Same-Day Discharge for Patients Undergoing Robot-Assisted Laparoscopic Radical Prostatectomy Is Safe and Feasible: Results of a Pilot Study

Introduction

Recent mandates instituted by the Affordable Care Act place an emphasis on patient satisfaction, decreased complications, and cost as measures of the delivery of high-quality healthcare. ^1,2 In the literature, all three of these metrics can be improved by utilizing minimally invasive surgical techniques and minimizing hospital stay. ^3,4 Specifically, radical prostatectomy (RALP) is one such surgical procedure that offers an opportunity for realizing these governmentally mandated metrics.

Radical retropubic prostatectomy (RRP) has been the standard surgical approach for the treatment of prostate cancer (PCa), with reports dating back to the 1940s. ⁵ Traditionally, this was performed via an open (open radical prostatectomy [ORP]) technique. However, with the advent and integration of laparoscopy and robotics, the standard approach for RRP has changed to robot-assisted laparoscopic radical prostatectomy (RALP). ^6,7 In moving toward a more minimally invasive approach, there have been significant advantages conferred to the patient with respect to length of stay (LOS), estimated blood loss (EBL), pain scores, and overall complication rates. ^{8 –10} In reviewing the literature, the average LOS has continued to decrease over recent years, ⁶ but very few groups have pushed to decrease LOS further as a means of decreasing cost, complications and increasing patient satisfaction. We present the results of our pilot study evaluating the safety and efficacy of same-day discharge (SDD) in patients undergoing RALP.

Methods

In this IRB-approved study, a retrospective review was performed of a prospectively maintained RALP database. This prospectively maintained database is reviewed in real time for quality improvement purposes. In reviewing our database, we discovered that there had been no RALP complications within 24 hours of surgery. As a result, starting April 2015, we began our SDD protocol for all patients undergoing RALP. Initially, all consecutive patients undergoing RALP were offered the SDD protocol. During this time, a total of nine patients were offered and accepted SDD. However, interim analysis revealed that government insurance (CMS) refused hospital reimbursement for SDD. As of that time, only patients with commercial insurance were offered SDD. For the remainder of the study period, the next consecutive patients with commercial insurance were offered SDD, two of whom accepted and two of whom declined.

At our center, the SDD protocol includes pre-operative counselling regarding the safety of SDD as well as a multimodal approach to pain control, which includes the use of non-narcotic analgesia (NSAIDS, ketorolac, and local anesthesia) and limitation of narcotic pain medication and intraoperative fluids during the surgery. As part of the protocol, all patients were offered to stay in the on-campus hotel and were called personally by the surgeon on the night of the surgery. Peri-operative and demographic data were prospectively collected on all patients who underwent RALP.

Analysis of pre- and post-protocol groups was done to ensure there was no selection bias in the individuals offered SDD. The pre-protocol group consisted of nine consecutive RALP patients who underwent the procedure immediately before we began offering SDD. We selected the patients whose surgeries were performed the closest in time to the protocol patients to limit learning curve and temporal bias. All patients in the pre-protocol group underwent the same surgery and recovery as the SDD group, but were not offered SDD and were, instead, admitted to the hospital by protocol and offered discharge on the first postoperative day. All surgeries were performed by a single surgeon (S.J.).

SDD and pre-protocol groups were analyzed for differences in sex, age, body mass index (BMI), surgery time, EBL, procedure, complications, LOS, and distance from home to the hospital. Statistical analyses were completed by using Mann–Whitney U, chi-squared, or fisher exact tests, where appropriate.

At our center, RALP is performed robotically by using the Intuitive daVinci^® Xi platform. Patients do not undergo a bowel preparation, and the skin is not shaved before the procedure. Patients are left in a supine positon for the operation. Before induction, patients are administered ketorolac and before incision, the skin is infiltrated with local anesthesia (0.5% Bupivicaine). Before closing the skin incisions, local anesthesia is again infiltrated.

Patients accepting SDD are placed into an extended recovery and are monitored in the recovery room for 4–6 hours. Once their pain is well controlled and their vital signs are confirmed to be stable, they are discharged with narcotic pain medication and instructions on adequate hydration and activity level. The surgeon calls each patient on the night of discharge and evaluates them in the clinic on postoperative day 7.

The same pre-, intra-, and postoperative protocol was used for patients who refused or were not offered SDD, and each of these patients was seen by the surgeon on POD 0 and 1, while in the hospital.

Results

During the study period, 21 patients had undergone RALP. Eleven of 21 patients were offered SDD, and nine (81.8%) accepted and were successfully discharged. Both the patients who elected to stay were successfully discharged on the next day. Both stayed because of anxiety of being sent home too soon, but did not have any peri-operative variables that were different than those who were successfully discharged via the SDD protocol. Patient age, BMI, prostate-specific antigen, operative time, EBL, prostate weight, distance from home to hospital, margin status, marital status, and household income were not statistically significantly different between the two groups and are depicted in Table 1. There have been no reported complications or readmissions for any of the patients in Group 1, with a median follow-up of 255 days (range 68–341).

Discussion

PCa remains the most common cancer diagnosed in men and the second leading cause of cancer-related deaths for men. ¹¹ Patients afflicted with PCa have the option of a surgery for their disease as a means for cure. It is estimated that 138,000 patients undergo prostatectomy yearly. ¹² RRP was historically an open surgery with high morbidity rates. ^13,14 However, with advancement of surgical techniques and technology, surgery for PCa has evolved greatly, much to the benefit of patients. One such advancement is the integration of laparoscopy and robotic surgery for the treatment of PCa. Multiple studies have shown that ORP and RALP have equivalent oncological and functional outcomes; however, RALP has been associated with shorter postoperative stays, pain, and blood loss. ¹⁵ In fact, Lim and colleagues showed that the mean LOS for ORP, laparoscopy, and RALP was 3.1, 2.1, and 1.4 days, respectively. ¹⁶

This markedly shortened LOS is the result of many changes to the surgical routine. The majority of these changes have been intended to minimize side effects of surgery and include decreasing operative time, pain, nausea, and psychomotor impairment status post-anesthesia. This approach has been termed “minimal impact surgery.” ¹⁷ The impact of these changes is evident in the fact that the growth of minimally invasive prostatectomy has been exponential since its introduction. ³

Minimally invasive techniques have become more popular and led to shorter hospital stays in many other areas of surgery as well. As a result, patients are increasingly able to be discharged on the day of surgery, termed outpatient surgery, ambulatory surgery, day case surgery, or SDD. Procedures that have had success with SDD include cholecystectomy, ⁵ hysterectomy, and appendectomy. The cholecystectomy was one of the first to gain popularity among surgeons, when it was discovered that patients experienced a more rapid recovery than open methods. ¹⁸ An immediate decrease in LOS and time before returning to work was seen, ¹⁹ with one study by Bailey finding that 90% of patients were able to be discharged within 24 hours of laparoscopic cholecystectomy (LC). ²⁰ However, recently, the LOS has been decreased even further, leading to SDD after LC. Psaila and colleagues found that 86% of LC patients were able to be discharged on the same day, by using techniques such as preoperative patient education and telephone follow-ups. ²¹

Within the field of urology, studies have been done on SDD after pubovaginal slings, ²² laparoscopic nephrectomy, ^23,24 and urethroplasty. ¹⁷ Ilie and colleagues did a study of 26 laparoscopic nephrectomy patients and found that by following the day case protocol, 84.6% were able to be discharged the same day. ²⁴ Similarly, MacDonald and colleagues found that they were able to increase the rates of SDD after anterior urethroplasty, from 27% historically to 85% by using minimal impact methods, including bupivacaine wound injections, aggressive nausea and pain control, and shortened operative time. ¹⁷

Of particular relevance is a study in which Dudderidge and colleagues found that 78% of patients with laparoscopic radical prostatectomy were able to be discharged after a one-night stay. In their study, they also found that 7% of patients were able to be discharged on the same day, with no overnight stay. ²⁵

Our study is similar to that of Dudderidge and colleagues, in that both were interested in decreasing the LOS after minimally invasive prostatectomy. However, there are some significant differences between our study and that by Dudderidge and colleagues, in both methods and results. The first difference is in our use of robotic techniques, which is more applicable to the current surgical era. We used an intraperitoneal approach, in contrast to Dudderidge and colleagues' retroperitoneal approach. We also did not use transversus abdominis plane blocks, which Dudderidge and colleagues used to decrease postoperative pain and to make discharge better tolerated. ²⁵ Lastly, our study found higher rates of voluntary patient agreement to SDD. This is believed to be due to increased time spent by the surgeon talking with patients, answering questions, and educating. Each patient was given the surgeon's cell phone number and told to expect a personal phone call on the day of surgery.

When SDD for a procedure is feasible, it results in significant cost savings. In a prospective study implementing SDD after appendectomies, the average savings per patient was $4111. ²⁶ Some estimates have shown outpatient surgeries to cost 40%–60% less than those performed with hospitalization. ^27,28 At our institution, the cost of a one-night stay with observation is ∼$4000. With ∼138,000 prostatectomies performed each year, ¹² the adaptation of SDD after RALP would result in substantial savings to the healthcare industry.

Patient satisfaction has been increasingly emphasized since the implementation of the ACA. This has proved to be another motivational factor for SDD. Okafor ²⁹ administered a health-related quality-of-life questionnaire to patients after short-stay or outpatient urethroplasty. Results showed that early discharge after urethroplasty was well tolerated by patients and they were satisfied with the timing of discharge. ²⁹ Patients treated as outpatients have also been shown to show shorter periods of emotional and psychological distress. ²⁷

In summary, we believe that there are many benefits to SDD, such as reduced cost, less stress to the immune system, ²³ and the ability to recover in the comfort of one's own home and faster convalescence, all of which have been shown to increase patient satisfaction. However, we present a small, retrospective review of nonrandomized patients, which may not accurately reflect a more generalizable result when applied to a larger number of patients.

However, our pilot study shows that SDD is safe and efficacious. The use of multimodal anesthesia and analgesia with appropriate pre-operative counselling is critical for successful SDD. We learned that prior authorization for SDD is essential for hospital reimbursement and needs to be explored before scheduling the surgery. We also believe that a pre-operative team to discuss SDD with the patient would help relieve some of the anxiety associated with going home “too soon.” Finally, we believe that further research needs to be conducted on a larger scale and, ideally in a randomized trial. We also believe that prospective tracking of patient satisfaction will be critical in appraising whether patients prefer SDD or not.

Conclusion

Based on the results of our pilot study, we believe that SDD after RALP is safe and feasible. Larger application of this protocol could result in lowered healthcare costs and increased patient satisfaction. Further studies are needed to confirm our findings.