Abstract
Objectives:
The COVID-19 pandemic has led to a long waiting list for elective surgery and increasing bed pressures from acute admissions. This led to widespread cancellations on the day of surgery even for cancer procedures. To address this, all inpatient stay robotic-assisted radical prostatectomy (RARP) cases were managed via our day surgery unit as a 23-hour stay. We report the safety and feasibility of our initial implementation.
Methods:
A standard operating procedure for admission via the day surgery unit, including a modified enhanced recovery pathway, for patients undergoing RARP with or without pelvic lymph node dissection (PLND) was devised. All pre-operative variables were collected, and all perioperative outcomes analysed. Primary outcomes were number of on the day cancellations, discharge failure as 23-hour stay and 30-day readmissions.
Results:
Between November 2021 and June 2022, 135 patients underwent RARP with or without PLND via the day surgery unit. Mean patient age was 65 (46–76) years. Mean operative time and estimated blood loss were 153 (67–281) minutes and 197 (50–700) mL, respectively. Concomitant lymph node dissection was performed in 32.7% of cases. No patient required blood transfusion or conversion to open. We had 3 (2.2%) discharge failures, all of which were due to clinical reasons. Our 30-day hospital readmission rate was 3.7%, while another 5.2% attended emergency department and were discharged without admission.
Conclusion:
Short (23-hour)-stay RARP is safe and feasible and reduces pressure on inpatient beds but requires a multidisciplinary approach and engagement from all stakeholders.
Level of evidence:
2
Introduction
There has been an increasing trend towards day surgery for robotic-assisted radical prostatectomy (RARP), with most of the evidence from centres in the United States. Available literature suggests that day surgery RARP does not lead to increased emergency visits, readmissions or complications compared to inpatient RARP, 1 but leads to significant savings in healthcare cost. 2 However, anecdotally, there is concern that major pelvic surgery and day surgery, for the presumed economic benefits, may not be in the patient’s best interest.
As a large tertiary referral centre with multiple acute specialities, there is significant pressure on the availability of elective inpatient beds. This pressure was exacerbated during the recovery phase of the COVID-19 pandemic, resulting in frequent cancellations of RARP cases on the day of surgery. Cancellation on the day of surgery is highly undesirable, particularly as a regional referral centre for RARP patient travel up to 280 miles for their procedure. Accordingly, this led to a drive towards finding an alternative to the reliance on elective inpatient beds. The solution was to utilise the day surgery unit, which permitted more efficient turnaround of patients. As there is currently no standardised enhanced recovery after surgery (ERAS) protocol for RARP as defined by the ERAS Society, 3 we updated our own streamlined pathway for patients undergoing RARP to standardise the process via the day surgery (ambulatory care) unit as a 23-hour stay. Patients stay for one night on the day of their surgery and are discharged from the day surgery unit the next morning by 10:00.
The present manuscript describes an 8-month pilot project to assess the effect of RARP under the 23-hour stay care model via the day surgery unit. The aim of the project was to assess whether the change to 23-hour stay care model resulted in fewer same-day cancellations of surgery, while maintaining the quality of patient outcomes. The specific objectives of the study were to assess:
The effect of admission to the day surgery unit on the proportion of RARP cases cancelled on the day of surgery.
Adherence to 23-hour stay care model.
The safety of 23-hour stay RARP surgery by assessing the rate of hospital readmission and 30-day complications.
Methods
Development of the streamlined ERAS protocol
Following concerns described above an expert group was convened to consider the problem and possible solutions. The group consisted of robotic prostatectomy surgeons, anaesthetists, senior ward nurses, day surgery matron and manager, and specialist cancer nurses. The key was to ensure that the day surgery team had the physical capacity to accommodate and were confident and equipped clinically to manage pelvic surgical patients instead of the low complexity cases they are accustomed to. Discussions were held with stakeholders of various levels of seniority to explore the feasibility of this pathway. Training was delivered by the robotic prostate surgeons and a senior urology nurse provided practical training over two half-day sessions, prior to its implementation. The day surgery team had direct access to the robotic team and patients were reviewed individually by the operating surgeon post-operatively on the day of surgery and prior to discharge from day surgery. To ensure safety and feasibility, we continuously audited our results and sought feedback from the day surgery team and presented results during monthly audit meetings.
The RARP service at our centre is delivered by two consultants, a senior robotic fellow, surgical care practitioners, prostate cancer nurse specialists, urology senior nurses, anaesthetist with special interest in robotic-assisted surgery and ward team.
All patients undergoing RARP with or without pelvic lymph node dissection (PLND) were admitted to our day surgery unit. We prospectively collected all pre-operative variables and analysed all perioperative outcomes between November 2021 and June 2022.
Our standard operating protocol (SOP) includes an enhanced recovery protocol as below.
Anaesthesia
Pre-operatively, all patients had glycerol suppositories and omeprazole the night before and on the morning of surgery.
General anaesthesia was maintained with inhalation anaesthetic agent (desflurane or sevoflurane), supplemented by remifentanil infusion. Intraoperative multi-modal analgesia was in the form of intravenous morphine, paracetamol, diclofenac and surgical site infiltration with local anaesthetic. Multi-modal anti-emetics included a combination of ondansetron, dexamethasone and metoclopramide. We do not use any form of central neuraxial blocks (intrathecal or epidural).
Surgery
Standard transperitoneal 6-port approach, which includes 1 × 12 mm camera, 3 × 8 mm robotic, 1 × 5 mm and 1 × 12 mm assistant port. Local anaesthesia infiltration was administered to all port sites (20 mL 0.5% bupivacaine with 1:200,000 adrenaline). Pneumoperitoneum is maintained at 12 mmHg with CO2 insufflation, patient is positioned at 25 degrees Trendelenburg and the robotic system used is the Intuitive Da Vinci Si.
Pelvic drain is not routinely inserted in patients undergoing RARP or RARP with PLND.
Perioperative care
Day 0: Regular observations, intravenous Hartmann’s solution 1 litre over 8 hours to maintain a good urine output, prevent blood clots and dilute any intravesical blood post-operatively, sit out and mobilise short distances, light diet as tolerated, thrombo-embolic deterrent (TED) leg stockings, all discharge paperwork and routine medications are ordered from pharmacy.
Day 1: Intravenous fluids to continue until 0600, mobilise (at least 800 m) on ward from 0600, surgical review by 0730, commence laxatives, TED stockings & low molecular weight heparin (LMWH) injections for 28 days, regular paracetamol with or without ibuprofen, avoid opiates where possible (opiates are not prescribed unless indicated by senior surgical team). Aim for discharge by 1000.
Post-operative care
On discharge, patients are provided with contact details of the urology and day surgery ward and cancer nurse specialists. All patients are contacted via telephone by the cancer nurse specialist within 72 hours of discharge. They have a trial without catheter (TWOC) at 7 days (single dose of ciprofloxacin given prior to TWOC) and are advised to recommence pelvic floor exercises with or without tadalafil 5 mg once daily if indicated (some patients are started on tadalafil the day after surgery depending on surgeon preference). PSA is done at 6 weeks post-op, with a telephone consultation follow-up with the consultant/senior fellow of the team at 6–8 weeks.
Results
In this pilot project, 135 patients underwent planned 23-hour stay RARP over an 8-month period (between November 2021 and June 2022).
Patient characteristics
In our cohort, the mean patient age was 65 (46–76) years. All patients were either American Society of Anaesthesiologist (ASA) score 1 or 2, and median body mass index (BMI) is 28. Mean operative time and estimated blood loss were 153 (67–281) minutes and 197 (50–700) mL, respectively. Concomitant lymph node dissection was performed in 32.7% of cases. No patients required blood transfusion or conversion to open surgery (Table 1).
Patient demographics and perioperative outcomes.
RARP: robotic-assisted radical prostatectomy; PLND: pelvic lymph node dissection; BMI: body mass index; LOS: length of stay; ASA: American Society of Anaesthesiologist; EBL: Estimated blood loss.
Same-day cancellations
No patients were cancelled on the day of surgery.
Discharge failure
2.2% (n = 3) failed to be discharged as a 23-hour stay due to clinical reasons. Specific reasons were (1) delay in mobilisation secondary to pain; (2) single temperature spike (37.8 C) associated with dizziness; and (3) concerns regarding catheter care and pain management.
30-day complication rate
8.9% recorded complications within 30 days, with the majority being Clavien-Dindo Grade I and II. There was one Clavien IIIb complication: intraoperative iatrogenic serosal tear of the small bowel on camera port entry, but this was recognised immediately and repaired at the time of RARP (Table 1).
30-day unplanned readmissions
Twelve patients (10.9%) presented to emergency department within 30 days of RARP, of which 7 patients (5.2%) were discharged and 5 patients (3.7%) were admitted to hospital. Reasons for these are outlined in Table 2.
Emergency department attendances and 30-day readmissions to hospital.
Discussion
This pilot study of 23-hour stay for RARP patients was undertaken to avoid on the day cancellations. The results show that this aim was achieved with no patients cancelled on the day of surgery for lack of patient beds. Moreover, only 2.2% were not successfully managed and discharged as a 23-hour stay. Comparing our results to literature, first it is important to note that the definition of day surgery in the United States includes 23-hour stay, while in the United Kingdom, 23-hour stay is categorised separately, although it could be managed as part of a day surgery unit. 4 In Australia, 23-hour stay care model is known as extended day surgery, where patients are managed and discharged from the day surgery unit within 23 hours of admission to the post-operative recovery unit. 5 Our target time of discharge from day surgery unit for the 23-hour stay care model is by 10:00 the morning after surgery, similar to that used by this Finnish study. 6
The results show that 97.8% of our RARP patients were successfully managed as a 23-hour stay via the day surgery unit. This is a higher rate than in other day case (same day discharge) cohorts, which range from 25.3% 7 to 51.9%, 8 and still higher when compared standard inpatient cohorts (90.4% with length of stay (LOS) < 2 days). 9 In a large multi-institutional study comparing day case RARP with inpatient RARP, they found that day case discharge failure was higher in patients who underwent lymph node dissection. 10 In contrast, none of our discharge failures had lymph node dissection. Our unplanned readmission rate of 3.7% is also favourable, and less than the figure of 5% in a meta-analysis for day case same day discharge RARP, 11 and comparable to that of other larger, non-same day discharge RARP cohorts.8,12 The most common cause of unplanned readmission to hospital is infection related (2.2% of the cohort), and all these patients are successfully treated with antibiotics.
Several improvements to patient care were evident from our results. First, there were no same-day cancellation of RARP cases. This is likely because the day surgery unit is ringfenced as a ‘green’ area and not affected by the pressure of acute admissions at our centre. Second, all patients were managed according to our modified ERAS pathway, and therefore received more streamline care, which has been shown in a meta-analysis to lead to a reduced LOS and reduced time to ambulate. 13 It is well known that early mobilisation and reduced use of opiates (hence reducing post-op nausea and vomiting) are key to successful discharge. In our study, prior to and during the initiation of the change to 23-hour stay RARP, staff were well trained and supported to care for patients on this pathway. All necessary documentation was completed on the day of surgery by the surgeon, so patients were not waiting unnecessarily due to administrative delays.
One of the main challenges in successfully implementing organisational change is changing the culture, in this case changing the perception of the surgical team that RARP is an inpatient surgical procedure, to that of a short 23-hour stay procedure. In addition, it was necessary to change the culture of the day surgery unit, where the majority of cases are high volume and low complexity, to accept patients who have undergone major pelvic surgery. This is because the day surgery unit is not a specialist ward and does not provide specialised urology nursing care. Engagement of stakeholders, close support and training were given to the day surgery team to inspire confidence and to ensure quality of care for patients.
Patients are counselled pre-operatively to manage their expectations, including information on catheter care and how to self-administer subcutaneous low-molecular-weight heparin injections. They are informed that it will be a short overnight stay and to expect to be discharged the next morning after their surgery. However, they are also reassured that should there be a need for a longer stay this would be arranged for them. Patients who travelled to our centre via air were booked into the patient hotel for 3 days pre-operatively (for self-isolation from COVID-19) and 3 days post discharge prior to flying home.
The perioperative anaesthesia care is also of utmost importance in ensuring successful implementation of 23-hour stay. Use of short-acting inhalational anaesthetic agents combined with short-acting opiates during the maintenance phase of anaesthesia to facilitate rapid recovery and return of cognition function, generous use of multi-modal anti-emetics, multi-modal analgesia including local anaesthetic surgical site infiltration, meticulous positioning to prevent risk of neurapraxia and use of post-operative oral opiates only if indicated on a per required basis are the core components of a successful day case procedure. Although neuroaxial blockade with intrathecal opiates are widely used routinely in almost half the centres performing RARP in the United Kingdom, 14 this is not our routine practice. None of our patients required post-operative intravenous opiates on the ward, nor were oral morphine prescribed routinely, despite randomised trials concluding that neuroaxial blockade with intrathecal opiates reduces IV morphine requirements in the post-operative period. 15 Despite not using neuroaxial blockade, we are successfully discharging patients as a 23-hour stay. Although our primary drive for this change in pathway was not targeted at cost savings, it is likely that admission via the day surgery unit and quicker patient turnover would save hospitals the cost of an inpatient bed. In addition, no cancellations on the day of surgery equates to maximum theatre utility and less cancer pathway breaches. However, no formal cost-effectiveness analyses have been performed and published in available literature.
The unique feature of our study is that our cohort of patients were not a carefully selected group but were all defaulted to 23-hour stay via day surgery unit. This is a similar concept used by Abaza et al., 2 who defaulted all their patients to same day surgery, but found that just under half were successfully discharged as a day case. The majority of the studies in this systematic review of day case RARP, patients are selected with stringent criteria qualify for day case RARP. 11 However, the key differences are that all studies in this systematic review were from centres outside the United Kingdom, and none of it were managed as a 23-hour stay. It is tricky for us to draw direct comparisons, as we found very limited published literature on 23-hour short stay RARP, which we believe is an efficient and safe steppingstone of utilising day surgery’s remit, and eventually moving towards achieving full day case (same day discharge) RARP.
A limitation of our study is that formal patient feedback and satisfaction scores were not collected. Literature has described different patient satisfaction outcomes: Bajpai et al. 16 found that their cohort who were discharged on the same day had lesser pain and interference to general activity after discharge, while Dobbs et al. 17 conducted a patient survey which showed two-thirds of their patients were not ready for discharge on the day of surgery with the main reason cited as pain control. As a centre that values patient-centred care and to ensure patient experience is not compromised, we plan to collect patient reported outcome measures (PROMs) to prospectively evaluate patient experience of 23-hour stay RARP.
Moreover, we have only reported the 30-day complications and readmission in this series, as we feel that most inappropriate discharges usually would represent within 30 days. However, more data is being prospectively audited to ensure safety and feasibility in the long term.
With a successful rollout of our pilot project for RARPs, this is now the default pathway at our centre for RARPs. In addition, we have also introduced the 23-hour stay care model for robotic-assisted pyeloplasty and robotic-assisted partial nephrectomy, with a view to continually introduce more ‘traditionally inpatient’ elective work via the day surgery unit.
Conclusion
In conclusion, a multidisciplinary approach to short (23-hour)-stay RARP is a key to success. Pre, peri and post-operative care must be comprehensive. Along with an enhanced recovery pathway, easy access to the surgical team and ward nurses after discharge and regular contact with the specialist nurses is of paramount importance. Successful implementation of the 23-hour stay care model would be a useful stepping stone towards same day discharge RARPs in the future.
Footnotes
Acknowledgements
The authors thank Graham Johnson, Manager, Day Surgery Unit; Georgina Jackson-Plume, Matron, Day Surgery Unit, Indu Francis & Hansley Coret, Surgical Care Practitioners, Addenbrooke’s Hospital, Cambridge University Hospitals.
Conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
Ethical approval
All patients were registered as part of The BAUS national outcomes audit and this quality improvement audit was registered with the institutional audit department (Ref. 4855). As a registered audit, NHS Research Ethics Committee (REC) stated that no ethical approval was needed. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. All patients gave informed signed written consent as best known at the time of intervention after discussion with the relevant surgeon and multidisciplinary team.
Informed consent
All patients gave informed signed written consent as best known at the time of intervention after discussion with the relevant surgeon and multidisciplinary team.
Guarantor
N.S.
Contributorship
N.S./B.W.L. conceived the study, edited and reviewed the manuscript. L.J.T. was involved in implementing the project, collection of data/statistical analysis and writing the manuscript. N.M. and K.G. were involved in data collection. V.P. was involved in specialist input for the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.
