A Single Overnight Stay After Robotic Partial Nephrectomy Does Not Increase Complications

Abstract

Objectives:

To evaluate the feasibility of postoperative day 1 (POD1) discharge after robotic partial nephrectomy (RPN) and to determine whether a protocol targeting a shorter length of stay (LOS) is associated with any difference in the rate of postoperative complications.

Materials and Methods:

We reviewed a prospectively maintained, multi-institutional database of patients who underwent RPN from September 2013 to September 2016. Three of the six participating surgeons used a protocol that targeted discharge on POD1, whereas three surgeons did not. Patient characteristics and postoperative complication rates between the two groups were compared.

Results:

A total of 665 patients were included, 455 of whom were treated by surgeons utilizing a POD1 discharge protocol, whereas 210 were not. The mean LOS for those in the POD1 protocol group was 1.13 days vs 2.02 days in the non-protocol group. Between groups, there were no differences in age (p = 0.098), body mass index (p = 0.164), tumor size (p = 0.502), or R.E.N.A.L. Nephrometry score (p = 0.974), but POD1 discharge protocol patients had higher age-adjusted Charlson comorbidity score (4 vs 2, p = 0.033), were less likely to have a hilar tumor (15.9% vs 23.1%, p = 0.03), and had a larger percent decrease in discharge estimated glomerular filtration rate (−15.9% vs −7.1%, p < 0.001). There were no differences in the rates of overall (p = 0.715), major (p = 0.164), medical (p = 0.089), or surgical complications (p = 0.301) or in complications by the Clavien–Dindo category (p = 0.13).

Conclusion:

Discharge on POD1 after RPN is feasible, reproducible by different surgeons, and not associated with an increased risk of postoperative complications.

Introduction

The intended advantages of minimally invasive surgery include less pain and blood loss as well as shorter hospitalization time and convalescence.^1
–3 Robotic partial nephrectomy (RPN) is currently the most commonly used minimally invasive approach to partial nephrectomy (PN),⁴ but despite the growing adoption of RPN, reported postoperative lengths of stay have stagnated in a range achievable with open surgery.⁵

Early recovery after surgery (ERAS) protocols after urologic surgery are increasingly being used to reduce postoperative hospital stays, improve both objective and subjective quality of patient care, and decrease hospital costs.^6,7 The combination of minimally invasive procedures with clinical pathways may allow the greatest reduction in postoperative length of stay (LOS), including demonstrated feasibility for overnight stay after RPN.^8
–10

The initial report in the literature demonstrating the feasibility of discharge after RPN on postoperative day 1 (POD1) was published in 2013 by Abaza and Shah before the current popularity of ERAS protocols.⁸ Despite demonstrating a 97% discharge rate on POD1 with only 2.7% readmission rate and the 5 years that have passed since, there remains resistance in many centers and even among many high-volume RPN surgeons to adopt overnight stays after RPN. According to a study based on “real-world” data from the Premier Hospital Database that included 39,773 RPN procedures performed in the United States, 19% to 33% of patients had a LOS >3 days after RPN depending on the surgeon's volume from very high to very low, respectively.¹¹

One criticism of implementing a single overnight stay protocol after RPN is that the complexity of the procedure mandates longer hospitalization to ensure avoidance of the complications inherent to nephron-sparing surgery.¹² Whether or not this criticism has supporting evidence, many surgeons remain attached to this concept as an established dogma. To assess whether the complexity and potential complications of RPN dictate a need for more than one night of hospitalization, we evaluated the rate of postoperative complications for patients who were treated with a protocol targeting discharge on POD1 compared with patients who were not. The safety and reproducibility of routine overnight stays were evaluated by comparison with surgeons routinely implementing longer lengths of stay to shed light on whether this practice prevents complications as purported by critics of discharge on POD1.

Materials and Methods

Data source and eligibility criteria

We reviewed a prospectively collected and institutional review board-approved multi-institutional database of 1868 patients who underwent RPN by six different surgeons between 2006 and 2016. Of these, 117 patients were excluded for clinical stage >cT1b tumors, multiple tumors, metastatic disease, or incomplete complications data recorded. Since several surgeons implemented a POD1 discharge protocol after having gained significant RPN experience, we limited our analysis to the last 3 years (September 2013 through September 2016). During this period, three of the six surgeons used a protocol that included routine discharge on POD1, defined as >80% of patients discharged by POD1. After exclusions, a total of 665 patients were treated during the study period of September 2013 through September 2016. Over the 3-year study period, 455 (68.4%) patients were treated by surgeons using a protocol targeting a POD1 discharge, whereas 210 (31.6%) patients were treated by surgeons not using a POD1 discharge protocol.

Discharge protocol

Postoperative care was not standardized across sites, but common elements among surgeons routinely discharging patients on POD1 are included in Table 1. Comorbidities or use of anticoagulation preoperatively was not considered contraindications to next day discharge such that all patients were included in the POD1 discharge plan regardless of these factors. Patients were discharged to their homes and not to a nursing or rehabilitation facility. Discharge criteria included adequate pain control on oral medications and toleration of regular diet. For those patients in the POD1 discharge group who ended up staying inpatient past POD1, the reasons for their extended hospital stay were not recorded but could include either medical reasons or patient comfort or preference.

Table 1.

Examples of Elements of Early Recovery After Surgery Pathway Implemented (Nonuniformly) Among Robotic Partial Nephrectomy Surgeons Using a Protocol Targeting Postoperative Day 1 Discharge

Commonly implemented techniques
Preoperative patient education, including setting expectations for discharge
Four-port technique when possible
Non-muscle-cutting (midline) extraction of specimens
Bupivacaine injection at incision sites
Avoidance of stents and drains
Avoidance of intravenous narcotics, instead using oral analgesics and/or intravenous ketorolac
Encouraging ambulation on POD0
Clear liquid or regular diet beginning on POD0
Early Foley catheter removal on POD1
Avoiding unnecessary laboratory studies

Statistical analyses

Postoperative complications were compared between groups, looking at the overall number of complications as well as the number of complications categorized as major (Clavien–Dindo score ≥3), medical, or surgical. Complication rates were compared between the two groups using chi-squared tests of independence. Patient, surgical, and tumor characteristics were compared between the two groups using chi-squared tests of independence or Fisher's exact tests for categorical variables and Mann–Whitney U tests for continuous variables.

Results

A total of 665 patients were included in the study. Of those, 455 (68.4%) were treated by surgeons targeting a POD1 discharge and 210 (31.6%) were treated by surgeons not using an overnight stay protocol. Of the patients treated by the three surgeons targeting a POD1 discharge, 410 of the 455 patients (90.2%) were discharged on POD1. Among these three surgeons, the individual rates of POD1 discharge by surgeon were 97.6%, 82.1%, and 80.0%. Overall, the mean LOS for patients treated with the POD1 discharge protocol was 1.13 days, which was significantly shorter than the mean LOS of 2.02 days for patients not treated with this protocol (p < 0.001). Of those patients not treated with the POD1 discharge protocol, 91.1% were discharged by POD3.

Full clinical and tumor characteristics for each group are listed in Table 2. There were no differences in preoperative patient or tumor characteristics except for a higher mean age-adjusted Charlson comorbidity score among patients in the POD1 discharge protocol group (4 vs 2, p = 0.033) and more hilar tumors in the non-POD1 discharge protocol group (23% vs 16%, p = 0.030).

Table 2.

Clinical, Operative, and Tumor Characteristics for Patients Undergoing Robotic Partial Nephrectomy With and Without a Postoperative Day 1 Discharge Protocol

	POD1 discharge protocol (N = 455)	No POD1 discharge protocol (N = 210)	p
Clinical characteristics^a
Age (years)	62.0 (53.0 to 70.0)	60.5 (50.0 to 68.0)	0.098
Male	91 (43.3%)	119 (56.7%)	0.357
Female	275 (60.4%)	180 (39.6%)	0.357
Body mass index (kg/m²)	29.5 (25.8 to 34.3)	28.7 (25.0 to 33.3)	0.164
Age-adjusted Charlson comorbidity index	4 (2 to 5)	2 (2 to 4)	0.033
Baseline eGFR (mL/min/1.73 m²)	83.8 (68.9 to 98.8)	84.5 (67.9 to 99.1)	0.881
History of abdominal surgery	139 (62.3%)	82 (57.7%)	0.382
Operative characteristics^a
Transperitoneal technique	388 (85.3%)	183 (87.1%)	0.520
Retroperitoneal technique	67 (14.7%)	27 (12.9%)	0.520
On-clamp	439 (96.9%)	194 (92.4%)	0.009
Off-clamp	14 (3.1%)	16 (7.6%)	0.009
Operative time (minutes)	162 (139 to 191)	152 (126 to 195)	0.122
Warm ischemia time (minutes)	14.9 (11.9 to 18)	16 (12 to 20)	0.003
Estimated blood loss (mL)	100 (50 to 150)	100 (50 to 150)	0.837
% Change in eGFR at discharge	−15.9% (−30.0% to −0.7%)	−7.1% (−17.7% to 2.8%)	<0.001
Mean length of stay (days)	1.13	2.02	<0.001
Tumor characteristics^a
Stage T1a tumors, by pathology	331 (72.7%)	161 (76.7%	0.284
Stage T1b tumors, by pathology	124 (27.3%)	29 (23.3%)	0.284
Tumor size (cm)	3.1 (2.2 to 3.1)	3.0 (2.2 to 4.0)	0.502
R.E.N.A.L. Nephrometry score	7 (6 to 8)	7 (6 to 9)	0.974
Hilar tumors	67 (15.9%)	46 (23.1%)	0.030
Malignant pathology	328 (76.8%)	163 (78.0%)	0.740

Bolded values indicate statistical significance with p < 0.05.

Unless otherwise noted, for continuous variables, the median value is reported with interquartile ranges in parenthesis. For categorical variables, the frequency is reported with percentages in parenthesis.

eGFR = estimated glomerular filtration rate; POD1 = postoperative day 1.

Between the POD1 discharge protocol group and the non-POD1 discharge protocol group, there were no significant differences in overall (9.5% vs 8.6%, p = 0.715), major (2.0% vs 3.8%, p = 0.164), medical (5.9% vs 2.9%, p = 0.089), or surgical (4.0% vs 5.7%, p = 0.309) complication rates (Table 3). Additionally, there were no differences in postoperative complications when categorized by the Clavien–Dindo score (Table 4).

Table 3.

Complications for Patients Undergoing Robotic Partial Nephrectomy With and Without a Postoperative Day 1 Discharge Protocol

	POD1 discharge protocol	No POD1 discharge protocol	Odds ratio (95% CI)	p
Overall complications^a	43 (9.5%)	18 (8.6%)	1.11 (0.64–2.03)	0.715
Major complications (Clavien–Dindo score ≥3)	9 (2.0%)	8 (3.8%)	0.51 (0.19–1.38)	0.164
Medical complications	27 (5.9%)	6 (2.9%)	2.14 (0.93–5.82)	0.089
Surgical complications	18 (4.0%)	12 (5.7%)	0.68 (0.32–1.47)	0.310

Frequencies presented with percentages in parenthesis.

CI = confidence interval.

Table 4.

Complications Categorized by the Clavien–Dindo Score in Patients Undergoing Robotic Partial Nephrectomy With and Without a Postoperative Day 1 Discharge Protocol

Clavien–Dindo score	POD1 discharge protocol	No POD1 discharge protocol	p
I	22 (4.8%)	7 (3.3%)	0.130
II	13 (2.9%)	3 (1.4%)
III	8 (1.8%)	8 (3.8%)
IV	2 (0.4%)	0 (0.0%)
V	0 (0.0%)	0 (0.0%)

Among patients treated by surgeons utilizing a POD1 discharge protocol, there were 43 (9.5%) patients who experienced a postoperative complication, 9 (2.0%) of whom experienced major complications with a Clavien–Dindo score of 3 or greater. One patient experienced two major complications, such that the total number of major complications in the POD1 discharge protocol group was 10. These included bleeding (N = 2), respiratory and renal failure (N = 1), myocardial infarction (N = 1), new-onset atrial fibrillation (N = 1), pseudoaneurysm (N = 2), small bowel obstruction (N = 1), urinary extravasation (N = 1), and an unspecified complication (N = 1). In those being treated by surgeons not utilizing the POD1 discharge protocol, there were 18 (8.6%) patients who experienced complications, 8 (3.8%) of whom experienced major complications. These complications included ventral or umbilical hernia (N = 4), pneumothorax (N = 2), hematuria (N = 1), and acute kidney injury (N = 1).

Discussion

A wide range of hospital stays have been reported after PN by various techniques (Table 5). The implementation of a clinical pathway in patients undergoing open partial nephrectomy have allowed a shortened LOS comparable to what has been reported in many contemporary RPN or laparoscopic partial nephrectomy series.^5,13 The first application of a clinical pathway to RPN was reported in 2013 and achieved a POD1 discharge in 97% of patients.⁸ Since then, other studies have identified a reduction in the LOS after RPN when implementing a clinical pathway,^9,10 but there remains a resistance to widespread acceptance of this concept.

Table 5.

Sample of Series That Report Mean Length of Stay After Either Open Partial Nephrectomy, Laparoscopic Partial Nephrectomy, or Robotic Partial Nephrectomy Procedures

Series	Surgery type	No. of patients	Mean LOS (days)
Gill et al.²⁰	Open	1029	5.8
Chughtai et al.⁵	Open	33	3.3^a
Peyronnet et al.³	Open	863	10.1
Sirohi et al.¹³	Open	38	2.0^a
Camp et al.²⁴	Open	2605	7.3
Luciani et al.²⁵	Open	73	9
Chang et al.²⁶	Open	122	6.1
Link et al.²¹	Laparoscopic	217	3.1
Gill et al.²⁰	Laparoscopic	771	3.3
Benway et al.²²	Laparoscopic	118	2.7
Camp et al.²⁴	Laparoscopic	1060	5.1
Luciani et al.²⁵	Laparoscopic	70	8
Chang et al.²⁶	Laparoscopic	122	6.9
Alimi et al.²⁷	Laparoscopic	50	4.6
Benway et al.²²	Robotic	129	2.4
Kaouk et al.²³	Robotic	187	3.6
Abaza and Shah⁸	Robotic	150	1.1^a
Peyronnet et al.³	Robotic	863	4.7
Maurice et al.²⁸	Robotic	74	2.2
Camp et al.²⁴	Robotic	610	4.1
Luciani et al.²⁵	Robotic	110	6
Chang et al.²⁶	Robotic	122	5.3
Alimi et al.²⁷	Robotic	50	3.6

Clinical pathway in use emphasizing early discharge.

LOS = length of stay.

Our current study is the largest series to date evaluating the implementation of a clinical pathway to RPN. As expected, the LOS in patients treated by surgeons using a protocol targeting POD1 discharge was significantly shorter than the LOS in patients not treated with that protocol. A potential criticism of reducing the LOS after RPN to an overnight stay is the contention that PN is a sufficiently complex procedure such that this could potentially increase complications. We found no significant difference in the rates of overall, medical, surgical, or major postoperative complications in those patients managed with a POD1 protocol compared with those who were not. Keeping patients for a second or third night, as was common practice for the surgeons not using the POD1 discharge protocol, did not result in additional complications being recognized or addressed, including during the longer initial postoperative stay.

While reducing the LOS after surgery has been linked to a reduction in cost of care in several surgical fields,^14,15 a common concern among those voicing opposition to early discharge strategies is that some patients may be negatively impacted for a financial gain. Contrary to such a concern, the primary goal of implementing a clinical pathway is to improve patient care and outcomes, including minimizing the time a patient is in the unfamiliar setting of the hospital rather than the comfort of his or her own home,⁷ whereas cost saving is a secondary goal. Nevertheless, for patients to have the opportunity to benefit from RPN, financial sustainability is necessary, and without taking advantage of the shorter LOS possible with RPN, the cost of RPN is higher than the alternatives.^16,17 Reducing the LOS could help to reduce the cost of RPN procedures,^18,19 in addition to allowing patients to recover in a more familiar home environment sooner. Our study showed no increase in the number of complications experienced by patients who were not treated with an early discharge protocol, which suggests that those patients who stayed an extra day or two did not have more complications identified during that time that could justify the extra days of hospitalization. Since our study also found no negative impact on complications when patients were discharged on POD1, other experienced surgeons may consider adopting a POD1 discharge protocol after RPN without expecting a requisite increase in complications.

Clearly, not all surgeons who perform RPN procedures will be comfortable discharging all patients on POD1 and may not have the experience and/or outcomes to justify this. Individual surgeons should reflect upon their own outcomes and whether or not their patients experience complications during the additional days of hospitalization that follow the first day. If they do not or only very rarely do, applying a clinical pathway with POD1 discharge is reasonable. All the surgeons in our study, whether implementing a POD1 discharge protocol or not, were very experienced and relatively high-volume RPN surgeons as reflected in the <10% complication rate in both groups. While this may limit the applicability of our findings to lower volume or less-experienced surgeons, it appears that the length of the initial hospital stay after RPN was not the determining factor in complications occurring among the surgeons represented.

This multi-institutional study was retrospective, so the clinical pathway and surgical techniques used by each surgeon were not standardized. While this represents a limitation of the study, it supports the reproducibility of POD1 discharge among other surgeons who might have differences in their surgical techniques and postoperative care. The goal of our study was not to determine which factors allowed early discharge, but rather to determine whether POD1 discharge is safe among multiple surgeons or whether keeping patients longer than POD1 is necessary to diagnose and treat potential postoperative complications that may arise. The complication rate was not significantly different among those treated by surgeons using an overnight stay protocol regardless of the details of their techniques, which can provide surgeons with reassurance about the ability to successfully implement their own preferred aspects of postoperative care when targeting a POD1 discharge.

Finally, due to the retrospective study design, the reporting of readmissions was not standardized and was inadequately reliable to allow robust comparison between the two groups. Since each institution represented one surgeon who either did or did not implement a POD1 discharge protocol, even minor inconsistencies in the capture of readmissions at one institution or another would bias the results significantly. Regardless, to the degree that complications of the similar Clavien–Dindo category would be expected to result in readmissions or outpatient management alone, we felt that the complication data reported herein provide an adequate insight into the impact of POD1 discharge even in the absence of the ability to report detailed readmission information.

Conclusion

Patients who were treated with a protocol targeting a POD1 discharge after RPN did not have a significantly different rate of postoperative complications when compared with patients who were routinely discharged on POD2 or POD3. Reducing the LOS after RPN to an overnight stay is feasible, and in our series was safely applied. We encourage surgeons performing RPN to consider whether or not POD1 discharge could be applied in their practice to further take advantage of the benefits afforded by minimally invasive surgery.

Footnotes

Author Disclosure Statement

Ronney Abaza, MD, FACS—Conmed (research grant), Intuitive Surgical (educational grant).

Funding Information

No funding was received for this article.

Abbreviations Used

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