Laparoscopic Nephrectomy as Outpatient Surgery

Outpatient Robotic Urological Surgery: An Evidence-based Analysis

BACKGROUND AND OBJECTIVE

One of the primary advantages of minimally invasive surgery is the shorter hospitalization time, which can potentially allow "outpatient" (OP) procedures. The recent advent of single-port (SP) robotics has further fueled the debate on this topic. We sought to provide an evidence-based analysis of the safety, feasibility, and advantages of robotic urological surgery in the OP setting.

METHODS

A literature search in PubMed was conducted in June 2024 to identify studies on the feasibility and safety of OP robotic urological surgery. Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria and the Population, Intervention, Comparator, Outcome model were used to select retrospective and prospective studies. Data collected included patient characteristics, operative outcomes, same-day discharge (SDD), and complication and readmission rates. Study quality was assessed using the Newcastle-Ottawa Scale. Data analysis and synthesis were performed using Review Manager and GraphPad Prism.

KEY FINDINGS AND LIMITATIONS

For 3291 patients in noncomparative studies, we found SDD rates of 46.17% for multiport (MP) robot-assisted radical prostatectomy (RARP), 77.35% for SP-RARP, 93.1% for robot-assisted radical or partial nephrectomy, and 93.3% for adrenalectomy. Among comparative studies involving 4130 patients, we found that the OP setting is feasible and safe. Comparison of overall complications between OP and inpatients (IP) settings revealed a relative risk (RR) of 0.66 (95% confidence interval [CI] 0.48-0.91; p = 0.01) favoring OP. The risk of readmission was lower risk for OP than for IP surgery (RR 0.53, 95% CI 0.33-0.85; p = 0.008). Comparison of MP-RARP and SP-RARP revealed that OP protocols are more easily achievable with SP-RARP (44.20% vs 79.59%; p < 0.001).

CONCLUSIONS AND CLINICAL IMPLICATIONS

OP robotic urological surgery is feasible and safe in selected patients and can enhance satisfaction and reduce costs. SP robotics could promote wider adoption of SDD protocols. Strict case selection minimizes complications. Differences in health care systems should be considered in future evaluations.

PATIENT SUMMARY

We examined the feasibility and safety of same-day hospital discharge after robot-assisted surgery for urology operations. We found that this option can be safely offered and may be even more viable if the use of robots allowing surgery through a single keyhole incision becomes more widespread.

Health-related Quality of Life Assessment in Renal Cell Cancer: A Scoping Review

BACKGROUND AND OBJECTIVE

In oncology, patient-reported outcome measures (PROMs) capturing health-related quality of life (HRQOL) play an increasing role in clinical trials, drug approval, and policy making. This scoping review aimed to identify and elaborate on HRQOL-focussed PROMs used in renal cell cancer (RCC) clinical trials.

METHODS

MEDLINE, Web of Science, PsychINFO, Academic Search Elite, CINAHL, Embase, and the Cochrane Library were searched systematically for original peer-reviewed articles on clinical trials including RCC patients and using PROMs, published between 1950 and 2023. Prespecified trial characteristics and information on the PROMs used were extracted. Frequencies and proportions of categorical data, and ranges and medians of continuous variables were calculated.

KEY FINDINGS AND LIMITATIONS

Of the 48 unique studies included, the majority followed a randomised controlled design (34, 71%) and evaluated systemic treatments (38, 79%). The trials used 27 different PROMs (max = 6, median = 2), of which only 4 (15%) were developed specifically for kidney cancer patients. Of the trials, 46% did not use any RCC-specific PROM. European Quality of Life-5 Dimensions (EQ-5D), European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), Functional Assessment of Cancer Therapy Kidney Symptom Index (FKSI) -15/19-item version, FKSI-Disease Related Symptoms, and Functional Assessment of Cancer Therapy-General (FACT-G) were the most frequently used questionnaires, with pain, ability to work, fatigue, worry, and sleep quality being the most commonly assessed issues.

CONCLUSIONS AND CLINICAL IMPLICATIONS

A variety of PROMs are used in RCC patients, hindering interpretability across trials. The PROMs used differ in terms of both the domains assessed and how the issues are translated into questionnaire items. Though RCC-specific PROMs exist, these have flaws in terms of relevance to patients. To answer predefined relevant HRQOL research questions, revised RCC-specific PROMs and standardisation of their integration into clinical trials are warranted.

PATIENT SUMMARY

Researchers are more and more interested in the health-related quality of life of kidney cancer patients and use questionnaires to measure it. This review shows that there are many different health-related quality of life questionnaires that are used in different combinations in clinical trials for kidney cancer patients. This makes it very difficult to compare these study results and draw reliable conclusions for the actual clinical treatment. It was even found that some of the questionnaires used do not capture things that patients actually consider important (eg, emotional issues such as dealing with thoughts about cancer and depression). Therefore, more work needs to be done to develop questionnaires that ask what is really important to kidney cancer patients' health-related quality of life. If these questionnaires are used in a consistent way in clinical trials, the results can be better compared. This will help treat kidney cancer patients in the best possible way.

The Safety and Feasibility of Ambulatory Minimally-Invasive Partial Nephrectomy: A Systematic Review and Meta-Analysis

PURPOSE

Emerging evidence supports the use of minimally invasive partial nephrectomy (MIPN) in ambulatory settings. We conducted a systematic review and meta-analysis to evaluate differences in perioperative characteristics, complication/readmission rates and satisfaction/cost data between ambulatory and standard-length discharge (SLD) MIPN.

METHODS

This study was prospectively registered in PROSPERO (CRD42023429854). A systematic literature search of PubMed, Embase, and Web of Science databases was conducted, including studies comparing ambulatory MIPN versus SLD MIPN for patients with renal masses. Studies were assessed for quality using the Methodological Index for Non-Randomized Studies score. Meta-analysis was performed for comparative studies, and non-comparative studies were included narratively.

RESULTS

Eleven studies were included with a pooled population of 20,575 patients, of which 1,419 (7%) had a length of stay less than 1 day and were considered the ambulatory group. There were no significant differences in the total complication rates (RR: 0.50, 95% CI: 0.24, 1.04; p = 0.06) or 30-day readmission rates (RR: 0.87, 95% CI: 0.56, 1.35; p=0.53) between the ambulatory and SLD groups. There were fewer > 3 Clavien-Dindo complications in the ambulatory group (RR: 0.34, 95% CI: 0.19, 0.59; p = 0.0002). Few studies reported average healthcare cost and patient satisfaction.

CONCLUSIONS

In appropriately selected patients, ambulatory MIPN is safe and feasible. Future studies are needed to quantify cost and patient satisfaction differences and further identify appropriate patient selection criteria for ambulatory MIPN.

SOURCES OF FUNDING

No funding.

Same day discharge robotic-assisted nephroureterectomy

Minimally invasive radical nephroureterectomy (RNU) decreases length of hospital stay compared to open RNU. We describe and demonstrate with video the first report of an outpatient robotic RNU.

The 5-factor frailty index for radical nephrectomy: Simplifying personalized preoperative risk-stratification

Radical nephrectomy is the gold standard treatment for large renal cell carcinoma. Given the rising incidence of renal cell carcinoma and higher prevalence of geriatric patients in the population, readily identifying patients preoperatively that are at risk for a more complicated postoperative course is critical. The 5-factor modified frailty index (5-IFi) is a scoring system that assigns 1 point for each of the following comorbidities: dependent functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients with higher 5-IFi scores have been shown to be at significant risk for increased postoperative morbidity and mortality in many cohorts, including patients that undergo radical nephrectomy. This simplified comorbidity index with only 5 components is much more clinically pragmatic than its predecessors. As we encounter an increasing volume of patients with renal cell carcinoma and geriatric surgical candidates, readily risk stratifying patients on a personalized basis may be informative for shared clinical and surgical-decision making.

Same-Day Discharge After Robot-Assisted Partial Nephrectomy: Is It Worth It?

Introduction and Objective: Robot-assisted partial nephrectomy (RAPN) has traditionally been performed as an inpatient procedure; however, recent studies have suggested the feasibility of same-day discharge (SDD) after RAPN. We aimed to evaluate the safety and cost-effectiveness of SDD for RAPN. Methods: A retrospective analysis was conducted on patients undergoing RAPN between January 2015 and July 2021. Comparison before and after the implementation of an SDD protocol was assessed through differences in postanesthesia care unit (PACU) time, length of stay, 30-day readmission rate, 30-day return to emergency department (ED) rates, unplanned office visits (OVs), and need for secondary procedures. A cost-efficacy model was generated to estimate the difference in expenditure between SDD and inpatient RAPN. Results: In total, 192 patients underwent RAPN with 74 being SDD and 118 being admitted postoperatively. After SDD protocol implementation, the percentage of patients discharged from the PACU increased from 0% to 76%. The safety profile of SDD was similar to the inpatient group, with no differences in readmission rates (1.4% vs 5.1%, p = 0.18) or return to ED (5.4% vs 9.3%, p = 0.33). Compared with inpatient RAPN, SDD was associated with increased time in PACU (375 vs 251 minutes, p < 0.001), resulting in an additional expenditure of $1,622 per patient. SDD patients were more likely to return for one or more unplanned OVs (17.6% vs 6.8%, p = 0.02). Overall, the total cost of SDD was significantly lower than inpatient RAPN ($5,222 per patient vs $8,425, p < 0.001). Conclusion: Despite a shorter postoperative monitoring period, SDD appears safe, with equivalent readmission rates, return to ED, and secondary procedures. SDD for RAPN saves ∼$3,000 per patient. In implementing an SDD protocol, clinicians should be cognizant of increased demands on PACU infrastructure and be willing to provide additional support in the office setting.

Same-day discharge following minimally invasive partial and radical nephrectomy: a National Surgical Quality Improvement Program (NSQIP) analysis

PURPOSE

Minimally invasive partial nephrectomy (MIPN) and radical nephrectomy (MIRN) have successfully resulted in shorter length of stay (LOS) for patients. Using a national cohort, we compared 30-day outcomes of SDD (LOS = 0) versus standard-length discharge (SLD, LOS = 1-3) for MIRN and MIPN.

METHODS

All patients who underwent MIPN (CPT 50,543) or MIRN (CPT 50,545) in the ACS-NSQIP database from 2012 to 2019 were reviewed. SDD and SLD groups were matched 1:1 by age, sex, race, body mass index, American Society of Anesthesiologists score, and medical comorbidities. We compared baseline characteristics, 30-day Clavien-Dindo (CD) complications, reoperations, and readmissions between SDD and SLD groups. Multivariable logistic regressions were used to evaluate predictors of adverse outcomes.

RESULTS

28,140 minimally invasive nephrectomy patients were included (SDD n = 237 [0.8%], SLD n = 27,903 [99.2%]). There were no significant differences in 30-day readmissions, CD I/II, CDIII, or CD IV complications before and after matching SDD and SLD groups. On multivariate regression analysis, SDD did not confer increased risk of 30-day complications or readmissions for both MIPN and MIRN.

CONCLUSION

SDD after MIPN and MIRN did not confer increased risk of postoperative complications, reoperation, or readmission compared to SLD. Further research should explore optimal patient selection to ensure safe expansion of this initiative.

Trends in outpatient versus inpatient urologic surgery at a university academic medical center

PURPOSE OF REVIEW

To analyze trends in outpatient and inpatient urologic surgeries at a large university academic medical center and test the hypothesis that the proportion of outpatient surgeries has been increasing as compared to inpatient surgeries in urology.

RECENT FINDINGS

We analyzed a total of 33,054 claims for urologic surgeries at a large university academic medical center from 2010 to 2020, of which 23.2% met inpatient criteria (n = 7695), whereas 76.7% were outpatient (n = 25,359). Although outpatient claims increased yearly by an average of 24%, inpatient claims increased yearly by an average of only 1%. Over the same period, Medicare-specific outpatient claims mirrored these trends, and Medicare-specific inpatient claims decreased.

SUMMARY

Outcomes of inpatient surgeries are used as a metric for quality by the Centers for Medicare and Medicaid Services (CMS) as well as US News and World Report (USNWR) rankings. However, with increasing numbers of minimally invasive operations, a large proportion of urologic surgeries are performed on an outpatient basis. As this trend continues, it will be important for organizations like CMS and USNWR to incorporate methods of measuring quality that better reflect outpatient surgical outcomes for the urologic subspecialty.

The shift from inpatient to outpatient hysterectomy for endometrial cancer in the United States: trends, enabling factors, cost, and safety

OBJECTIVE

To evaluate trends in outpatient versus inpatient hysterectomy for endometrial cancer and assess enabling factors, cost and safety.

METHODS

In this retrospective cohort study, patients aged 18 years or older who underwent hysterectomy for endometrial cancer between January 2008 and September 2015 were identified in the Premier Healthcare Database. The surgical approach for hysterectomy was classified as open/abdominal, vaginal, laparoscopic or robotic assisted. We described trends in surgical setting, perioperative costs and safety. The impact of patient, provider and hospital characteristics on outpatient migration was assessed using multivariate logistic regression.

RESULTS

We identified 41 246 patients who met inclusion criteria. During the time period studied, we observed a 41.3% shift from inpatient to outpatient hysterectomy (p<0.0001), an increase in robotic hysterectomy, and a decrease in abdominal hysterectomy. The robotic hysterectomy approach, more recent procedure (year), and mid-sized hospital were factors that enabled outpatient hysterectomies; while abdominal hysterectomy, older age, Medicare insurance, black ethnicity, higher number of comorbidities, and concomitant procedures were associated with an inpatient setting. The shift towards outpatient hysterectomy led to a $2500 savings per case during the study period, in parallel to the increased robotic hysterectomy rates (p<0.001). The post-discharge 30-day readmission and complications rate after outpatient hysterectomy remained stable at around 2%.

CONCLUSIONS

A significant shift from inpatient to outpatient setting was observed for hysterectomies performed for endometrial cancer over time. Minimally invasive surgery, particularly the robotic approach, facilitated this migration, preserving clinical outcomes and leading to reduction in costs.

Complications after scrotal surgery - still a major issue?

OBJECTIVE

Gold standard treatment of symptomatic hydrocele or spermatocele is surgery. Despite a minor procedure, complications such as bleeding and infections leading to reoperations may be devastating for the patients. In autumn 2018, an accumulation of complications was seen in our department. The aim of this study was to investigate the rate and grade of complications and to identify potential means to reduce these.

MATERIALS AND METHODS

Patient records of all patients undergoing surgical repair of hydrocele or spermatocele from December 2017 to November 2018 were examined. Results were audited to identify potential causes of complications. The focus was on the perioperative hemostasis and postoperative activity restrictions. The outcome was compared to a consecutive patient series operated the following year.

RESULTS

Sixty-five men were operated on during the first period. Twenty-two patients contacted the department postoperatively due to swelling or pain, 19 patients were examined at the hospital and six patients were re-operated 1-9 times. The following year, 69 patients were operated on. Of these, 16 patients contacted the department postoperatively (p = 0.17), 13 patients were examined at the hospital, and five patients were re-operated (p = 0.68). There was the same complication rate in patients operated by specialist urologists or supervised younger doctors. However, patients preoperatively examined and informed by a specialized urologist had significantly fewer complications compared to those informed by urological residents and interns (p = 0.012).

CONCLUSION

Despite the change in patient information and increased awareness of possible complications, a high proportion of patients still were in need of unplanned contact to the department and reoperation.

Partial nephrectomy should be classified as an inpatient procedure: Results from a statewide quality improvement collaborative

OBJECTIVES

To examine length of stay (LOS) and readmission rates for all minimally-invasive partial nephrectomy (MIPN) and MI radical nephrectomy (MIRN) performed for localized renal masses ≤7 cm in size (cT1RM) within 12 Michigan urology practices. Both RN and PN are commonly performed in treating cT1RM. Although technically more complex and associated with higher complication rates, Centers for Medicare & Medicaid Services considers MIPN an outpatient procedure and MIRN is inpatient.

METHODS

We collected data for renal surgeries for cT1RM at MUSIC-KIDNEY practices between May 2017-February 2020. Data abstractors recorded clinical, radiographic, pathologic, surgical, and short-term follow-up data into the registry for cT1RM patients.

RESULTS

Within MUSIC-KIDNEY, 807 patients underwent MI renal surgery at 12 practices. Median LOS for cT1RM patients after MIPN (n = 531, 66%) was 2 days and after MIRN (n = 276, 34%) was also 2 days. Among patients undergoing laparoscopic or robotic PN, 171 (32%), 230 (43%), and 130 (24%) stayed ≤1, 2, ≥3 days. Among patients undergoing laparoscopic or robotic RN, 81 (29%), 112 (41%), and 83 (30%) stayed ≤1, 2, ≥3 days. No significant difference was observed between MIPN and MIRN on LOS commensurate with outpatient surgery (≤1-day, OR = 0.97, P = 0.87).

CONCLUSIONS

Less than one-third of patients had a LOS ≤1-day and LOS was comparable for MIPN and MIRN. Centers for Medicare & Medicaid Services should be advised that MIPN is a more complex surgery than MIRN, most patients receiving a MIPN will require a ≥2-day hospital stay and it would be more appropriate to classify MIPN an inpatient procedure with MIRN.

Ambulatory Robotic-Assisted Partial Nephrectomy: Safety and Feasibility Study

OBJECTIVE

To evaluate the feasibility and safety of performing robotic-assisted laparoscopic partial nephrectomy (RAPN) as outpatient surgery in patients with renal masses.

MATERIALS AND METHODS

We analyzed RAPN performed by a single surgeon at an academic medical center from July 2018 to June 2019 and identified those individual patients who were discharged on the same day. These cases were then compared to a concurrent inpatient RAPN group. Relationships with outcome analyzed using Fisher's exact test and Student's t test.

RESULTS

Twenty-three of 84 RAPNs (27.4%) were performed as ambulatory. Mean age was 57.4 years. Average tumor size was 2.24 cm. The mean total operative time was 99.4 minutes. Average estimated blood loss was 51.0 mL. When compared to the cohort of patients who stayed overnight, on multivariate analysis, the tumor size (2.24 ± 0.71 vs 3.65 ± 1.55 cm, P <0.001), and operative time (99.5 ± 25.1 vs 131.2 ± 30.8 minutes, P <0.001) were less in ambulatory cases. No differences were seen in regards to Charlson comorbidity index, age, gender, body mass index, estimated blood loss, or surgical approach. Within 90 days of postoperative period, the readmission rate for the entire cohort was 0.

CONCLUSION

RAPN can be performed safely as ambulatory in select patients with comparable outcome without complication or hospital readmission.

Day-case laparoscopic nephrectomy: Feasibility and safety

Purpose:

The method of surgery and its recovery play an important part in a success of any surgery. Implementing a minimal invasive approach with enhanced recovery protocol permits Nephrectomy to be performed as a day-case (DC) procedure. Here we report our initial experience with laparoscopic nephrectomy (LN) as DC surgery with an aim to assess its feasibility and safety.

Patients and methods:

In this retrospective observational study, nine patients underwent DC LN performed by a single surgeon (NR). LN was performed in the standard way followed by enhanced recovery pathway of care for DC. We collected data regarding demographic information, medical co-morbidities, preoperative outcomes, complications and readmission rates. The data was analysed and evaluated.

Results:

There were four (44.4%) women and five (55.5%) men with a median age of 35 years (range 17–52 years). Eight (88.9%) patients had benign diseases associated with non-functioning kidneys and one (11.1%) patient had a renal tumour. All patients (100%) were successfully discharged the same day with no major complication (Clavien Dindo Grade > I). Readmission rates were 0%.

Conclusion:

In our small series, DC LN is feasible and safe with a belief that the results are easily reproducible. Increasing experience in laparoscopic surgery with implementation of enhanced recovery protocol may help to increase the success rate of LN as DC.

Robotic versus laparoscopic urological surgery: incidence of reoperation and complications

Objective: To report the introduction of minimum invasive surgery in Denmark with focus on the reoperation and complication rates. Materials and methods: Data were prospectively collected at the national UroLap database. The database was established in 2003 in Denmark to register all laparoscopic urological procedures as well as their peri- and post-operative outcomes. In the period from 2009-2014, 10,843 patients were registered with the database, of which 10,546 (97%) had a complete Clavien-Dindo score within the first 30 postoperative days. Results: The mean age of patients was 60.5 years (S.D. = 16.2), and 415 patients (4%) were under the age of 17 years. The male-to-female ratio was 4:1. At the end of 2010, 25% of surgeries used the robotic technique, but the frequency of robotic surgeries increased to 56% in 2014. No complications were reported in 74.6% of the urological procedures. The mortality rate was reported at only 0.27% of all patients. Patients who underwent a urological procedure performed by consultant urologists had a lower rate of complication compared to procedures performed by trainees (p = 0.03) but not staff doctors (p = 0.9). There were no significant differences in complication rates between staff doctors and trainee (p = 0.2). Conclusion: Robotic and laparoscopic urological procedures are associated with low serious complication rates. Postoperative complications were more common among surgeries performed by trainees. The robotic approach is associated with a shorter L.O.S. compared to the laparoscopic approach and linked to lower reoperation rates.

A Single Perioperative Injection of Dexamethasone Decreases Nausea, Vomiting, and Pain after Laparoscopic Donor Nephrectomy

Background. A single dose of perioperative dexamethasone (8–10 mg) reportedly decreases postoperative nausea, vomiting, and pain but has not been widely used in laparoscopic donor nephrectomy (LDN). Methods. We performed a retrospective cohort study of living donors who underwent LDN between 2013 and 2015. Donors who received a lower dose (4–6 mg)  (n = 70) or a higher dose (8–14 mg) of dexamethasone (n = 100) were compared with 111 donors who did not receive dexamethasone (control). Outcomes and incidence of postoperative nausea, vomiting, and pain within 24 h after LDN were compared before and after propensity-score matching. Results. The higher dose of dexamethasone reduced postoperative nausea and vomiting incidences by 28% (P = 0.010) compared to control, but the lower dose did not. Total opioid use was 29% lower in donors who received the higher dose than in control (P = 0.004). The higher dose was identified as an independent factor for preventing postoperative nausea and vomiting. Postoperative complication rates and hospital stays did not differ between the groups. After propensity-score matching, the results were the same as for the unmatched analysis. Conclusion. A single perioperative injection of 8–14 mg dexamethasone decreases antiemetic and narcotic requirements in the first 24 h, with no increase in surgical complications.