Safety and feasibility of same-day discharge laparoscopic radical prostatectomy: a systematic review

Postoperative pain, recovery and discharge after robot-assisted laparoscopic prostatectomy: A multicentre, single blinded, randomised controlled trial

BACKGROUND

General anaesthesia is standard of care for patients undergoing robot assisted laparoscopic prostatectomy (RALP). However, postoperative pain and bladder discomfort remains an issue, and optimising pain management could improve recovery and promote earlier home discharge. The main objective of this trial was to evaluate if patients receiving spinal anaesthesia are more frequently home ready at 8 pm on the same day compared with multimodal pain management following RALP under general anaesthesia.

METHODS

This pragmatic, randomised controlled, multicentre trial was performed between January 2019 to December 2021. Patients undergoing RALP under general anaesthesia were randomised to either multimodal analgesia using parecoxib and morphine intra-operatively (Group GM) or spinal anaesthesia with bupivacaine and sufentanil (Group GS). The primary aim, home readiness, was assessed using a post-anaesthesia discharge scoring system.

RESULTS

Of 202 patients analysed, 27% patients reached home readiness criteria after 12 h, 46% after 24 h and 79% after 48 h, without differences between the groups. Urge to pass urine was greater in group GM than in group GS (p ⟨0.001) and lasted for a median of two hours in both groups. More patients expressed satisfaction with postoperative care in group GS (p ⟨0.001). No other significant differences were found between the groups.

DISCUSSION

We found no difference in time to home readiness between the groups. Approximately one-fourth of the patients achieved home readiness the same day after surgery without difference between the groups. Fewer patients had urge, and patient satisfaction was greater in group GS.

State of art of robotic prostatectomy: the way we do it in Catalonia, Spain

INTRODUCTION AND OBJECTIVE

Robotic-assisted laparoscopic prostatectomy (PLAR) seems to improve functional outcomes, however there is not a consensus of a standard procedure. The aim of this study was to identify the PLAR "state of art" in Catalonia, Spain.

MATERIAL AND METHODS

This was a cross-sectional survey-based study conducted among urologists across Catalonia, Spain. The survey was distributed through online platforms and the professional urology society. All statistical analyses were performed using Stata software, v20.

RESULTS

59 urologists completed the survey, revealing PLAR as the most commonly used technique (79.7%). Most urologist (70%) create the pneumoperitoneum using a controlled incision with direct access and 78.3% use the Airseal technology. The intraperitoneal approach is performed in >90% of cases. Endopelvic fascia preservation is not routinely performed. 34.5% of the survey not perform the dorsal vein complex suture. All preserves the bladder neck when oncologically safe. Nerve-vascular bundles bleeding control is performed using standard coagulation or suturing. 34% performed posterior reconstruction. Only use hemostatic devices when evident bleeding and 70% does not routinely left a drainage. Multivariable analysis showed that center volume had a significant independent association with dorsal venous complex suturing (OR 0.073, 95%CI 0.07-0.826), nerve-vascular bundles suturing hemostasis (OR 11.67, 95%CI 1.07-127.60) and endopelvic fascia preservation (OR 13.64, 95%CI 1.087-201.27), but there was no correlation with time the bladder catheter or days hospitalized.

CONCLUSIONS

The study provides an overview of the state of PLAR in Catalonia, Spain, showing significant variability and reflecting a commitment to advancing surgical technology and patient care.

Advancements in Performance of Percutaneous Nephrolithotomy in Ambulatory Surgery Centers: Outcomes and Lessons From 1250+ Cases

OBJECTIVE

To evaluate the safety and efficacy of routine ambulatory percutaneous nephrolithotomy (PCNL) in a freestanding ambulatory surgical center.

METHODS

Patients were treated between 2015 and 2022 by one of three experienced endourologists in Maryland. The surgery center is free-standing, with the nearest hospital approximately 10 minutes away. Patient characteristics and surgical datapoints, including need for transfer, were gathered prospectively at the time of surgery. Subset analyses were performed in patients with staghorn calculi or elevated body mass index, as they represent higher-risk populations.

RESULTS

A total of 1267 patients underwent ambulatory PCNL with a median stone diameter of 32 mm. The average recovery time was 87 minutes, with 1.7% of patients requiring transfer to the hospital, generally for postoperative hypotension or inadequate pain control. 166 patients with body mass index >40 were safely treated, with no significant difference in transfer rate (P = .5). 2.8% of patients had a complication, with the majority being Clavien-Dindo grade I or II. 88 patients with staghorn calculi were treated, with a 6% transfer rate. Staghorn calculi were the only factor found on multivariable analysis to be a significant predictor of transfer (OR 3.56 (1.17-10.82) P < .05).

CONCLUSION

Ambulatory PCNL may safely be performed in a surgery center in most patients. These outcomes reflect the real-world experience of high-volume surgeons and demonstrate a multiyear paradigm shift in PCNL from an inpatient procedure to an outpatient procedure in a surgery center.

Integrating Prehabilitation into the Cancer Survivorship Framework

The aim of prehabilitation is to improve the physical and emotional health of patients before upcoming surgery or therapies. This mini-review focuses on current advances in urological prehabilitation and how it can be used together with enhanced recovery after surgery and conventional rehabilitation protocols. Urological prehabilitation has primarily focused on improving urinary continence, erectile function, bone density, and lean body mass, with some promising results for all of these outcomes. Although all cancer patients should be considered for prehabilitation, older or medically frail individuals may derive the greatest benefit. PATIENT SUMMARY: This mini-review discusses prehabilitation as part of the care for cancer patients. Although the research on prehabilitation is evolving, current studies generally demonstrate that it may help to enhance a patient's strength and endurance before upcoming surgery or other treatments.

Assessment of routine same-day discharge surgery for robot-assisted radical prostatectomy

INTRODUCTION

It is important for robotic surgery to be cost-effective, especially by reducing the length of stay (LOS). Therefore, we developed a protocol for day-case robot-assisted radical prostatectomy (RARP). This study aimed to validate this as a safe practice of care and to assess the potential benefits to the hospital and patient.

METHODS

In this single-centre study, all patients booked for RARP between April 2022 and October 2022 were screened for suitability for day case. All tumour types were included. Exclusion criteria were a history of complex abdominal surgeries, salvage prostatectomy, body mass index (BMI) > 35 and patient living alone or > 150 km away from the hospital. All day-case RARPs were performed as a morning case with a protocol for review throughout the day with evening discharge if mobilising independently and eating/drinking well. The primary outcome of the study was success rate of discharge home on day of surgery (DOS) with secondary outcomes of readmissions and complications. A patient questionnaire was completed at home including both visual analogue scale (VAS) for pain and satisfaction rating.

RESULTS

Forty-five patients underwent day-case RARP over a 6-month period with minimum of 30 days of follow-up. 41/45 (91%) had successful DOS discharge home. The four admissions overnight were due to dizziness, low oxygen saturation, intraoperative complications and a diagnosis of COVID-19. There were no readmissions and no 30-day complications. The most common issues at home were catheter discomfort and constipation with low mean VAS pain score and low nausea reported. The overall patient satisfaction rating was very high at 4.8/5, and 97% said they would recommend to a family member. The cost saving for the hospital was 400 pounds per patient.

CONCLUSION

Day-case procedure is a viable, safe and efficient pathway for appropriately selected and counselled patients undergoing RARP.

Day Surgery in Children Undergoing Retroperitoneal Robot-assisted Laparoscopic Pyeloplasty: Is It Safe and Feasible?

Background

Robot-assisted pyeloplasty is the most frequently performed robotic procedure in children. A retroperitoneal approach limits surgical trauma and avoids peritoneal irritation. This led to the establishment of the criteria for day surgery (DS) and a related clinical care pathway.

Objective

To assess the feasibility and safety of DS in children undergoing retroperitoneal robot-assisted laparoscopic pyeloplasty (R-RALP).

Design setting and participants

We performed a bicentric prospective study (NCT03274050) over 2 yr involving the two major paediatric urology teaching hospitals in Paris. A clinical pathway and a prospective research protocol were specifically established.

Intervention

DS in selected children undergoing R-RALP.

Outcome measurements and statistical analysis

The primary outcomes were DS failure, 30-d complications, and readmission rates. The secondary outcomes included preoperative characteristics, perioperative parameters, and surgical outcomes. Quantitative variables were expressed as medians with interquartile ranges.

Results and limitations

Thirty-two children fulfilled specific inclusion criteria and were consecutively selected for DS following R-RALP. The median patient age was 7.6 yr (4.1-11.8) and weight 25 kg (14-45). The median console time was 137 min (108-167). There were no intraoperative complications or conversions. Six children were kept under observation overnight and discharged the following day due to persistent pain (n = 3), parental anxiety (n = 2), or a prolonged procedure (n = 1). The median duration of hospital stay of the 26 children in the DS setting was 12.7 h (12.2-13.2). During the 30-d period, there were four emergency room visits (15%) resulting in two patients requiring readmission (8%): one for febrile urinary tract infection (Clavien-Dindo II) and one child with no JJ stent for urinoma (Clavien-Dindo IIIb). Radiological studies confirmed improvement in dilatation for all cases with no recurrence (median follow-up: 15 mo).

Conclusions

This prospective case series is the first to demonstrate the feasibility and safety of DS in children undergoing R-RALP, obviating the need for routine inpatient care. Excellent results can be achieved by careful patient selection, a clear clinical pathway, and a dedicated team. Further evaluation is warranted to assess the cost effectiveness.

Patient summary

This study shows that day surgery after robotic pyeloplasty is both safe and effective in selected children.

Short-Term Patient Outcomes After Implementation of Robotic-Assisted Radical Prostatectomy Under Opioid Free Anesthesia at an Ambulatory Surgery Center

PURPOSE

Opioid free anesthesia (OFA) is associated with decreased risk of PONV and need for rescue analgesia, making it ideal for patients anticipating same-day discharge. The purpose of this project was to describe the perioperative care and short-term outcomes for patients undergoing robotic-assisted radical prostatectomy (RARP) under OFA at an ambulatory surgical center (ASC).

DESIGN

A retrospective descriptive design was used to examine the perioperative care and short-term outcomes of patients undergoing RARP under OFA at an ASC.

METHODS

The records of all sequential patients undergoing RARP over an 18-month period were reviewed. Data collected included patient comorbidities, surgical procedures, medications administered, verbal numeric rating scale (VNRS) for pain scores, times to oral intake, ambulation, and discharge, patient disposition, and unplanned return to the ER or hospital within 30 days.

FINDINGS

Data were extracted from 54 sequential records. Median VNRS scores were zero throughout PACU stay. Fifty-three patients (98.1%) were successfully discharged home, with an average postoperative stay of 250.8 (SD 35.0) minutes. There were no complaints of post-discharge nausea and vomiting or intractable pain at 72 hours after surgery. One patient was transferred to the hospital and two patients returned to the emergency room within 30 days.

CONCLUSIONS

Although generalizability is limited, these results suggest that carefully selected patients can be discharged home after RARP under a balanced OFA technique. Innovative practices are needed to address the current backlog of patients needing non-emergent surgery. Discharge home avoids the increase in resource consumption and infection risk associated with hospital admission.

Ambulatory anesthesia and discharge: an update around guidelines and trends

PURPOSE OF REVIEW

Provide an oversight of recent changes in same-day discharge (SDD) of patient following surgery/anesthesia.

RECENT FINDINGS

Enhanced recovery after surgery pathways in combination with less invasive surgical techniques have dramatically changed perioperative care. Preparing and optimizing patients preoperatively, minimizing surgical trauma, using fast-acting anesthetics as well as multimodal opioid-sparing analgesia regime and liberal prophylaxis against postoperative nausea and vomiting are basic cornerstones. The scope being to maintain physiology and minimize the impact on homeostasis and subsequently hasten and improve recovery.

SUMMARY

The increasing adoption of enhanced protocols, including the entire perioperative care bundle, in combination with increased use of minimally invasive surgical techniques have shortened hospital stay. More intermediate procedures are today transferred to ambulatory pathways; SDD or overnight stay only. The traditional scores for assessing discharge eligibility are however still valid. Stable vital signs, awake and oriented, able to ambulate with acceptable pain, and postoperative nausea and vomiting are always needed. Drinking and voiding must be acknowledged but mandatory. Escort and someone at home the first night following surgery are strongly recommended. Explicit information around postoperative care and how to contact healthcare in case of need, as well as a follow-up call day after surgery, are likewise of importance. Mobile apps and remote monitoring are techniques increasingly used to improve postoperative follow-up.