Letter: Letter to the Editor for “Trifecta of Same-Day Discharge after Single-Port Robotic-Assisted Simple Prostatectomy”

Dear Editor,

Haberal et al. introduce a rigorous “trifecta” definition for evaluating the success of same-day discharge (SDD) following single-port robotic-assisted simple prostatectomy (SP-RASP): discharge on the same day, no 90-day complications, and no readmissions. ¹ Although this reframing is both clinically relevant and timely given the expanding interest in ambulatory urologic procedure, several key analytical and contextual gaps temper the generalizability and strategic application of their findings.

Most notably, the study omits any assessment of functional recovery parameters such as continence restoration, catheter-free rates, or return to baseline International Prostate Symptom Score—outcomes that are not only expected in benign prostatic hyperplasia (BPH) interventions but pivotal when counseling patients for outpatient procedure. ² The clinical success of SDD must hinge not just on freedom from complications but also on early recovery of voiding function, especially given that urinary retention was the most common postoperative complication. Reporting the time to catheter removal or continence recovery would have added depth to the SDD metrics.

Second, the role of social and health system factors in SDD failure remains entirely unexamined. The analysis assumes a physiological basis for failure (e.g., blood loss or specimen weight), but the decision to hospitalize from recovery is often driven by nonclinical elements such as delayed transport, patient anxiety, insufficient at-home support, or institutional protocols. ³ Without documenting the context for postoperative admissions, attributing failure to purely intraoperative variables risks overfitting.

Furthermore, no consideration is given to preoperative frailty or functional reserve. Although age-adjusted Charlson Comorbidity Index was reported, metrics such as gait speed, sarcopenia, or frailty scores—more sensitive predictors of postdischarge resilience—were not included. ⁴ In a cohort undergoing minimally invasive procedure intended for outpatient recovery, such parameters may be more predictive of safe discharge than traditional surgical or pathological metrics.

Another limitation is the absence of detailed anesthetic and recovery protocols, which are known to substantially influence the feasibility of SDD. Factors like type of anesthesia, pain control protocols, mobilization timelines, or early voiding trials—all of which affect recovery readiness—are unreported. ⁵ These factors could explain the 24.2% of patients who failed discharge despite having no complications or readmissions.

In addition, the classification of failure does not distinguish between patients failing for safety reasons vs logistical issues, nor does it provide temporal clustering of complications. For example, two readmissions within 90 days are weighted equally to a same-day admission from the Post-Anesthesia Care Unit, although their implications for the SDD model differ significantly.

Last, despite citing minimal opioid prescriptions as a positive finding, no data on long-term analgesic use or postoperative quality of life were captured. Opioid avoidance at discharge does not preclude delayed use, nor does it reflect whether patients require subsequent pain interventions from outpatient providers or urgent care, both of which are relevant in evaluating outpatient safety.

In conclusion, the authors present an ambitious and commendably strict model of outpatient surgical success in BPH management. However, to operationalize SP-RASP within an SDD pathway, future studies must integrate functional outcomes, social support factors, frailty assessments, perioperative recovery protocols, and patient-centered quality metrics. Until then, the proposed trifecta remains a valuable yet incomplete surrogate for outpatient efficacy.