Outpatient Robotic Radical Prostatectomy: Matched-Pair Comparison with Inpatient Surgery

Abstract

Purpose:

To evaluate our initial experience with outpatient robotic radical prostatectomy (RRP) and to prospectively compare outcomes with an inpatient RRP group.

Materials and Methods:

We conducted a prospective study on 30 carefully selected, motivated patients consenting for outpatient RRP (2011–2013). Inclusion criteria comprised age <65 years, American Society of Anesthesiologists score <3, body mass index <35 kg/m², localized prostate cancer, and primary treatment. Postoperatively, close monitoring was conducted by telephone for the first 24 hours, with routine follow-up subsequently. This outpatient group was prospectively matched 1:1 with a concurrent inpatient RRP group who satisfied inclusion criteria for, but did not undergo, outpatient RRP. Validated questionnaires were administered prospectively to determine patient satisfaction and functional outcomes.

Results:

All outpatient RRP procedures were performed effectively. Twenty-six patients (87%) were discharged the same day of surgery, four stayed overnight for various reasons. On comparing outpatient and inpatient groups, there were no significant demographic or perioperative differences, except for shorter hospital stay (14 hours vs 44 hours, p < 0.01). In both groups, 92% of patients were completely continent (no pads) at 2 months follow-up. Time to complete continence in the outpatient and inpatient groups was 32 days vs 43 days (p = 0.09). Validated questionnaires revealed both groups were comparable as regards patient/family satisfaction, days of narcotic usage, days to return to work, and days to feeling 100% recovered.

Conclusion:

Our initial experience with outpatient RRP is promising. Outpatient RRP is associated with excellent patient satisfaction and functional outcomes comparable with inpatient RRP. Patient motivation and preoperative counseling are vital for success.

Introduction

With ongoing changes in the U.S. healthcare system, hospitals have financial incentives for decreasing hospital stay, without compromising quality. Rising healthcare costs and managed care payment systems have altered the approach for practicing medicine, wherein almost all patients, medical or surgical, are being managed in a more efficient manner to reduce hospital days and minimize costs. Although these efficiencies are being implemented daily, the best interests of the patient remain of utmost importance.

Radical prostatectomy is one procedure where urologists have attempted to shorten the duration of hospital stay. Evolution of the surgical approach from open to robotic has resulted in decreased patient pain and discomfort, while delivering desirable oncologic and functional outcomes. After robotic radical prostatectomy (RRP), it has become standard practice for patients to spend at least one night in the hospital. Studies have demonstrated that despite a shortened hospital stay, patients remained satisfied with the outcome of their surgical procedure.¹

Herein, we describe our initial experience with outpatient RRP in 30 patients, wherein patients were prospectively enrolled to be discharged from the hospital the same day of surgery after meeting specific study criteria for same-day discharge from the facility. To our knowledge, this is the first study in the literature to compare outpatient RRP with a matched-pair, concurrent inpatient RRP group.

Materials and Methods

From January 2011 to December 2013, 950 patients underwent RRP for prostate cancer at our institution. After obtaining Institutional Review Board approval to add a modified patient recovery and satisfaction questionnaire (Supplementary Data; Supplementary Data are available online at www.liebertpub.com/end) to our prospectively maintained database, we enrolled 30 selective patients who were motivated to undergo outpatient RRP, defined as discharge from the hospital on the same day of surgery. This inclusion criteria comprised age <65 years, American Society of Anesthesiologists (ASA) score <3, body mass index (BMI) <35 kg/m², localized prostate cancer, and primary treatment. Exclusion criteria comprised prior major pelvic or abdominal surgery and obstructive sleep apnea. Specific study exit criteria were prospectively established, including the surgeon's intraoperative assessment (difficult surgery, significant bladder neck reconstruction, and significant blood loss), any surgical or medical complications, and obtaining clearance from both the anesthesia and surgical team regarding patients' clinical recovery before discharge, including satisfying patient/family expectations. Study endpoint was at 2 months follow-up.

Surgical setting

RRP surgeries were performed at our main teaching hospital as well as at an affiliated outpatient surgery center. All cases were scheduled as the first case of the day, to allow for timely patient recovery, appropriate postoperative clinical assessment, and review of laboratory data in the evening before discharge. Two hours preoperatively, the patient was administered heparin (5000 units subcutaneously) and intravenous broad-spectrum antibiotics, and sequential compression stockings were applied. RRP with or without pelvic lymph node dissection was performed in a routine manner, with no restriction in fellow or resident assistance. Intraoperative intravenous fluids were minimized per the anesthesiologist and intravenous nonsteroidal (Toradol 30 mg) was given at completion of urethro-vesical anastomosis. Narcotic usage was minimized intraoperatively and postoperatively and pain control was primarily achieved with nonsteroidal analgesics. Typically, a 16F supra-pubic catheter was used to drain the bladder. Typically, urethral Foley catheter and pelvic suction drains were not employed.

Discharge criteria

Specific study same-day discharge criteria comprised the patient being afebrile and hemodynamically stable (heart rate <100 beats per minute, systolic blood pressure >100 mm Hg, oxygen saturation >90% on room air, hematocrit >28%, and urine output 30 mL/hour), pain well controlled by oral Toradol (10 mg every 8 hours) or Vicodin (5/500 mg, 1–2 tablets every 6 hours as needed), tolerating oral liquids without nausea or vomiting, and being ambulatory.

Discharge instructions included clear liquids until flatus followed by regular diet, antibiotics until catheter removal, stool softener, and analgesics as already mentioned. All patients were discharged to their home, except for those from out of town who were asked to stay in town for a minimum of one night after discharge to ensure they felt comfortable enough before travelling a longer distance. Patients were given the attending surgeon's and also the resident's/fellow's cell phone number and encouraged to call for any questions or issues.

Follow-up

Patient data were collected for 2 months after surgery for the purposes of this study. Immediate follow-up consisted of a phone call by the attending surgeon and/or fellow/resident on the night of discharge and again on the morning of postoperative day (POD) 1 to enquire about general well-being, pain/discomfort level, bowel function, and ambulation. On POD 5, the patient was asked to occlude the supra-pubic catheter with a stopper and resume voiding per urethra; immediately after each voiding, the patient was directed to open the supra-pubic tube to record postvoid residual volumes. On POD 7 to POD 10, patients returned to the hospital for a cystogram to confirm water-tight anastomotic healing before removal of the supra-pubic catheter. Patients were asked to fill questionnaires at baseline, at 1 week, and at 2 months regarding the Sexual Health Inventory for Men (SHIM), International Prostate Symptom Score (IPSS), and a modified patient recovery and satisfaction questionnaire (Supplementary Data).

Statistical analysis

The outpatient RRP group (n = 30) was prospectively matched 1:1 with a concurrent group undergoing standard inpatient RRP (n = 26) over the same time frame who satisfied inclusion criteria for, but did not undergo, outpatient RRP. Differences between subgroups were calculated using the Chi-square or exact Fischer test for categorical data and the Student's t-test or Kruskal–Wallis test for continuous data. Statistical significance was determined based on a two-sided significance level of 0.05. Data analysis was performed using SAS v. 9.3 software (SAS Institute, Inc., Cary, NC).

Results

All outpatient and inpatient RRP procedures were completed effectively, without open conversion. In the outpatient group, one patient (3.8%) had a partial circumference left ureteral injury, which was primarily suture repaired over a Double-J stent; a pelvic drainage tube was placed and this patient was discharged as outpatient without any sequela. In the fourth patient, significant bladder neck reconstruction intraoperatively was necessary, thereby this patient did not meet study exit criteria (in the operative assessment), and was admitted as inpatient overnight. These four study patients did well postoperatively without any complications; however, since they were not discharged as same-day surgery patients, their data were censured from subsequent comparative analysis and are reported separately. Median age was 58 (50–69) years and median prostate-specific antigen (PSA) was 7.4 (5.3–13.1). Median estimated blood loss was 100 (50–150) mL and median hospital stay was 31.5 (31–51) hours. Median pathologic Gleason score was 7 (6–7). One patient (pT_2c, Gleason 6) had a positive margin <1 mm. All patients reported “excellent” for all categories and would recommend this procedure.

Demographic data were similar between the groups (Table 1). Rate of negative surgical margins was comparable on pathology analysis (96.1% vs 92.3%); one patient (pT_3bN₀M_x) in the outpatient group and two (pT_2cN₀M_x, pT_3aN₀M_x) in the inpatient group had positive margins. Table 2 depicts intraoperative and postoperative data. Mean operative time and blood loss were similar between groups. No transfusions were required for any patient. Hospital stay was the main significantly different data point between the groups (14 ± 1.2 hours vs 44 ± 17.9 hours; p < 0.01).

Table 1.

Demographics of RRP Patient Cohorts

Variable	Outpatient RRP, mean ± SD or N (%)	Inpatient RRP, mean ± SD or N (%)	p
N	26	26	1.00
Age (years)	56.60 ± 7.04	61.9 ± 6.33	0.12
Body mass index (kg/m²)	25.30 ± 3.95	27.27 ± 1.64	0.46
ASA score	1.90 ± 0.53	2 ± 0.50	0.07
Baseline PSA (ng/mL)	7.21 ± 7.08	6.16 ± 3.29	0.47
Prostate volume on TRUS (cc)	36.10 ± 12.67	37.14 ± 16.54	0.88
Clinical stage			0.9
T_1c	16 (61.5)	11 (42.3)
T_2a	2 (7.7)	9 (34.6)
T_2b	3 (11.5)	4 (15.4)
T_2c	5 (19.3)	2 (7.7)
Biopsy Gleason score			0.12
3 + 3	16 (61.5)	14 (53.8)
3 + 4	8 (31.3)	3 (11.5)
4 + 3	1 (3.8)	6 (23.2)
4 + 4	1 (3.8)	3 (11.5)

ASA = American Society of Anesthesiologists; PSA = prostate-specific antigen; RRP = robotic radical prostatectomy; SD = standard deviation; TRUS = trans-rectal ultrasonography.

Table 2.

Perioperative Outcomes

Variable	Outpatient RRP, mean ± SD or N (%)	Inpatient RRP, mean ± SD or N (%)	p
N	26	26	1.00
OR time (minutes)	167.91 ± 37.67	178 ± 47.31	0.25
EBL (mL)	168.75 ± 185.16	102 ± 45.16	0.22
Prostate specimen weight (g)	49.01 ± 12.91	81 ± 100.66	0.15
Specimen Gleason score			1.00
3 + 3	8 (30.8)	6 (23.1)
3 + 4	11 (42.3)	15 (57.7)
4 + 3	6 (23.1)	4 (15.4)
4 + 4	0	0
4 + 5	1 (3.8)	1 (3.8)
Pathologic stage			0.92
pT_2a	5 (19.3)	6 (23.1)
pT_2b	2 (7.7)	0
pT_2c	13 (50)	14 (53.8)
pT_3a	1 (3.8)	2 (7.7)
pT_3b	5 (19.5)	4 (15.4)
Positive margins	1 (3.9)	2 (7.7)	0.56
Hospital stay (hours)	14 ± 1.21	44 ± 17.97	<0.01
Complications	1 (3.9)	0	0.32
Follow-up (months)	11.65 ± 3.57	9 ± 3.63	0.39
Cystogram showing anastomotic leak (POD 7)	0	1 (3.85)	0.32

Median data of the four study patients who were not discharged as same-day surgery, and whose data were censured from subsequent analyses: Median age 58 (50–69) years, PSA 7.4 (5.3–13.1) ng/mL, EBL 100 (50–150) mL, hospital stay 31.5 (31–51) hours, and RRP specimen Gleason score 7 (6–7). One patient (pT_2c, Gleason 6) had a positive margin <1 mm. All patients reported “excellent” for all questionnaire categories and would recommend this procedure.

EBL = estimated blood loss; OR = operative time; POD = postoperative day.

Bold text indicates statistically significant values.

Table 3 reports the continence rates for the two groups. At the end of the 2 months follow-up period, 92% of the patients in both groups were continent (no need for pads). Time to continence was 32 days for the outpatient group and 43 days for the inpatient RRP group (p = 0.09). We were unable to obtain continence information for one patient in the inpatient RRP group.

Table 3.

Continence Rates

Days after surgery	Outpatient cohort, mean ± SD or N (%)	Inpatient cohort, mean ± SD or N (%)	p
15	1 (4)	3 (12)	0.34
30	20 (76)	16 (64)	0.22
45	23 (88)	20 (80)	0.41
60	24 (92)	23 (92)	0.33
Time to continence (days)	32.4 ± 20.6	43 ± 92.9	0.09

Continence is defined as usage of no pads.

Table 4 reports responses to the follow-up questionnaires. All patients in the outpatient RRP group (100%) reported “excellent” for all categories and would recommend this procedure. Only one patient (3.8%) in the outpatient group needed pain medications for more than 7 days postoperatively. Mean days to return to work were 6.9 in the outpatient RRP group vs 9.2 days in the inpatient group (p = 0.35); more than 75% of the outpatient group reported returning to work within 9 days postoperatively. Mean preoperative IPSS was found to be significantly different between the groups: 4.00 ± 3.97 for the outpatient group vs 9.00 ± 7.0 for the inpatient group, p = 0.02; however, preoperative to postoperative percentage change in IPSS was comparable. In addition, percentage reduction in SHIM score, preoperative vs postoperative, was found to be significantly greater in the outpatient group: 60.2% vs 45.5%, p = 0.04.

Table 4.

RRP Patient Cohort Questionnaire Scores

Variable	Outpatient cohort, mean ± SD or N (%)	Inpatient cohort, mean ± SD or N (%)	p
Preoperative IPSS	4.00 ± 3.97	9.00 ± 7.00	0.02
Postoperative IPSS on POD 60	4.91 ± 2.15	6.78 ± 1.24	0.05
IPSS percentage change	22.37 ± 1.07	23.75 ± 2.32	0.21
Preoperative SHIM	22.00 ± 3.88	19.00 ± 5.00	0.10
Postoperative SHIM on POD 60	9.90 ± 4.78	11.02 ± 3.45	0.06
SHIM percentage reduction	60.2 ± 14.24	45.5 ± 8.37	0.04
Narcotic usage, days	4.77 ± 2.38	3.48 ± 2.90	0.19
Return to work, days	6.91 ± 5.80	9.20 ± 5.72	0.35
Days to full recovery (100%)	26.50 ± 19.19	51.9 ± 35.47	0.87
Response to “How would you rate the overall experience?”	4.83 ± 0.41	5 ± 0.0	0.78
Response to “Would you recommend the same procedure to a family member or friend?”	Yes—100%	Yes—100%	1.00

IPSS = International Prostate Symptom Score; SHIM = Sexual Health Inventory for Men.

Bold text indicates statistically significant values.

Discussion

Excellent patient care with low costs is the ultimate goal of any medical system. Due to the current emphasis on the financial aspects of modern-day healthcare, novel ways of lowering hospital costs are actively being pursued by all parties, including insurance companies, hospitals, physicians, and patients. With the advent of newer, more expensive technologies, one way to optimize healthcare costs is by minimizing hospital stay and related fees.

Widespread use of surgical robotics has provided certain advantages, such as reduced blood loss and transfusions, decreased postoperative pain, and earlier hospital discharge.³ However, these improvements in patient outcomes have come at an increased dollar cost, driven by the expensive robotic technology.⁴

Our study aimed to explore the feasibility of performing outpatient RRP in selected patients with prostate cancer. We examined a group of 26 patients undergoing outpatient RRP and prospectively compared outcomes in a matched 1:1 manner with those undergoing the same RRP surgery, but with overnight hospital stay. Both patient groups met the same preoperative study criteria but the inpatient group was either not interested/motivated to be discharged early or was not granted insurance authorization to undergo outpatient RRP.

Outpatient radical prostatectomy was described using the perineal open surgical approach in 250 patients.⁵ Of those surveyed, 17% reported problems postoperatively (majority being catheter related); however, 95% reported satisfaction with the treatment. Martin and colleagues were the first to report a feasibility study of outpatient RRP in 11 patients. All of them were discharged without the need for overnight hospital stay.² No complications were reported and, based on responses to the follow-up questionnaire, 87.5% of the patients were “extremely satisfied” with the experience. No hospital readmissions were reported. However, data were not compared with those undergoing inpatient RRP.

In our study, 30 patients were enrolled to undergo planned outpatient RRP. However, four patients failed to be discharged on the same day of surgery. Three of these patients met the predetermined discharge criteria, but they postoperatively changed their minds about early discharge despite having no clinical issues; these patients were admitted overnight and discharged the next day without any issues. We believe that these data reinforce the concept of patient selection and patient motivation being key drivers of effective same-day surgery.

Baseline demographics (age, ASA score, BMI, and prostate weight on transrectal ultrasonography) were similar between our groups, as were the operating time and blood loss. One patient sustained a small, partial circumference ureteral injury that was suture repaired primarily during surgery, without impacting timing of outpatient discharge. From an oncologic perspective, the clinical and pathologic stages were evenly distributed between the groups; pT₂ disease was present in 77% of patients in each group, indicating good matching at baseline between the groups. Our positive surgical margin rate, 4% in the outpatient group and 8% in the inpatient group, is similar to that of recent RRP series.^6
–8

Notably, mean hospital stay was significantly shorter in the outpatient group, 14 hours compared with 44 hours (p < 0.01). Upon satisfying objective discharge criteria, the outpatient group was discharged home; out-of-town patients were asked to stay at a hotel of their choice. Patients were proactively contacted that same night as well as on POD 1 to ensure postoperative stability. Maintaining close contact with our patients is key in ensuring smooth recovery and fundamentally provides constant confidence and reassurance. No patient needed to be readmitted in the outpatient group.

Regarding early continence rates, both inpatient and outpatient groups had more than 90% of continence (no need for pads) within 60 days after surgery, which is similar to those in RRP series within the literature.⁷ Our SHIM data are incomplete because of the 2-month study endpoint. Main limitations of our study include the small number of patients and the lack of a prospective randomized comparison with inpatient RRP, which is needed. Also, our modified patient recovery and satisfaction questionnaire is not validated. In addition, all surgeries were performed by experienced surgeons with extensive robotic and laparoscopic experience (>9,000 case volume).

Conclusions

To our knowledge, this is the first study in the literature to compare matched groups undergoing outpatient and inpatient RRP. Careful patient selection, motivated patient/family, preoperative counseling to appropriately set expectations, and proactive early postoperative monitoring are essential for excellent clinical outcomes and patient satisfaction. Our initial experience with outpatient RRP is promising.

Footnotes

Author Disclosure Statement

I.S.G. declares conflict of interest for EDAP, Mimic, and Hansen Medical. M.M.D. declares conflict of interest for Hansen Medical, Auris Robotics, Procept Biorobotics, and Baxter. The remaining authors have no competing financial interests.

Abbreviations Used

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