Same day surgery for radical retropubic prostatectomy: is it an attainable goal?

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

Purpose

Day case or same-day discharge (SDD) pure laparoscopic or robot-assisted radical prostatectomy (RP) has risen over the last few years with the aim of discharging patients within 24 h, reducing costs and length of stay, and facilitating return to active life. We perform a systematic review of literature to evaluate the feasibility of SDD RP.

Methods

A systematic review search was performed and the following bibliographic databases were accessed: PubMed, Science Direct, Scopus, and Embase. This was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines.

Results

Based on the literature search of 509 articles, 12 (1378 patients) met the inclusion criteria (mean age: 63 years). All studies were unicentric except one. The mean SDD surgeries experience per centre was 66 cases .The means operative time and blood loss were 154 min and 126.5 ml, respectively. Mean SDD failure was 7.4%. Concomitant lymph node dissection was performed in 56.2%. The overall complication rate was 10.2% of cases; with a majority of Clavien grade I or II. Mean readmission rate after discharge was 5%. SDD generated cost reductions compared to inpatient surgery with variable differences according to the considered healthcare system.

Conclusions

Day-case RP is a safe and feasible strategy in selected cases with multicentre proofs of concept. Its widespread use in routine practice needs further research due to biases in patient selection. Implementation of peri-operative pathways such as ERAS and prehabilitation improves patient adherence to SDD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-022-03944-1.

Predictive factors for prolonged hospital stay after retropubic radical prostatectomy in a high-volume teaching center

Objective:

To evaluate the length hospital stay and predictors of prolonged hospitalization after RRP performed in a high-surgical volume teaching institution, and analyze the rate of unplanned visits to the office, emergency care, hospital readmissions and perioperative complications rates.

Materials and Methods:

Retrospective analysis of prospectively collected data in a standardized database for patients with localized prostate cancer undergoing RRP in our institution between January/2010 - January/2012.

A logistic regression model including preoperative variables was initially built in order to determine the factors that predict prolonged hospital stay before the surgical procedure; subsequently, a second model including both pre and intraoperative variables was analyzed.

Results:

1011 patients underwent RRP at our institution were evaluated. The median hospital stay was 2 days, and 217 (21.5%) patients had prolonged hospitalization. Predictors of prolonged hospital stay among the preoperative variables were ICC (OR. 1.40 p=0.003), age (OR 1.050 p<0.001), ASA score of 3 (OR. 3.260 p<0.001), prostate volume on USG-TR (OR, 1.005 p=0.038) and African-American race (OR 2.235 p=0.004); among intra and postoperative factors, operative time (OR 1.007 p=0.022) and the presence of any complications (OR 2.013 p=0.009) or major complications (OR 2.357 p=0.01) were also correlated independently with prolonged hospital stay. The complication rate was 14.5%.

Conclusions:

The independent predictors of prolonged hospitalization among preoperative variables were CCI, age, ASA score of 3, prostate volume on USG-TR and African-American race; amongst intra and postoperative factors, operative time, presence of any complications and major complications were correlated independently with prolonged hospital stay.

Enhanced recovery pathway for radical prostatectomy: Implementation and evaluation in a universal healthcare system

INTRODUCTION

Enhanced recovery pathways are standardized, multidisciplinary, consensus-based tools that provide guidelines for evidence-based decision-making. This study evaluates the impact of the implementation of a clinical care pathway on patient outcomes following radical prostatectomy in a universal healthcare system.

METHODS

Medical charts of 200 patients with prostate cancer who underwent open and minimally invasive radical prostatectomy at a single academic hospital from 2009 to 2012 were reviewed. A group of 100 consecutive patients' pre-pathway implementation was compared with 99 consecutive patients' post-pathway implementation. Duration of hospital stay, complications, post-discharge emergency department visits and readmissions were compared between the 2 groups.

RESULTS

Length of hospital stay decreased from a median of 3 (inter-quartile range [IQR] 4 to 3 days) days in the pre-pathway group to a median of 2 (IQR 3 to 2 days) days in the post-pathway group regardless of surgical approach (p < 0.0001). Complication rates, emergency department visits and hospital readmissions were not significantly different in the pre- and post-pathway groups (17% vs. 21%, p = 0.80; 12% vs. 12%, p = 0.95; and 3% vs. 7%, p = 0.18, respectively). These findings were consistent after stratification by surgical approach. Limitations of our study include lack of assessment of patient satisfaction, and the retrospective study design.

CONCLUSIONS

The implementation of a standardized, multidisciplinary clinical care pathway for patients undergoing radical prostatectomy improved efficiency without increasing complication rates or hospital readmissions.

Optimization of an early discharge program after laparoscopic radical prostatectomy

OBJECTIVE

To assess the safety of hospital discharge 24 hours after laparoscopic radical prostatectomy and to identify possible factors associated with longer hospital stays.

MATERIAL AND METHODS

Retrospective study of patients diagnosed with localized prostate cancer underwent to laparoscopic radical prostatectomy consecutively between May of 2007 and December of 2010. Those patients who met the following requirements were discharged in less than 24 hours: absence of complications, drainage debit minor than 50 cc, normal oral tolerance, no significant bladder haematuria and good functional recovery. Logistic regression analysis was conducted in order to assess the possible associated variables with longer hospital stays.

RESULTS

A total of 266 patients were analysed. The follow-up median was 34 months. Eighty patients (30.1%) were discharged in less than 24 hours. Average stay (SD) of all series was 2.9 days (3.08). Solely HTA, neurovascular bundles sparing and the development of lymphadenectomy were statistically significant between both groups in univariate analysis (discharge<24 hours vs. discharge>24 hours). In multivariate analysis, only HTA (OR=1.98 [CI 95%:1.13-3.47], P=.016) and lymphadenectomy performance (OR=2.56 [CI 95%:1.18-5.56] P=.017) were independent predictive variables of hospital stays longer than 24 hours.

CONCLUSIONS

Early hospital discharge of patients underwent to LRP is feasible and safe. In our series, the lymphadenectomy performance and the HTA were associated factors to longer hospital stay.

A cost containment strategy for radical retropubic prostatectomy: Results from implementation of a clinical pathway program

Health care costs from the management of prostate cancer are estimated at $1.5 billion per year. As the number of radical prostatectomies being performed increases, a simultaneous rise in these costs can be expected. However, diminishing resources and the expanding managed care environment necessitate measures to curtail and even reduce these inflationary trends in health care expenditure. With this in mind, we established a collaborative clinical pathway for patients undergoing radical retropubic prostatectomy at our institution. The goals of the pathway were to reduce patient costs and hospital stay and to promote efficient use of resources for the procedure. We studied 71 patients who underwent radical retropubic prostatectomy and were managed according to the pathway during the first year of its implementation (July 1994 through July 1995). Outcome variables for these patients were compared with those of a group of 65 patients who underwent an identical procedure during the previous year (July 1993 through June 1994) before implementation of the pathway. Outcome parameters that were compared included hospital charges, length of stay (LOS), operating room (OR) time, units of packed red cells transfused, morbidity, and mortality. The overall hospital charges since implementation of the pathway decreased by 17.2% when corrected for inflation (p ≤ 0.006). LOS also decreased from a mean of 6.4 days to 5.2 days. There was no significant change in OR time. Overall complications remained unaffected (12.3% vs 12.6%). Based on these results, we conclude that establishment of an individualized, procedure-oriented clinical pathway for patients undergoing radical retropubic prostatectomy can result in significant reduction in patient costs without appreciable effect on morbidity and mortality.

Is one-day hospitalization after open pyeloplasty possible and safe?

OBJECTIVES

A critical pathway was developed to determine whether open pyeloplasty could be performed in preadolescent and adolescent children with ureteropelvic junction (UPJ) obstruction with patients safely discharged after a 1-day hospitalization.

METHODS

Twenty-six consecutive children who underwent open dismembered pyeloplasty for the treatment of UPJ obstruction and followed a critical pathway for preoperative education, operative management, and postoperative care were evaluated. The patients received a caudal anesthetic for preventive analgesia unless not technically possible and postoperative ketorolac (Toradol) unless contraindicated. A child was required to fulfill five strict criteria to be discharged from the hospital.

RESULTS

The 26 patients with UPJ obstruction consisted of 18 boys and 8 girls (age range 2.4 months to 16.7 years). Of the 26 patients, 24 (92%) were discharged on the first postoperative day, with a mean length of hospitalization of 1.1 days (range 1 to 3). All patients younger than 6 years of age (19 patients) were discharged on the first postoperative day. Of the 25 patients who received a caudal block, 24 (96%) were discharged on the first postoperative day. All patients tolerated the procedure well without major complications.

CONCLUSIONS

This is the first study, to our knowledge, to describe a detailed critical pathway for open pyeloplasty to treat UPJ obstruction. This enabled all children younger than 6 years of age and more than 90% of all patients to be discharged uniformly on the first postoperative day.

Klinischer Behandlungspfad „laparoskopische Prostatektomie“

METHODS

In this study we investigated the anesthesiological module of a clinical pathway. We chose the pathway of "laparoscopic prostatectomy" as an example for time-consuming minimally invasive surgery and 40 patients were randomly assigned to 2 groups receiving either total intravenous anesthesia (TIVA) using propofol/ remifentanil or balanced minimal flow anesthesia using desflurane/ remifentanil. During this module the indicators of quality such as vigilance, pain, postoperative nausea and vomiting (PONV) and mobilization were measured. Costs were evaluated and analyzed by a bottom-up procedure.

RESULTS

There were no anesthesia-related deviations from clinical pathways and both forms of anesthesia management were equally well tolerated by the patients. No significant difference was observed regarding hemodynamic measurements or PONV. The patients in the desflurane/ remifentanil group recovered more rapidly (p=0.037) and had more pain. The amount of analgesic agents given immediately following anesthesia was significantly higher than in the TIVA group (p=0.017). The median anesthesia costs per minute for laparoscopic prostatectomy in the propofol group were 2.79 EUR (minimum cost 2.41 EUR, maximum cost 3.21 EUR) and in the desflurane group 2.68 EUR (minimum cost 2.45 EUR, maximum cost 3.39 EUR). The total anesthesia costs for both groups were within the proceeds matrix range for diagnosis-related groups (DRG). However, the cost analysis for medication was slightly higher than the proceeds matrix range for DRGs.

CONCLUSION

Both forms of anesthesia can be implemented for time-consuming surgical procedures and allow a cost-effective anesthesia management. Anesthesiological procedures must go hand-in-hand with the type of anesthesia selected. The prophylactic use of analgetics for desflurane/ remifentanil anesthesia should be given earlier and in higher doses than in propofol/ remifentanil anesthesia. The prophylactic use of antiemetics following laparoscopic procedures of long duration is indicated. Optimizing anesthesiological procedures could lead to a continuous improvement in the quality of therapeutic pathways.

Safely reducing length of stay after open radical retropubic prostatectomy under the guidance of a clinical care pathway

BACKGROUND

Collaborative care pathways have proven to be a safe and effective method of decreasing length of hospital stay (LOS) and costs after radical retropubic prostatectomy (RRP). In the current study, the authors evaluated the safety and efficacy of a pathway transitioning from a 3-day to a 2-day LOS.

METHODS

The authors performed a retrospective chart review of 994 patients who underwent RRP at the study institution between July 1994 and December 2001. A total of 561 patients were managed on a 3-day LOS pathway, 172 were managed during the transition period from 3 to 2 days, and 261 were managed on a 2-day LOS pathway. Statistical analysis was performed comparing preoperative variables and complications among the three groups.

RESULTS

No statistically significant differences were found in comparisons of preoperative and demographic variables including age, race, medical comorbidities, preoperative prostate-specific antigen level, clinical stage of disease at presentation, and biopsy Gleason score. Forty-nine of the 561 patients (8.7%) remained longer than their targeted 3-day LOS, whereas 14 of 261 patients (5.4%) were hospitalized for longer than their targeted 2-day LOS, a difference that approached statistical significance (P = 0.058). During the transition period, 99 of 172 patients (57.6%) were discharged on postoperative Day 2 and 73 patients (42.4%) were discharged on postoperative Day 3. Complication rates were found to be significantly lower (P = 0.013) in the 2-day LOS group (2.3%) compared with the 3-day LOS group (7.0%) and the transition group (8.1%). The rate of readmission remained constant at 3% during this time period.

CONCLUSIONS

Overall, greater than 90% of patients were discharged within 2-3 days of surgery with acceptable complication rates, suggesting that in a consistent patient population, the transition from a 3-day LOS to a 2-day LOS can be done successfully without compromising patient safety. Evaluation currently is ongoing with regard to a 1-day LOS.

Cost comparison of radical retropubic and radical perineal prostatectomy: single institution experience

OBJECTIVES

To perform a detailed comparison of the in-house hospital costs of patients undergoing radical perineal prostatectomy (RPP) and radical retropubic prostatectomy (RRP) performed with or without bilateral staging lymph node dissection (BPLND) for localized prostate cancer.

METHODS

A retrospective cost review was done of a cohort of 402 consecutive radical prostatectomies performed at our institution during a 21-month period. The procedure was performed as RPP in 279 (69.4%) and RRP in 123 (30.6%) patients, of whom 10.4% and 61.8%, respectively, underwent BPLND under the same anesthesia. The hospital costs were evaluated for each patient using the categories of surgical, nursing, laboratory/transfusion, and pharmacy. Surgical costs were further subdivided into operating room, anesthesia, and recovery room costs. Univariate and multivariate statistical analyses were applied to identify predictors of procedure-related costs.

RESULTS

The median hospital costs of patients undergoing RPP (7195 dollars, range 5052 dollars to 36,237 dollars) were substantially lower than those of patients undergoing RRP (9757 dollars, range 6935 dollars to 27,771 dollars; P = 0.001). The median costs for patients undergoing radical prostatectomy without BPLND were significantly lower in the RPP (7100 dollars, range 5052 dollars to 28,604 dollars) versus RRP (9169 dollars, range 6935 dollars to 16,705 dollars) patients (P = 0.001). The costs for RPP with BPLND (10,048 dollars, range 7529 dollars to 36,237 dollars) versus RRP with BPLND (9973 dollars, range 7658 dollars to 27,771 dollars) were not significantly different (P = 0.900). Patient age and nerve-preservation status did not significantly influence the procedure-related hospital costs.

CONCLUSIONS

RPP may result in lower in-house costs per patient than RRP in those patients who do not require BPLND. Total hospital costs depend largely on the factors of operating room time, length of stay, and laboratory and transfusion requirements, which may vary among institutions.

Current trends in the management of radical retropubic prostatectomy: is short-stay RRP feasible in the United Kingdom?

BACKGROUND

Our aim was to review UK practice in the management of radical retropubic prostatectomy and identify opportunities to reduce LOS to American levels.

METHODS

A survey was conducted of BAUS members regarding LOS and postoperative management.

RESULTS

Out of 551 surveys 126 were returned. Mean LOS in the UK is 5.2 days. Opiate analgesia, PCA and postoperative epidural may delay discharge. Diet and mobilization are commenced at 1.7 and 2.1 days, respectively.

CONCLUSION

Care pathways can safely reduce LOS to 2 days. Protocols to reduce LOS in the UK should be assessed and their impact on cost and quality-of-life evaluated.

Can single dose preoperative intrathecal morphine sulfate provide cost-effective postoperative analgesia and patient satisfaction during radical prostatectomy in the current era of cost containment?

We retrospectively analyzed the analgesic efficacy and surgical outcomes of a single preoperative intrathecal long-acting morphine sulfate injection (0.25-0.5 mg) and postoperative intravenous (i.v.) ketorolac in 62 patients who underwent radical retropubic prostatectomy (RRP). Total postoperative analgesic requirement was documented along with assessment of length of hospital stay, pain control and time for resumption of normal activity. Postoperatively, 45% of patients required only nonsteroidal agents (ketorolac), whereas 55% needed a mean of 13.3 mg of supplemental i.v. morphine sulfate. Mean hospital stay was 2.3+/-0.3 days. Eighty-two per cent of patients felt the length of hospital stay adequate. Ninety-seven per cent of patients were satisfied with anesthesia selected and 95% of patients considered pain control on postoperative days 1 and 2 as effective. All patients resumed to full physical activity by 5.3+/-0.4 weeks after surgery. We conclude that a single preoperative injection of intrathecal morphine sulfate combined with i.v. ketorolac postoperatively results in effective analgesia, diminished supplemental narcotic requirement and high patient satisfaction during radical retropubic prostatectomy.

The economic costs of early stage prostate cancer

The economic costs of early stage prostate cancer are significant, and will likely increase as the proportion of older men grows in the population of industrialised nations. In the US, total costs have been estimated to range from US dollars 1.72 billion to US dollars 4.75 billion annually (1990 costs). Costs related to early stage prostate cancer arise from screening, staging and treatment. Cost-effectiveness models of population-based prostate cancer screening indicate that such screening could result in as much as US dollars 27.9 billion (1988 values) in charges to the US healthcare system. Evidence-based cancer-staging strategies would result in significant reduction of wasted expense. Rational allocation of healthcare dollars for prostate cancer screening and treatment may ultimately depend on data from randomised controlled trials.

Laparoscopic radical prostatectomy: is it feasible and reasonable?

Laparoscopic radical prostatectomy is an extremely challenging procedure for even experienced laparoscopic surgeons, and it is not practical to expect most urologists to learn the technique. Nevertheless, it is a feasible procedure and has short-term results comparable with conventional radical prostatectomy. For LRP to be an acceptable and reasonable alternative, the oncologic results must be equivalent to the results of RRP, and significant advantages is morbidity (hospital stay, pain, incontinence, impotence) must be attained; otherwise, the steep learning curve and the additional expense of the procedure make it difficult to justify as an alternative therapeutic modality. Beside a reduction in the transfusion rate, no other significant advantages of LRP over radical prostatectomy have been demonstrated definitively to date. As a result, the role of LRP in the management of prostate cancer remains investigational, and patients should be informed appropriately. The oncologic results and low morbidity of nerve-sparing RRP set a high standard for a laparoscopic technique to equal.

Surgical and postoperative factors affecting length of hospital stay after radical prostatectomy

BACKGROUND

Radical prostatectomy continues to comprise the mainstay of therapy for localized prostate carcinoma. However, caring for radical prostatectomy patients accounts for approximately half of the $1.7 billion annual cost of prostate carcinoma treatment. Length of stay (LOS) after surgery appears to be one of the main components of this cost. The first step in reducing cost is to identify those variables associated with LOS. Radical prostatectomy can be performed using two very different surgical techniques and with each technique different costs are incurred. The objective of the current study was to identify factors associated with LOS as a function of surgical approach. To reduce potential biases due to patient requests for longer hospitalization or physician preferences in that regard, secondary objectives were to identify factors associated with time to fluid intake (TTF) and time to consume solid foods (TTS).

METHODS

An institutional-based, retrospective chart review of 313 men with clinically localized prostate carcinoma who underwent either a perineal (RPP) or retropubic (RRP) prostatectomy at a single university center from March 1988 to October 1996 was undertaken. Information regarding LOS was available for 311 patients. Linear regression models were used to assess the association between covariables and LOS. Poisson regression models for count data were used to assess associations between covariables and the secondary endpoints of TTF and TTS. Covariables included: preoperative (age, race, prostate specific antigen, Gleason score, clinical stage, lymph node resection, comorbidity, and admission time), intraoperative (surgical approach, surgeon, operative time, estimated blood loss, transfusion requirement, anesthetic approach, and American Society of Anesthesiologists score), and postoperative (pain management complications and transfusions) parameters.

RESULTS

The median LOS was 4 days (range, 1-19 days) for RPP and 5 days (range, 3-16 days) for RRP approaches. The final model included six main effects and three interaction terms. Overall, LOS decreased over time with LOS decreasing at a faster rate in patients who underwent RPP. In general, patients who underwent RRP had an increased LOS compared with patients who underwent RPP. Complications from surgery and age increased the LOS for all patients; however, the increase was greater in patients who underwent RPP. In addition, the use of intraoperative epidural anesthesia and the increased use of postoperative narcotics were associated with increased LOS for patients undergoing both surgical approaches. TTF and TTS were significantly longer for patients who underwent the retropubic approach compared with those patients who underwent the perineal approach. After adjustment for surgical approach no other covariables were found to be associated with TTF. After adjustment for surgical approach, the occurrence of complications was found to be associated with TTS, indicating that patients who experienced complications took longer before they could tolerate solid foods.

CONCLUSIONS

In view of the importance of clinical care pathways in reducing medical expenditures from radical prostatectomy, the results of the current study may contribute to the further refining of these pathways by highlighting the differences and similarities among the variables affecting LOS as a function of surgical approach.

Using outcome data and patient satisfaction surveys to develop policies regarding minimum length of hospitalization after radical prostatectomy

OBJECTIVES

Changes in health care economics have prompted new clinical pathways for radical prostatectomy to reduce length of hospitalization after surgery to 1 day. We evaluated satisfaction, outcomes, and short-term morbidity in 187 consecutive patients with overnight hospitalization after radical retropubic prostatectomy (RRP).

METHODS

In 1995, we initiated a critical pathway for RRP that included epidural anesthesia with or without spinal anesthesia and postoperative methadone, acetaminophen, and ibuprofen for pain control. Patients were discharged when they were afebrile, tolerating a regular diet, ambulating without assistance, and using oral medications for analgesia. An 18-item satisfaction survey was mailed to each patient 3 weeks after discharge. Responses to the postoperative survey, morbidity, blood loss, and use of transfusions were recorded.

RESULTS

Of 252 patients who underwent RRP, 187 (74. 2%) were discharged 1 day after surgery. The mean age of patients was 61.4 years (range 42 to 73). A pelvic lymphadenectomy was performed in addition to the RRP in 32 men (17%). Epidural anesthesia with or without spinal anesthesia was used for all but 3 patients. The mean estimated blood loss was 1166 mL, and 24 patients (12.8%) required transfusion, with a mean of 1.9 U (range 1 to 6) of packed red blood cells. The postoperative complication rate was 11. 8%, of which 2.1% (n = 4) were definitely or probably related to our protocol. These complications included clot retention (n = 2), gastrointestinal bleeding (n = 1), and spinal headache (n = 1). Three of 187 patients were readmitted to the hospital within 30 days but only one (0.5%) required admission because of our protocol. The survey response rate was 91.4%. No patient was dissatisfied with his overall care, and only 10.5% of patients would have preferred to stay in the hospital longer.

CONCLUSIONS

One-day hospitalization after RRP is associated with minimal postoperative morbidity and high patient satisfaction. Similar data are needed for RRP from other centers before policy decisions regarding the length of stay after this procedure are made.

Use of electronic mail for postoperative follow-up after ambulatory surgery

The authors report on a patient who used electronic mail to report satisfactory recovery from ambulatory surgery and anesthesia. The potential benefits and pitfalls of using electronic mail for patient follow-up and communication, as well as research purposes, are reviewed. Potential benefits include cost savings, ease in collecting quality improvement data, and the potential for increased reporting of unpleasant events. Potential pitfalls include lack of universal access (with racial and socioeconomic differentials), privacy and security concerns, and potential slow responses to messages that might require emergent responses or actions.

Does the choice of anesthetic technique affect the recovery of bowel function after radical prostatectomy?

OBJECTIVES

Return of bowel function after radical prostatectomy surgery may be the limiting factor in discharging these patients from the hospital. Recent studies have shown that postoperative epidural infusion of bupivacaine decreases time to return of bowel function compared with intravenous and epidural morphine in patients after abdominal surgery. This study focuses on the role of the intraoperative anesthetic technique on recovery of bowel function, intraoperative blood loss, and the incidence of postoperative deep venous thrombosis (DVT) in patients undergoing radical retropubic prostatectomy and pelvic lymphadenectomy.

METHODS

Forty patients undergoing prostatectomy were randomized to either group A (general endotracheal anesthesia, including muscle relaxation and mechanical ventilation, followed by postoperative intravenous morphine patient-controlled analgesia) or group B (thoracic epidural anesthesia using bupivacaine, combined with "light" general anesthesia using a laryngeal mask airway and spontaneous ventilation, followed by epidural morphine analgesia). Intra- and postoperative data were collected on blood loss, volumes of crystalloid and colloid infused, blood transfused, duration of anesthesia and surgery, anesthetic and surgical complications, time to recovery of bowel function, quality of postoperative pain control, and time to discharge from hospital. Each patient underwent lower extremity venous ultrasonography to detect DVT.

RESULTS

Twenty-one patients received general anesthesia and 19 received combined epidural and general anesthesia. Intraoperative blood loss was significantly lower in the epidural group, and times to first flatus and first bowel movement were also shorter in this group. There were no significant differences in duration of anesthesia or surgery, quality of postoperative analgesia, side effects of analgesia, or time to discharge from hospital. There was no DVT detected in any patient.

CONCLUSIONS

The combined anesthetic technique of thoracic epidural anesthesia and "light" general anesthesia with spontaneous ventilation decreased intraoperative blood loss and shortened the time to return of bowel function. However, this earlier return of bowel function was not great enough to realize a difference in time to hospital discharge. There was no evidence of increased complications secondary to epidural anesthesia or of prolonged anesthetic time necessary to place epidural catheters.

Overnight hospitalization after radical prostatectomy: the impact of two clinical pathways on patient satisfaction, length of hospitalization, and morbidity

Changes in health care have prompted efforts to reduce length of hospitalization while maintaining quality care. Therefore, we evaluated short-term outcomes after radical retropubic prostatectomy on 100 consecutive men undergoing surgery for clinically localized prostate cancer performed under epidural anesthesia followed by epidural morphine or combined with spinal anesthesia using bupivacaine and fentanyl (25 micrograms) and followed by i.m. methadone (10-20 mg). All patients received oral acetaminophen and ibuprofen beginning 4 h after surgery. Length of hospital stay, responses to written satisfaction survey, postoperative morbidity and readmission to the hospital were recorded. Using either pathway, 83% of the patients were discharged after one night in the hospital. The mean hospital stay was 1.34 +/- 1.10 and 1.28 +/- 1.0 days, respectively. Although three men were rehospitalized, it was not because of the early discharge. More than 95% of patients were satisfied with pain control, and patients discharged after one night were not more likely to be dissatisfied than patients hospitalized longer.

IMPLICATIONS

Both clinical pathways provide excellent anesthesia and analgesia and allow discharge 1 day after radical retropubic prostatectomy. Shortened hospital stay does not increase patient dissatisfaction or add to postoperative morbidity. Patients undergoing other pelvic and abdominal operations may also derive similar benefits using these pathways.

Impact of a clinical pathway for radical retropubic prostatectomy

OBJECTIVES

Cost containment has become an important issue in medical practice. With the implementation of collaborative care programs and critical pathways, substantial reduction in overall costs can be achieved while maintaining the quality of care and patient satisfaction.

METHODS

Our series consists of 856 consecutive patients treated with radical retropubic prostatectomy by 24 surgeons in a single hospital between January 1, 1994, and January 31, 1997. A clinical pathway for radical retropubic prostatectomy was implemented July 1, 1994. The patients were subdivided into three groups: (1) baseline: patients who underwent surgery in the 6 months immediately before the pathway onset (n = 113); (2) nonpathway: 75 patients treated off the clinical pathway; and (3) pathway: 668 men placed on the clinical pathway. We compare average length of stay and average hospital charges among the three groups. We also compare average length of stay among physician volume groups: high volume physicians performed at least 12 operations per year; low volume physicians performed less than 12 operations per year. Charges were further broken down by department. Patient satisfaction was recorded by an outside source after discharge. Postoperative complications were assessed in the clinical pathway and nonpathway groups.

RESULTS

Average hospital charges and average length of stay were $12,926 and 5.8 days for baseline patients, $11,795 and 5.0 days for nonpathway patients, and $10,042 and 4.0 days for pathway patients, respectively. Implementation of the clinical pathway was associated with lower charges and length of stay in the pathway group as well as the nonpathway group, with larger reductions in pathway patients. With continuous reassessment and modification of the clinical pathway, both average hospital charges and average length of stay have progressively decreased from $10,540 and 4.9 days in 1994 to $8766 and 2.7 days in January 1997. Charges were uniformly reduced in radiology, laboratory, pharmacy, operating room, anesthesia, and nursing or routine care. Patient satisfaction was similar in the pathway group and the nonpathway group. Incidence of postoperative complications did not differ significantly between the pathway and nonpathway groups. Length of stay and hospital charges were significantly lower for high than low volume surgeons, irrespective of the declines observed over time (P = 0.0001 and 0.0001, respectively).

CONCLUSIONS

Average hospital charges and average length of stay for all surgeons were lowered significantly with the implementation of a clinical pathway and continue to decrease with continuous reassessment. The pathway was not associated with any increase in postoperative complications or patient dissatisfaction. Surgeons who operate frequently have lower average lengths of stay and hospital charges than those who operate infrequently.

Ambulatory radical retropubic prostatectomy

OBJECTIVES

To review the experience of 40 consecutive patients who underwent radical retropubic prostatectomy and to determine if and how the procedure could be performed safely on an ambulatory basis.

METHODS

Between June 20, 1994 and November 26, 1996, 40 consecutive men with clinically localized prostate carcinoma underwent radical retropubic prostatectomy. Retrospective data regarding the patient population, patient satisfaction, clinical outcome, and length of hospitalization were evaluated.

RESULTS

The average age for the patients was 62.6 years (range 44 to 75) with an average PSA of 10.44 ng/mL. Eighty percent (32 of 40) of the patients were discharged on postoperative day 1, 17.5% (7 of 40) were discharged on postoperative day 2, and 2.5% (1 of 40) were discharged on postoperative day 7. The average operative time was 89.5 minutes (range 65 to 135), measured from the time of incision to completion of closure. The organ-confined rate was 80% (32 of 40). The continence evaluated at 6 months was 90.9% (30 of 33). The potency at 4 months was 35% (10 of 28) and at 1 year was 55.6% (10 of 18). Postoperative complications were minimal, with 7.5% (3 of 40) bladder neck contractures and 2.5% (1 of 40) wound infections. Patient satisfaction assessed by questionnaires revealed that 90% (36 of 40) thought that the length of hospitalization was adequate and 97.5% (39 of 40) would choose to have the procedure again. A second series of 15 patients have also undergone radical retropubic prostatectomy utilizing a pelvic block to expedite discharge. Of these 15 procedures, 10 were performed on an ambulatory basis.

CONCLUSIONS

Radical retropubic prostatectomy can be performed expediently with the maintenance of patient satisfaction, continence rates, potency rates, recurrence rates, complication rates, and pathologic results. The advantage to such an approach is expedited patient discharge, cost savings to the medical system, and no alteration in patient recovery or clinical outcome, such as organ-confined rate, potency, and continence. In this series, the majority of patients were discharged on postoperative day 1. On the basis of this experience, we have performed the procedure on an outpatient basis, while maintaining the same high quality of care. To date, 10 patients have undergone ambulatory radical retropubic prostatectomy and were discharged the same day of surgery without complications.

Postoperative epidural analgesia following radical retropubic prostatectomy: outcome assessment

BACKGROUND AND OBJECTIVES

We retrospectively examined the effects of epidural analgesia on patients undergoing radical retropubic prostatectomy (RRP).

METHODS

Patients (203) underwent radical retropubic prostatectomy under either general or epidural anesthesia alone or a combined general epidural technique. Of those, 143 had an epidural catheter placed and underwent radical retropubic prostatectomy under general anesthesia followed by postoperative epidural analgesia (Group E+G). Twenty-eight patients had the operation under epidural anesthesia followed by epidural analgesia in the postoperative period (Group E). Thirty-two patients had general anesthesia for the operation and postoperative systemic analgesia (Group G).

RESULTS

There were no significant differences between the groups with respect to age, height, weight, ASA status, or operation time. The length of postoperative hospital stay was significantly longer in the general anesthesia group patients as compared to the other two groups (P < 0.05). Intraoperative blood loss and blood replacement were significantly higher in the general anesthesia group (P < 0.001). There were no significant differences between the groups with respect to return of bowel function postoperatively, or incidence of complications.

CONCLUSIONS

Epidural anesthesia and analgesia following radical retropubic prostatectomy have demonstrated a number of beneficial effects. These include decreased blood loss and shorter hospital stay.

Laparoscopic radical prostatectomy: initial short-term experience

OBJECTIVES

To determine the feasibility and efficacy of a laparoscopic approach to the radical retropubic prostatectomy (RRP).

METHODS

A transperitoneal laparoscopic technique was developed to perform an RRP. Intra-abdominal access was obtained through five 10-mm trocars. After dissection of the prostate, the urethrovesical anastomosis was created via a transvesical approach. The prostate was removed by extending the umbilical incision.

RESULTS

Between September 1991 and May 1995, nine laparoscopic RRPs were performed. The operative time averaged 9.4 hours. Only 1 of 9 patients had a positive surgical margin that involved the urethra. Six of 9 patients were completely continent postoperatively. Of the 4 patients who were potent preoperatively, 2 continued to have erections. There were three complications: cholecystitis, thrombophlebitis associated with a pulmonary embolism, and a small bowel hernia into a trocar site.

CONCLUSIONS

Laparoscopic radical prostatectomy is feasible but currently offers no advantage over open surgery with regard to tumor removal, continence, potency, length of stay, convalescence, and cosmetic result.

Late venous thromboembolic disease after radical prostatectomy: effect of risk factors, warfarin and early discharge

PURPOSE

We determined the incidence of late venous thromboembolic disease after radical prostatectomy, and the influence of risk factors, length of hospital stay and warfarin anticoagulation.

MATERIALS AND METHODS

Patients undergoing radical prostatectomy received routine deep vein thrombosis prophylaxis that consisted of intermittent pneumatic compression stockings, early ambulation and warfarin administration during hospitalization with the goal of achieving a prothrombin time international normalized ratio of 1.5 or greater. When patients returned to the hospital for postoperative evaluation, venous duplex ultrasonography of the lower extremities was done. All patients were contacted at 2 months to ensure that they did not suffer a clinical thromboembolic event.

RESULTS

One of 158 patients consenting to the study had a symptomatic thromboembolic event for a clinical incidence of 0.6% (95% confidence interval 0.0 to 3.5). Duplex ultrasonography was performed 21.4 +/- 7.8 days postoperatively and 3 of the 106 patients who completed the study had a positive ultrasound for an incidence of 2.8% (95% confidence interval 0.6 to 8.1). None of these patients suffered a symptomatic thromboembolic event. Age, body mass index, length of hospital stay, operative time, estimated blood loss, prostate specific antigen and Gleason score were evaluated for a statistical relationship with thromboembolic events. Only higher body mass index and length of hospitalization approached statistical significance.

CONCLUSIONS

Late deep vein thrombosis can occur after radical retropubic prostatectomy. Shorter prophylaxis period, secondary to shorter periods of hospitalization, did not increase the risk of thromboembolic events. The combination of intermittent pneumatic compression stockings and warfarin anticoagulation may be contributing to the relatively low deep vein thrombosis rate in our study compared to previous studies.

Patient satisfaction with short stays for radical prostatectomy

OBJECTIVES

We evaluated the effects on patient satisfaction of shortened postoperative hospital stays after radical retropubic prostatectomy (RRP).

METHODS

A previously validated, self-administered instrument was used to assess satisfaction with care in a retrospective, cross-sectional study of 129 men who had undergone RRP after implementation of a short-stay clinical care pathway. Health-related quality of life outcomes, comorbidity, and sociodemographic data were also measured with established instruments.

RESULTS

Satisfaction with care was uniformly high and did not vary with length of stay (LOS), time since surgery, or health-related quality of life.

CONCLUSIONS

Decreased LOS mandated by the need for a cost-efficiency path does not adversely affect patient satisfaction.

Prospective development of a cost-efficient program for the pubovaginal sling

OBJECTIVES

We designed and implemented a cost-containment program for patients undergoing a pubovaginal sling procedure. We sought to test the hypothesis that preoperative patient education could reduce the length of hospital stay in these patients. Our goal was to decrease hospital charges while maintaining quality of care.

METHODS

A multidisciplinary group of clinic and hospital staff identified factors that contribute to a patient's hospital charges for a pubovaginal sling procedure. A program of preoperative patient education to teach intermittent self-catheterization was combined with the elimination or control of items considered unnecessary to the delivery of safe, efficient care. Patient care was standardized from the preoperative visit to discharge planning. The difference in the mean values of 38 prestudy patients was compared with 15 study patients with a Wilcoxon rank sum test.

RESULTS

Length of hospital stay was reduced from a mean of 2.8 to 1.1 days after implementation of the program (P < 0.0001). This decreased length of stay, combined with a reduction in routine laboratory studies (97% decrease; P < 0.0001), operating room charges (11% decrease; P < 0.01), and medications (35% decrease; P < 0.01), led to significantly reduced hospital charges. Total hospital charges decreased by 35%, from a mean of $4862 to a mean of $3153 (P < 0.0001). There was no increase in morbidity. Patient satisfaction with length of hospital stay did not change significantly following implementation of the program.

CONCLUSIONS

With a program of preoperative patient education combined with a critical review of the factors contributing to a patient's hospital charges, it is possible to implement a cost-efficient program for a pubovaginal sling, leading to a 35% reduction in mean total hospital charges. This approach directed toward other incontinence procedures could be expected to yield comparative results.

Maintaining quality of care and patient satisfaction with radical prostatectomy in the era of cost containment

OBJECTIVES

To determine the effect of shortened hospital stay after radical retropubic prostatectomy on costs, adverse surgical outcomes, and patient satisfaction.

METHODS

The effect of changes in preoperative counseling, perioperative care, and analgesic management on hospital length of stay; mean cost per case and cost per hospital day; and 30-day complication, hospital readmission, and mortality rates were analyzed for a consecutive sample of 374 patients undergoing radical prostatectomy between July 1989 and November 1995. Satisfaction with length of stay, analgesic regimen, and surgical outcome was assessed in a random subset of 150 patients by anonymous questionnaire.

RESULTS

Length of stay (LOS) was shortened from a median 7 to 2 nights after surgery during the study (P < 0.0001), whereas the acute complication, 30-day readmission, and 30-day mortality rates remained constant. Reducing LOS resulted in a 43% decrease in mean cost per case while mean cost per day increased by 22% to 35%. Overall patient satisfaction was high, with 83.5% of patients rating LOS as "just right" and 89.2% reporting they were "satisfied" or "very satisfied" with their pain control after surgery.

CONCLUSIONS

Shortened LOS after radical retropubic prostatectomy can be accomplished safely and can meet with high levels of patient satisfaction while significantly reducing hospital-related costs. The potential for further incremental reductions in cost with reductions in LOS to less than 2 nights appears to be small, and future efforts at cost reduction for this procedure should center on decreasing the intensity of care during hospitalization.