Several years ago, as we made evening rounds on patients status-post robot-assisted sacrocolpopexy (RASC), we began to wonder, why are we routinely keeping these patients overnight? Often, we found them sitting in bed or a chair, having coffee and reading the newspaper, as if at home relaxing on a weekend. Our colleagues in urological oncology had begun decreasing length of stay and complications using minimally invasive techniques and enhanced recovery after surgery (ERAS) protocols for more invasive, lengthy and complex cases in sicker patients. Gynecologists had begun publishing data to support same-day discharge (SDD) following laparoscopic hysterectomy. It was time to reevaluate the need for standard postoperative admission following RASC.

ERAS protocols were first developed and popularized by colorectal surgeons in the early 2000s to optimize perioperative care. Although details of various protocols differ, core principles include preoperative optimization and counseling, minimization of perioperative stress, opioid-sparing multimodal analgesia and early mobilization. In concert with advances in minimally invasive techniques, ERAS protocols have significantly reduced length of stay and improved outcomes across specialties.¹

Compared to other subspecialties such as urological oncology, female pelvic medicine and reconstructive surgery (FPMRS) cases have fewer complications and faster recovery at baseline. Minimally invasive techniques are now the norm. A logical target for perioperative improvement using ERAS protocols within FPMRS is therefore SDD in minimally invasive reconstructive surgery, particularly RASC. RASC cases often also include supracervical hysterectomy, additional transvaginal pelvic floor reconstruction or placement of a synthetic mid urethral sling for stress urinary incontinence, but are nevertheless 2 to 4 hours in length with patients traditionally discharged the next day, with few complications.

In 2015, we began discharging patients home following robotic pelvic floor reconstruction on the day of surgery as part of a feasibility study. Initial results in the first 10 patients were encouraging, with 80% successful SDDs and no increase in unplanned postoperative encounters or complications compared to historical controls.² These initial promising results led to a collaboration with our urogynecology colleagues in 2018 to perform a prospective cohort study of a SDD ERAS protocol following minimally invasive sacrocolpopexy with or without hysterectomy or mid urethral sling.³ Among 47 women in the study SDD was accomplished in 37 (79%). There were few emergency department (ED) visits (2, or 4.3%) or readmissions (1, or 2.1%) and, compared to historical controls, no difference in rates of adverse events or unplanned health care encounters following SDD. Patient satisfaction was also extremely high with SDD (96%).

The prospective trial used a formal SDD ERAS protocol including a preoperative educational video, celecoxib and gabapentin, and specific anesthesia protocols. However, we in the urology department have pared down our practice to what we believe to be its essential components, including detailed preoperative patient education and counseling regarding perioperative course, minimization of opioids and standardized postoperative Foley plans (see Appendix). Our anesthesia teams follow general best practices in the ERAS era: liberalized nothing-by-mouth (NPO) guidelines, postoperative nausea prophylaxis, minimization of intraoperative opioids and fluids, and use of preoperative acetaminophen and postoperative ketorolac when safe. Following these practices, our last 50 RASC cases (April 2019 to October 2020) have resulted in a SDD rate of 84%. There were no readmissions, and just 2 ED visits at 5 and 6 days postoperatively for urinary tract infection and subjective shortness of breath, respectively.

Our experience demonstrates that SDD is safe and feasible for RASC in the ERAS era. Benefits of SDD include avoidance of theoretical risks of medical error and hospital-acquired infections, financial savings and reduced burden on the health care system. During the COVID-19 pandemic, we have been able to continue to offer RASC even during local COVID-19 surges with limited hospital bed availability due to standardized SDD. With these apparent benefits and as evidence of safety and feasibility grows, we believe SDD should become routine for most RASC patients.