The artificial urinary sphincter (AUS) remains the gold standard management for men with stress urinary incontinence (SUI).¹ However, AUS implantation has been shown to have higher complication rates relative to men undergoing urethral sling placement for SUI.² Traditionally, after AUS implantation, patients are admitted for overnight observation and continuation of antibiotics, with a voiding trial prior to discharge the following morning. Contemporary urological practice continues to see increasing utilization of outpatient surgery and early discharge (≤24 hours), and AUS implantation is no exception.^3,4 There is a paucity of population-based research to characterize the frequency and safety of this practice following AUS implantation. We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) database to study these factors, and to compare perioperative (30-day) morbidity and mortality between early discharge (ED, ≤24 hours) and late discharge (LD, >24 hours) cases between 2007 and 2016.

We identified 1,176 patients (232 ED and 944 LD cases). Operative time was shorter in ED compared to LD cases (83 vs 95 minutes, p <0.001). Hypertension was more prevalent among LD cases (60.3% for ED vs 69.1% LD, p <0.001). The 30-day complication rate was similar in both groups (4.3% for ED vs 3.4% for LD, p=0.498). Multivariable analysis revealed that surgery after 2012 was associated with ED (OR 3.66, p <0.001; fig. 1).

Figure 1. Factors associated with early vs late discharge. ASA, American Society of Anesthesiologists®. WBC, white blood count.

There is no agreed on standardized postoperative management following AUS implantation in the immediate postoperative period, and practice patterns vary widely. The rationale for admission after AUS implantation is largely for the administration of additional intravenous antibiotics and assessment for postoperative urinary retention, with a voiding trial the morning following surgery. The International Continence Society 2015 Consensus Statement recommends a brief period of postoperative catheterization, usually overnight.⁵ This expert panel acknowledged there are poor data available regarding the ideal period of postoperative catheterization, but notes same-day removal may increase the likelihood of retention, while greater than 48 hours of catheterization has been demonstrated to increase the chances of urethral erosion.

We noted that after 2012, patients were greater than 3 times more likely to be discharged early (p ≤0.001, OR 3.66). In 2007, 0% of this patient population qualified as ED, but by 2016, 32.5% of AUS cases were considered ED (fig. 2). The paradigm shift along with the increasing utilization of same-day outpatient surgery is multifactorial and largely related, reducing the cost of health care and minimizing unnecessary costs of hospitalizations and treatments without compromising outcomes. Certainly, this is apparent across many subsets of urological surgery.^6,7

Figure 2. Proportion of patients in each year by early vs late discharge post-AUS surgery.

While our data are revealing regarding the trends in ED and safety of this management approach, our analysis has limitations. The NSQIP database does not provide specific data on the etiology of SUI and associated factors, such as radiation history or prior urethral surgery, that may impact the complexity of the surgery. The database does not provide operative details on cuff sizing and the chosen pressure-regulating balloon, or details on operative technique and surgeon preference (perineal or scrotal incision), which may influence the outcomes. Furthermore, this data set does not distinguish outcomes and practices between high and low volume implanters, or differences between ambulatory surgery center and hospital-based surgery. The NSQIP database also does not distinguish between patients who are discharged home the same day and those who are kept overnight, but less than 24 hours, and discharged home the following morning. Practically, there is not a difference between a discharge the following morning (ED category) and those who are discharged on the same day but in the afternoon (LD category); we would expect these outcomes to be similar.

At a national level, there are no differences in postoperative morbidity between early and late discharges, and ED has become more prevalent over time. Surgical practice patterns continue to evolve in the United States, with increasing emphasis on quality of care and reducing health care costs with shortened hospitalizations. This paradigm shift in the postoperative management of men undergoing AUS should continue to gain traction with more data demonstrating the safety of this approach.