Outpatient Robot-Assisted Radical Prostatectomy: Are Patients Ready for Same-Day Discharge?

Abstract

Purpose:

Several case series have demonstrated the safety and feasibility of outpatient robot-assisted radical prostatectomy (RARP) in well-selected patients; however, the patient perspective of this practice has not been well explored. In this study, we explored patients' perspectives on the potential barriers and benefits of outpatient RARP.

Materials and Methods:

We developed a multidimensional questionnaire to assess socioeconomic status, presence of caretaker at home, preferred transportation to the emergency room in case of chest pain or postsurgical complications, readiness for discharge at postanesthesia care unit (PACU), and potential barriers for discharge. In addition, patients were asked to provide an estimate of overnight hospitalization costs and their willingness to pay out-of-pocket expenses for their overnight stay. Patients who underwent RARP between August 1, 2018, and April 30, 2019, were asked to fill the questionnaire within the first week following their operation.

Results:

During our study, 157/292 (53.8%) of men undergoing RARP from a single high-volume robotic surgeon completed the survey. Patients who completed <80% of the survey (n = 5) were excluded from the final analysis. Thirty-seven (24.3%) patients felt that they would have been ready for discharge immediately from PACU, and 48 (31.6%) patients after extended recovery and before midnight. Only 17.8% (n = 27) of the patients claim that they experienced a medical intervention in the hospital that could not have been managed at home. The main barriers for same-day discharge were pain (55.9%, 80/143), catheter discomfort (44.7%, 64/143), insufficient education about catheter care (31.4%, 45/143), postoperative nausea and vomiting (15.3%, 22/143), and medical complications (13.2%, 19/143).

Conclusions:

Two-thirds of patients following RARP did not feel ready to be discharged on the day of their surgery. Further research is necessary to identify patients who may benefit from this approach to reduce health care costs while minimizing patient postoperative morbidity.

Introduction

In the United States, health care costs are soaring. An aging population, newly available therapies, and an influx of insured patients following the passage of the Patient Protection and Affordable Care Act (ACA) in 2010 have resulted in a perfect storm for rising health care expenditures.¹ From 2006 to 2020 and beyond, the annual direct costs associated with cancer care are projected to rise from $104 billion to over $173 billion.² By 2025, health care spending is projected to consume 20.1% of the annual gross domestic product of the United States.¹ These rising costs collectively represent an existential threat to the sustainability of the health care system in the United States.

Escalating health care costs have driven both governmental and commercial payers to pursue several strategies, including the utilization of ambulatory surgery centers and bundled payment models to reduce health care costs.³ In turn, clinicians have attempted to identify operations and patients, which may be amenable to an outpatient approach.

Minimally invasive operations represent an ideal target for cost containment. While robot-assisted radical prostatectomies (RARP) are associated with shorter length of stay and reduced estimated blood loss compared with open techniques,⁴ there are also significant fixed and variable costs associated with the purchase and utilization of the robotic platform.⁵ Initial descriptions of same-day discharge or outpatient RARP have been reported from high-volume robotic centers in well-selected patients.^6,7 Abaza et al.⁸ reported that 49.2% of 500 men who underwent RARP were discharged the same day of surgery. Within this series, the authors estimated an overall reduction in charges of $518,814 over 18 months ($345,876 per year) without increased costs amassed from emergency room (ER) visits or hospital readmissions compared with their standard postoperative pathway with overnight admission.⁸

While outpatient RARP appears to be a safe and feasible method to reduce health care costs associated with the treatment of prostate cancer, it is unknown how patients perceive the risks and benefits associated with this practice. To assess this, we developed a multidimensional survey to assess the patient characteristics and patients' perceived barriers to outpatient RARP, administering this survey to men in the first week following RARP within a high-volume robotic practice.

Materials and Methods

Survey instrument

Following study approval by the institutional review board, a multidimensional survey was created in plain language English to investigate patient perspectives' regarding the potential benefits and barriers with regard to outpatient RARP. Included questions were chosen by consensus of the authors and were not formally validated. The questionnaire consisted of 14 questions pertaining to socioeconomic status, presence of caretaker at home, preferred transportation to the ER in case of chest pain and postsurgical complications, readiness for discharge at postanesthesia care unit (PACU), and potential barriers for discharge. In addition, patients were asked to provide an estimate of overnight costs associated with hospitalization and their willingness to pay out-of-pocket expenses for their overnight stay.

Survey population

The survey was offered to all patients who underwent RARP between August 1, 2018, and April 30, 2019, from a single high-volume robotic surgeon (D.I.L). Before surgery, all patients were offered an optional educational course taught by a urology physician assistant to provide information regarding their clinical course following the operation and postoperative expectations. All RARP patients had bilateral pelvic lymph node dissection. No surgical drains were placed at the time of the operation, and all patients were placed on a standardized early recovery after surgery protocol with a robot-assisted transversus abdominis plane block instillation of 20 mL of 0.5% bupivacaine at the completion of the case.^9,10 All patients were admitted postoperatively following RARP. Medical or nursing staff initially assessed patient interest for study participation during the first week following their operation (either inpatient or during their first clinic appointment for catheter removal). Patients who consented to take part in the study were able to read and understand the survey, and those who completed at least 80% of questions were included in the final analysis. There were no specific exclusion criteria for survey administration beyond these inclusion criteria. Surveys were self-administered, and results were collected and stored in a deidentified and secured REDCap (Vanderbilt University, Nashville, TN) database.¹¹

Statistical analyses

Variables collected in the database included patient sociodemographics, presence of caretaker at home, preferred transportation to the ER in case of chest pain and postsurgical complications, readiness for discharge at PACU, potential barriers for discharge, patient's estimation of overnight hospitalization costs, and their willingness to pay out-of-pocket expenses for their overnight stay.

For variables with non-normal distribution, data were presented as median and interquartile range (IQR). Means and medians were reported for continuous variables. Statistical analyses were performed with SPSS software version 22.0 (IBM SPSS Statistics; IBM Corp, Armonk, NY).

Results

Overall, 157 of the 292 (53.8%) men who underwent RARP during the study period consented to fill out the survey. Patients who completed <80% of the survey (n = 5) were excluded, leaving a total of 152 patients. Descriptive demographic data for this cohort are shown in Table 1.

Table 1.

Sociodemographics of Survey Participants

	Survey respondents (n = 152)
Median age (IQR)	63.6 years (58.9–67.5)
Race, n (%)
White	121 (79.6)
African American	18 (11.8)
Asian	5 (3.3)
Latino	1 (0.7)
Other	4 (2.6)
Prefer not to answer	3 (2.0)
Insurance status, n (%)
Private	95 (62.5)
Medicare	47 (30.9)
Medicare + private	5 (3.3)
No response	5 (3.3)
Annual household income, n (%)
<30,000	4 (2.6)
30,000–59,999	12 (7.9)
60,000–119,999	29 (19.1)
120,000–179,999	28 (18.4)
180,000+	40 (26.3)
Prefer not to answer	39 (25.7)
Education level, n (%)
High school graduate or less	17 (11.2)
Some college, no degree	29 (19.1)
College degree (bachelors/associates)	49 (32.2)
Graduate/professional degree	56 (36.8)

IQR = interquartile range.

The median patient age at the time of surgery was 63.6 years (IQR 58.9–67.5 years) with a range from 47 to 81 years. Most men self-identified their race as white (121, 79.6%), with smaller cohorts of African American (n = 11.8%), Asian (n = 5, 3.3%), other (n = 4, 2.6%), and Latino (n = 1, 0.7%). This cohort featured a high degree of educational attainment as most patients (n = 105, 69.1%) had earned a college degree, with a substantial subset of men (n = 56, 36.8%) with either a graduate or professional degree.

While most patients (n = 144, 94.7%) had a caretaker available at home, eight patients (5.2%) described themselves as self-dependent. In the event of postoperative chest pain, 65.7% (n = 100) of the patients would travel to the ER by ambulance, while only 24.3% (n = 37) would present to the ER if they had surgical complications. The majority of men (n = 97, 63.8%) had private insurance coverage, while all men who provided their insurance status had private, Medicare, or combined health care insurance (147/147, 100%).

Patient responses to the questionnaire are shown in Table 2. Approximately one-quarter of patients (n = 37, 24.3%) felt that they would have been ready for discharge immediately from the PACU, with a smaller additional group of men (n = 11, 7.2%) who felt that they would have been comfortable with same-day discharge following extended recovery. Overall, 48 of the 152 respondents (31.6%) reported that they would have been comfortable with same-day discharge following RARP. The majority of the patients (83.8%, 114/137) estimated the cost of overnight to be >$1000; however, only 12.6% (16/127) were willing to pay out-of-pocket costs >$1000.

Table 2.

Patient Questionnaire Responses

	Responses	n (%)
How much do you think your overnight stay costs?	<$500	4 (2.6)
	$500–$1000	17 (11.2)
	$1000–$2000	23 (15.1)
	$2000–$3000	38 (25)
	$3000–$4000	53 (34.9)
	No answer	17 (11.2)
The average cost for overnight stay in an academic hospital in Pennsylvania is ∼2000 $. If you had to, how much are you willing to pay out of your pocket to cover this stay?	<$100	18 (11.8)
	$100–$500	49 (32.2)
	$500–$1000	33 (21.7)
	$1000–$2000	15 (9.9)
	$2000–$3000	1 (0.7)
	$3000–$4000	0
	I would not pay	10 (6.5)
	No answer	26 (17.1)
Do you have a person who can take care of you at home? If yes, who is this person?	Yes	144 (97.4)
	No	8 (5.3)
Do you have a car?	Yes	198 (97.4)
Do you have a car?	No	4 (2.6)
In case of emergency after discharge, how would you come back to the emergency room? (check all that apply)	Driving yourself	25 (16.4)
	Asking someone to drive you to the hospital	111 (73)
	Hail a cab	3 (2)
	Ambulance	37 (24)
	Use Uber/Lyft	7 (4.6)
If you have had chest pain “not during the recovery period,” how would you come back to the emergency room? (check all that apply)	Driving yourself	11 (7.2)
	Asking someone to drive you to the hospital	56 (36.8)
	Hail a cab	0
	Ambulance	100 (65.8)
	Use Uber/Lyft	5 (3.3)
In retrospect, would you have been able to return home yesterday directly from the postanesthesia care unit?	Yes	37 (24.3)
	No	115 (75.7)
In retrospect, would you have been able to return home yesterday before midnight after a prolonged stay in the postanesthesia care unit?	Yes	48 (31.6)
	No	104 (68.4)
If you do not feel that you could have been discharged home yesterday, what factors required staying overnight in the hospital in your experience? (check all that apply) (n = 143)	Pain	80 (55.9)
	Nausea/vomiting	22 (15.3)
	Catheter discomfort	64 (44.7)
	Insufficient education on catheter care	45 (31.4)
	Insufficient education on what to expect following surgery	30 (19.7)
	Medical event following surgery (such as low blood pressure)	19 (13.2)
	Other	29 (20.3)

Only 17.8% (n = 27) of the patients claimed that they had a medical intervention in the hospital that could not have been taken care of at home. The main barriers for same-day discharge were pain (55.9%, 80/143), catheter discomfort (44.7%, 64/143), insufficient education about catheter care (31.4%, 45/143), postoperative nausea and vomiting (15.3%, 22/143), and medical causes, such as low blood pressure, A-fib, and hypoglycemia (13.2%, 19/143).

Discussion

Several high-volume centers of excellence have reported their initial experience regarding the safety and feasibility of outpatient RARP.^6
–8,12 These studies have demonstrated that outpatient RARP may be performed with similar complications and outcomes,^6,8,12 as well as improved postoperative patient satisfaction with less pain, reduced interference with general activities, and improved overall health perception compared with inpatient RARP.¹³ While these studies are promising, they are also reflective of well-selected patient populations with limited comorbidities, ideal body mass indexes, and adequate social support. Presently, the unique patient-derived barriers and concerns toward outpatient RARP are yet to be explored. We sought to address this deficit by creating a novel survey instrument to assess patient perspectives regarding outpatient RARP.

In our study population, approximately one-fourth of men (n = 37, 24.3%) felt that they would have been comfortable for discharge directly from PACU and nearly one-third of men (n = 48, 31.6%) reported that they would have been comfortable for discharge the same day of surgery. We found that postoperative pain (52.6%) and catheter discomfort (42.1%) were the most common concerns for patients, which they felt necessitated an overnight stay in the hospital after surgery. Furthermore, about 30% of RARP patients reported that they had insufficient education on catheter care. Therefore, our study reveals that patients may benefit from additional preoperative counseling regarding catheter care education and postoperative pain management.

The first description of an outpatient approach for RARP was described in 2010 by Martin et al.⁶ in a small series of 11 men undergoing RARP without concomitant lymph node dissection. Since then, several centers have reported their experience with the practice and have demonstrated that same-day discharge after RARP does not appear to result in increased postoperative complications or readmissions compared with overnight admission.^7,8,12
–14 As surgeons have become more experienced with RARP, some of the initially restrictive criteria used for patient selection such as body mass index or need for a lymph node dissection have been expanded in more recent series.^8,14 A summary of the available studies regarding outpatient RARP is shown in Table 3.

Table 3.

Outpatient Robot-Assisted Radical Prostatectomy Studies

Study	Martin, 2010⁶	Berger, 2016⁷	Bajpai, 2019¹³	Abaza, 2019⁸	Banapour, 2019¹²	Khalil, 2019¹⁴
Patients	11	26 (30 enrolled)	100	246	26	258
Mean patient age (range)	62.2	56.6 ± 7.04	63.3 ± 3.6	62 (42–81)	61.4 ± 7.0	NR
Mean body mass index	26	25.3 ± 3.95	25.6 ± 4.6	29.7 (20–53)	27.1	28.8 ± 5
Mean operative time (range)	117.6	167.91 ± 37.67	75.6 ± 10.1 (console)	159 (113–200)	95.3 ± 14.8	187.8 ± 74.5
Pelvic lymph node dissection	0 (0%)	NR	NR	246 (100%)	0 (0%)	80 (31.0%)
Pelvic drain at discharge	0 (0%)	−0 (0%)	NR	0 (0%)	5 (19.2%)	NR
Postoperative complications	0 (0%)	1 (3.9%)	4 (4.0%)	34 (6.8%)	1 (3.8%)	8 (3.1%)
Emergency room visit	0 (0%)	NR	4 (4.0%)	5 (1.0%)	1 (3.8%)	NR
Readmission	0 (0%)	0 (0%)	0 (0%)	8 (1.6%)	0 (0%)	6 (2.6%)

NR = not reported.

While outpatient RARP appears to be a safe and feasible practice,^8,14 within our patient population, only 31.6% of men undergoing RARP felt that they would have been comfortable with same-day discharge, potentially reflecting a discrepancy between patient perceptions and the current clinical practice. These findings might be attributed to several factors. Abaza et al.⁸ noted that while 49.2% (n = 246) of the men in their series were same-day discharges, there was a strong relation to surgical case timing: while 69.5% of men scheduled as a first case (ending ∼9:30 AM) were discharged the same day of surgery, only 2.4% of men scheduled as a third case (ending ∼4:00 PM) were discharged the same day of surgery. As a full operative schedule for our service is five RARP operations in a day, our lower rate of patients meeting same-day discharge criteria may be reflective of more cases ending later in the day and not allowing for adequate recovery time for a same-day discharge.

Differences in patient perspectives regarding outpatient discharge may also be strongly culturally driven. Congnard et al.¹⁵ reported their experience to assess the feasibility of outpatient RARP in France and found that only 1/97 (1.0%) of their patients met all requirements for same-day discharge. They attributed this low rate of patients meeting discharge criteria resulting from a combination of late discharge from the PACU and specific French practices requiring discharge by 9 PM.¹⁵ As with any outpatient surgical approach, close coordination with the anesthesia team and nonopioid pain management strategies, including regional anesthesia blocks,¹⁶ may be helpful to promote earlier return to bowel function and limit complications such as ileus that may lead to ER visits and possible readmissions.¹⁷ In an effort to reduce patient concerns related to insufficient counseling regarding postoperative expectations and catheter care, we offer a physician assistant-led prostate cancer support group to patients both pre- and postoperatively, which has been shown to be beneficial in improving prostate cancer-specific quality of life.¹⁸ Specifically for patients undergoing outpatient RARP, we have included in our preoperative counseling that the practice does not appear to be associated with increased rates of complications compared with overnight admission.^12,14

It is also important to note that within the literature, there is some variability in the definition for outpatient prostatectomy. For example, Abaza et al.⁸ reported their single-center experience with discharge the same day of surgery with a mean time to discharge of 5.8 hours, while Khalil et al.¹⁴ utilized the National Surgical Quality Improvement Program (NS-QIP) and defined same-day discharge as patients who stayed <1 day. As such, it is not clear if these patients represent an outpatient discharge model as described in several studies^6,8,12 or are more reflective of a 23-hour observation model. Given this, it may not be appropriate to directly compare studies given varying outpatient discharge requirements, surgical techniques, and surgeon experience.

Our study does have some important limitations. First, our study is derived from a single clinical practice of a single experienced robotic surgeon who has performed more than 6000 RARPs during his career. Our patient population is generally well educated, all patients had insurance before surgery and the majority of men had social support at home. The homogeneity of this population may limit the generalizability of these findings to the general population. As all patients were insured before surgery, this may contribute to our finding that only a small minority of men (12.6%, 16/127) were willing to pay out-of-pocket costs >$1000. Our study was not powered to detect a correlation between the sociodemographic characteristics and patient perception regarding outpatient RARP, and the survey instrument is not a validated questionnaire. Finally, survey enrollment was voluntary and while the 53.8% response rate is in line with similar patient surveys in the prostate cancer literature,^19,20 it is not known if some selection bias was introduced as a result of this enrollment strategy. Despite these limitations, this survey represents the largest available sample for patient perspectives regarding outpatient RARP and can serve as a roadmap for identifying barriers to implementation of this approach as this practice becomes more widespread.

Going forward, targeted interventions may be helpful to provide additional patient education and address specific concerns identified in this survey. Previously, patients undergoing minimally invasive gynecologic and pelvic operations have been shown to perceive same-day discharge more favorably if provided with evidence-based statement regarding the benefits and safety of the practice.²¹ In that study, almost all patients (96.1%) reported that they would feel comfortable with same-day discharge if it were recommended by their surgeon. In addition, emerging techniques, including single-port prostatectomy with the recently approved da Vinci SP system (Intuitive Surgical, Sunnyvale, CA), may help facilitate same-day discharge.^22,23 Furthermore, clinical practices such as telemedicine²⁴ or text messaging interventions²⁵ may be helpful adjuncts to increase patient comfort and satisfaction with outpatient RARP and could help to identify patients who are at high risk for complications and readmission.

Conclusions

Two-thirds of patients surveyed following RARP did not feel ready to be discharged on the day of their surgery. These findings demonstrate some of the potential barriers to implementation of an outpatient RARP pathway and help to bridge the gaps that exist between policymakers, physicians, and patient perspectives. Further research and multicenter validation will be necessary to identify patients who may benefit from this approach to reduce health care costs while minimizing patient postoperative morbidity.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Abbreviations Used

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