Robotic surgery has become the mainstay for major urologic procedures including prostatectomy, partial nephrectomy, and increasingly for any urologic condition requiring abdominal surgery. While urologists have used robotics for > 20 years, recent attention has been given to early recovery after surgery (ERAS) protocols in robotic surgery to improve outcomes and reduce lengths of stay (LOS).

The minimally invasive nature of robotic surgery lends itself ideally to enhanced recovery protocols, with most amenable to same-day discharge with experience and patient preparation. Additionally, narcotic avoidance has become an important mandate in health care with development of opioid-free strategies in urology (eg, ureteroscopy) gaining traction.¹ Robotic surgery represents an excellent target for avoiding opioids, especially compared with traditional, open surgical alternatives.

Opioid Avoidance

Postoperative opioids contribute to ileus/constipation, confusion/sedation, nausea/vomiting, and a real risk of addiction. Intravenous narcotics (eg, morphine/dilaudid) are absolutely unnecessary after any robotic urologic surgery with not one of > 7000 patients in our experience requiring these. Oral narcotics are also avoidable in most patients when counseled on potential harms and instructed to use these only for severe pain. Patients should be educated that some postoperative pain is natural and to medicate with a goal pain score of 2 to 3 rather than zero since a hazardous amount of narcotics would be needed to eliminate pain completely.

We routinely use ketorolac (including partial or radical nephrectomy) and recommend acetaminophen and ibuprofen with 10 tramadol tablets prescribed, which most don’t use. Regional blocks (eg, TAP [tranversus abdominis plane] blocks), intravenous lidocaine, and other strategies have been described. While not required, these could be used by surgeons seeking novel methods to reduce opioids. Ice packs may help at extraction incisions or Exparel (long-acting bupivacaine; Pacira Pharmaceuticals, Inc, Tampa, Florida)/pain pumps for larger extractions (eg, nephrectomy).

One method of reducing pain with level I evidence is reducing insufflation pressure from the traditional 12 to 15 mm Hg to the lowest level safely possible. We have performed > 2000 consecutive prostatectomies and other pelvic surgeries with pneumoperitoneum of 5 to 6 mm Hg regardless of body habitus using AirSeal (CONMED, Largo, Florida). In our randomized, controlled study comparing 15 mm Hg vs 6 mm Hg, we found lower mean and peak pain scores and faster return of bowel function at lower pressure.² We perform kidney and other upper tract surgery at 8 mm Hg, and when bowel encroaches given the lack of gravity retraction in pelvic surgery using Trendelenburg, we never need to exceed 12 mm Hg.

Same-Day Discharge

While outpatient surgery can reduce cost, open hospital beds for others, and reduce exposure to nosocomial infections (including COVID),³ a major motivation is patient preference for recovering in the comfort of home as long as they know it is safe. Complications within the first 24 hours after robotic urologic surgeries are exceedingly rare such that requiring all patients stay overnight is likely unnecessary.

Benefits of recovery at home include less sleep disturbance than hospitals,⁴ earlier resumption of nutrition, and earlier ambulation at home compared with hospitals challenged by staffing shortages, which may reduce deep vein thrombosis and ileus. Again, while reducing cost is not the main reason to offer ambulatory surgery, it will benefit hospitals that usually receive global payments for surgeries regardless of how long patients are hospitalized, which may help offset robot acquisition and instrument costs. Of note, while we initially believed that buying a single-port robot might be needed to facilitate same-day discharge,⁵ we have since found that this is unnecessary with thousands of multiport robotic surgery patients discharged the same day since returning our SP robot 2 years ago (Figure 1).

We began offering outpatient robotic prostatectomy in 2016⁶ and partial nephrectomy in 2018 and progressed from 20% in year 1 to now 99% of prostatectomies and 97% of partial nephrectomies. Excluding robotic cystectomy given bowel used for diversions, we discharge all patients from the recovery room without increased complication or readmission rates compared with our historical overnight routine (Figure 2). We uniformly do ambulatory robotic surgery with recovery room discharge at 3 hospitals and a freestanding, private ambulatory surgery center and have done so in settings without residents/fellows or advanced practice providers such that it is likely feasible to at least some degree in most hospitals with experienced surgeons (Table 1).

Table 1. Outcomes of Standardized Robotic Surgery Clinical Pathway With Routine Same-Day Discharge Protocol Over 2 Years in All Patients Having Robotic Urologic Surgery by Author (Excluding Cystectomy)

Patient education is critical, and avoidance of drains may also facilitate patient acceptance. Even bladder catheters (eg, prostatectomy) can be psychologically challenging, so avoiding abdominal drains will minimize the “sick role” in patients’ minds and prevent an extra office visit for drain removal if not staying overnight. We performed > 6000 robotic surgeries with urinary tract violation since implementing drain-avoidance and used a drain in < 1%. We would have needed to leave > 900 drains to prevent/identify each urine leak and > 2500 drains to prevent each percutaneous drain that had to be placed (Table 2). Experienced robotic surgeons with low urine leak rates should consider drain avoidance to facilitate same-day discharge.⁷

Table 2. Outcomes of Drain Avoidance in All Patients Undergoing Robotic Urologic Surgeries by Author With Urinary Tract Violation

Setting expectations is critical. We introduce same-day discharge if “everything goes as planned” at the first office visit and in all printed educational materials, preoperative teaching, and again in the preoperative area. Most patients know that procedures like laparoscopic cholecystectomy are routinely outpatient now and are pleased that they will be allowed to go home once they know it is safe and know they can call 24/7 if problems arise as explained on a “medical alert” wallet card we provide. Similar to laparoscopic cholecystectomy, patients are not disqualified from same-day discharge based on age or comorbidities, and surgical complexity (heminephrectomy, solitary kidney, caval thrombus, etc) is also not a barrier with experience, which has allowed for our 99% success rate across all procedure types.

Robotic Cystectomy

Robotic cystectomy is likely the procedure in urology that has disappointed the most in reducing LOS, potentially because open cystectomy surgeons have been progressive in applying ERAS protocols. Robotic cystectomy is ripe for ERAS application. By combining robotic surgery with ERAS, we reduced our mean LOS after cystectomy from 3.3 days with ERAS to 2.1 days after alvimopam became available.^8,9 For the past 2 years, we have performed robotic cystectomy routinely with an overnight stay alone.

Conclusion

The minimally invasive nature of robotic surgery makes it ideal for ERAS protocols. Surgeons should consider implementing such strategies with a goal of reducing narcotic use and LOS for better outcomes.