PROSTATE CANCER Should Same-day Discharge After Robotic Radical Prostatectomy Be the Standard of Care?
By: Connor Latiolais, BS, Louisiana State University School of Medicine, New Orleans; Kyle Szymanski, MD, University of Colorado School of Medicine, Denver; Janet Kukreja, MD, MPH, FACS, University of Colorado, Denver; Mary E. Westerman, MD, Louisiana State University Health Science Center, New Orleans, School of Medicine, Louisiana State University Health Science Center, New Orleans | Posted on: 07 Sep 2023
Across surgical disciplines, studies have consistently shown that outpatient surgeries result in comparable or even improved patient outcomes, including reduced complication rates, shorter hospital stays, faster recovery, and increased patient satisfaction.1,2 The shift toward outpatient surgery has been driven by factors such as cost-effectiveness, improved surgical techniques, enhanced recovery protocols, and advancements in anesthesia and pain management.
In 1996, Klein et al described implementation of a protocol which decreased the median length of stay from 7 to 2 days following radical prostatectomy while maintaining a high level of patient satisfaction.3 Similarly Litwin et al reported that, following a clinical pathway to decrease length of stay (median 3 nights), there was no detrimental impact on patient satisfaction.2
Almost 20 years later, Abaza et al described implementation of a same-day discharge (SDD) protocol.4 Starting in 2016, this option was discussed preoperatively with patients subsequently deciding after surgery whether to go home or stay overnight. They found that among 500 consecutive patients the overall rate of SDD was 49.2%, but notably increasing to 65% in the last 100 patients (see Figure). There was no increase in readmission rate (0.4% for SDD vs 2.8% for admitted, P = .68). Complication rates were lower in SDD patients (4.4% vs 9%, P = .05) with fewer Clavien III complications (0.8% vs 4%, P = .036). The major factor associated with patients electing SDD was operative end time. Nearly 70% of first-start patients chose SDD compared to 2.5% of third-start patients (ending late afternoon).
A multi-institutional study in France found that planned SDD was successful in 95.8% of patients (n=358) undergoing same-day robot-assisted laparoscopic prostatectomy.5 On multivariable analysis, factors associated with failure were performance of a pelvic lymph node dissection and blood loss. There was significant surgeon and site variability with SDD representing 15%-60% of the surgeon robot-assisted radical prostatectomy cohort and 10%-30% of the center robot-assisted radical prostatectomy cohort. However, like Abaza et al’s initial study, rates of SDD continuously increased over the study time period, ultimately approaching 60% at some centers.
COVID-19 accelerated the move toward SDD. A retrospective analysis of 2 large Northeastern hospitals found that SDD increased from 4.4% at the end of the fourth quarter of 2020 to 45% by the second quarter of 2022.6 The authors found no difference in patient characteristics between the 2 groups (SDD and overnight admission). Similar to Ploussard et al’s findings,5 factors associated with SDD were institution and surgeon volume (higher-volume surgeons were predictive of SDD).
Szymanski et al reported that, between January 2019 and December 2021, 139/497 (28%) of prostatectomies completed by 4 fellowship-trained urologic oncologists at a single institution were done as SDD.7 There were no significant clinicodemographic features between the inpatient and outpatient groups. Increased operative time and blood loss were the only factors associated with admission. Notably surgeon level variation was not analyzed. Importantly, the authors found that there was a higher rate of readmission (5% vs 0%, P = .007) and emergency department visits (mean 0.15 vs 0.05, P = .02) among patients who were admitted. Overall complication rate was 7.2% vs 19.8% in the inpatient vs outpatient group. SDD also did not increase clinical staff workload, with no difference in number of phone calls to clinic or number of electronic health record messages.
Moving from selective to universal SDD, between October 2021 and October 2022, Abaza et al reported a 99% success rate in 352 consecutive radical prostatectomy cases with a 2.5% readmission rate.8 Cases were done in either an ambulatory surgery center without overnight stay capability (n=162) or a hospital (n=197), determined by patient risk factors (BMI, severe cardiac disease, etc) and insurance coverage.
In summary, the existing data show that same-day prostatectomy is safe and does not result in higher readmission rates or increased clinical burden. The critical component of SDD acceptance is preoperative patient counseling. Notably this is discussed extensively in the papers by Litwin2 and Klein3 et al as fundamental to patient acceptance of decreased length of stay in the open surgery era. Likewise, Abaza et al describe the critical importance of patient education, noting that over time the patients became more comfortable as they could explain that most patients elected SDD without experiencing any unexpected issues.4,8 Similarly, Ploussard et al reported 76% adherence with SDD protocols when discussed at the preoperative visit.9 We observed a similar trend at our institution. In 2021 we began offering the option of SDD to patients. Once we recognized the safety and improvement in patient recovery, it became our standard of care. Over a 1-year period between May 2022 and May 2023, 86% of our prostatectomies were successfully done as SDD.
Future studies demonstrating cost-effectiveness, patient satisfaction/return to work, and/or improved outcomes are likely needed for SDD to be considered the standard of care. However, the literature supports the safety and feasibility of SDD, and surgeons should feel confident in discussing the option with their patients.
- Allahabadi S, Cheung EC, Hodax JD, et al. Outpatient shoulder arthroplasty—a systematic review. J Shoulder Elb Arthroplast. 2021;10.1177/24715492211028025.
- Litwin MS, Shpall AI, Dorey F. Patient satisfaction with short stays for radical prostatectomy. Urology. 1997;49(6):898-903.
- Klein EA, Grass JA, Calabrese DA, et al. Maintaining quality of care and patient satisfaction with radical prostatectomy in the era of cost containment. Urology. 1996;48(2):269-276.
- Abaza R, Martinez O, Ferroni MC, et al. Same day discharge after robotic radical prostatectomy. J Urol. 2019;202(5):959-963.
- Ploussard G, Dumonceau O, Thomas L, et al. Multi-institutional assessment of routine same day discharge surgery for robot-assisted radical prostatectomy. J Urol. 2020;204(5):956-961.
- Labban M, Frego N, Qian Z, et al. MP80-06 Trends and safety profile of same-day discharge for robot-assisted laparoscopic prostatectomy: a retrospective analysis of two tertiary centers in the Northeastern United States. J Urol. 2023;209(Suppl 4):e1153.
- Szymanski K, Lacouture H, Zakrajsek J, et al. MP67-20 Feasibility of outpatient robot assisted laparoscopic prostatectomy. J Urol. 2023;209(Suppl 4):e951.
- Abaza R, Salka B, Carey B, Pettay K, Martinez Silva O. MP80-05 New paradigm in robotic prostatectomy: planned same day discharge in all patients. J Urol. 2023;209(Suppl 4):e1153.
- Ploussard G, Almeras C, Beauval JB, et al. Same-day discharge surgery for robot-assisted radical prostatectomy in the era of ERAS and prehabilitation pathways: a contemporary, comparative, feasibility study. World J Urol. 2022;40(6):1359-1365.