A, Favilli A, Laganà AS, Gozzini E, et al. Health-related quality of life after hysterectomy for endometrial cancer: the impact of enhanced recovery after surgery shifting paradigm. Gynecologic and Obstetric Investigation. 2024; 89: 304–310.

[27] Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J; Enhanced Recovery After Surgery Study Group. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Archives of Surgery. 2011; 146: 571–577.

[28] Gómez-Hidalgo NR, Pletnev A, Razumova Z, Bizzarri N, Selcuk I, Theofanakis C, et al. European Enhanced Recovery After Surgery (ERAS) gynecologic oncology survey: status of ERAS protocol implementation across Europe. International Journal of Gynecology & Obstetrics. 2023; 160: 306–312.

[29] Chen L, He W, Liu X, Lv F, Li Y. Application of opioid-free general anesthesia for gynecological laparoscopic surgery under ERAS protocol: a non-inferiority randomized controlled trial. BMC Anesthesiology. 2023; 23: 34.

[30] Corrado G, Vizza E, Cela V, Mereu L, Bogliolo S, Legge F, et al. Laparoscopic versus robotic hysterectomy in obese and extremely obese patients with endometrial cancer: a multi-institutional analysis. European Journal of Surgical Oncology. 2018; 44: 1935–1941.