Examining the Relationship Between Operative Time and Hospitalization Time in Minimally Invasive and Open Urologic Procedures

Patient characteristics predicting prolonged length of hospital stay following robotic-assisted radical prostatectomy

Objective:

The objective of this study is to determine the preoperative patient characteristics predicting prolonged length of hospital stay (pLOS) following robotic-assisted radical prostatectomy (RARP).

Methods:

The National Surgical Quality Improvement Program (NSQIP) database was used to select patients who underwent RARP without other concomitant surgeries between 2008 and 2016. Patients’ demographics, comorbidities, and laboratory markers were collected to evaluate their role in predicting pLOS. The pLOS was defined as length of stay (LOS) >2 days. A multinomial logistic regression was constructed adjusting for postoperative surgical complications to assess for the predictors of pLOS.

Results:

We obtained data for 31,253 patients of which 20,774 (66.5%) patients stayed ⩽1 day, 6993 (22.4%) patients stayed for 2 days, and 3486 (11.2%) patients stayed for >2 days. Demographic variables – including body mass index (BMI) <18.5: odds ratio (OR) = 2.8, 95% confidence interval (CI) = [1.7–4.8]; smoking: OR = 1.2, 95% CI = [1.1–1.4]; and dependent functional status: OR = 3.1, 95% CI = [1.6–6.0] – were predictors of pLOS. Comorbidities – such as heart failure: OR = 4.6, 95% CI = [2.0–10.8]; being dialysis dependent: OR = 2.7, 95% CI = [1.4–5.0]; and predisposition to bleeding: OR = 2.0, 95% CI =  [1.5–2.7] – were the strongest predictors of extended hospitalization. In addition, pLOS was more likely to be associated with postoperative bleeding, renal, or pulmonary complications.

Conclusion:

Preoperative patient characteristics and comorbidities can predict pLOS. These findings can be used preoperatively for risk assessment and patient counseling.

Could the high-power laser increase the efficacy of stone lithotripsy during retrograde intrarenal surgery?

OBJECTIVE

To compare a high-power setting holmium yttrium aluminum garnet (Ho:YAG) laser lithotripsy to the established low-power setting approach during Retrograde Intrarenal Surgery (RIRS).

MATERIAL AND METHODS

Our study analyzed the data of consecutive patients managed with RIRS. The patients were divided into 2 groups according to the employed laser settings of power, energy and frequency; dusting (20W=0.5Jx40Hz) (Group1) and stone "self-popping" (60W=1.5-2Jx30-40Hz) (Group 2). Perioperative outcomes including operative time (OT) and stone disintegration time (SDT) were compared between groups. Stone-free rate (SFR) was evaluated 1 month after the surgery.

RESULTS

Overall, 174 patients with 179 renal units were included. The dusting mode was utilized in 98 patients (100 renal units), whereas 76 patients (79 renal units) underwent the stone "self-popping" technique. The SFR was 82.1% for both groups. The OT and SDT were 60.1 ± 18.6min and 32.6 ± 9.4min respectively for Group 1, and 44.9 ± 15.5min and 16.5 ± 4.7min respectively for Group 2. According to the final analysis, laser lithotripsy using stone the "self-popping" technique was significantly faster compared to the dusting technique with a coefficient value of 14.12min (CI = 8.8 - 19.44) and 15.84min (CI = 13.44 - 18.2) for OT and SDT, respectively.

CONCLUSION

The stone "self-popping" technique with the power at 60W, frequency at 30-40Hz and energy at 1.5-2.0J is a safe and effective modality for the active treatment of renal stones. In comparison to the dusting mode, it resulted in significantly faster procedures (14.12min) possessing similar SFR.

Identifying Preoperative Predictors of Operative Time and Their Impact on Outcomes in Robot-Assisted Partial Nephrectomy

Objective: To identify preoperative characteristics in patients with renal masses that influence operative time during robot-assisted partial nephrectomy (RAPN) and evaluate the relationship between operative time and length of stay (LOS), complication rates, and overall outcome. Materials and Methods: We queried our institutional database to identify a cohort of patients who underwent RAPN by two experienced robotic surgeons between 2012 and 2019. A multivariable regression model was developed to analyze operative time, LOS, and any grade complication within 30 days postoperatively using the bootstrap resampling technique. Results: A total of 392 patients were included. On multivariable analyses, prior abdominal surgery (p = 0.001) was associated with 22 minutes of increase in operating room time, as well as adhesive perirenal fat (22 minutes, p = 0.001). For each one unit increase in nephrometry score, there was a 4-minute increase in operating room time (p = 0.028), and for each one-cm increase in tumor size, there was an associated 12-minute increase in operating room time (p < 0.001). For each 1 year increase in age, there was an associated 0.024-day increase in LOS [odds ratio (OR) (0.013-0.035)]; in addition, for every one-cm increase in tumor size there was a 0.18-day associated increase in LOS [OR (0.070-0.28)]. Each 1-hour increase in operating room time was associated with a 0.25-day increased LOS [OR (0.092-0.41)]. Only tumor size was found to be associated with any grade complication. Conclusions: Patients with a history of abdominal surgery, larger complex tumors, and significant Gerota's fat undergoing robotic partial nephrectomy should anticipate longer operative times. Older patients with larger tumors and longer operative times can anticipate a longer LOS. Tumor size appears to be the common determinant of all three outcomes: operative time, LOS, and any grade Clavien complication.

Single overnight stay after robot-assisted partial nephrectomy: a bi-center experience

BACKGROUND

Despite hospital length of stay (LOS) being shorter for robot-assisted partial nephrectomy (RAPN) compared to its open counterpart, several series in the literature report on average a LOS of 2-3 days or more. We aimed to assess factors predicting a prolonged length of stay (beyond a single overnight stay) in patients undergoing RAPN.

METHODS

Patients who underwent RAPN between 2010 and 2019 at two USA Centers were included and divided into two groups according to LOS: the study group included all patients who were discharged on POD1, whereas the control group included patients with LOS ≥2 days. Demographics, surgical and perioperative outcomes were compared between the groups. Multivariable logistic regression analyses were used to identify independent predictors of LOS ≥2.

RESULTS

Overall, 173 (60.5%) patients discharged on POD1, and 113 (39.5%) discharged on POD≥2. Patients in the study group presented a lower mean BMI (29 vs. 32, P=0.02). Retroperitoneal approach was performed in 13.3% patients with shorter LOS (P<0.001). There was a statistically significant difference in median OT (144 vs. 168 min, P=0.005) and WIT (19 vs. 23 min, P=0.001). We observed six postoperative complications (3.6%) in patients discharged on POD1 and 35 (30.5%) in control group (P<0.001). Major complications (Clavien-Dindo grade ≥III) were observed in three of POD1 patients (1.8 vs. 6.1%, P<0.001). There was no difference in hospital readmission rate. On logistic regression analysis, independent predictors of prolonged LOS were OT (OR=1.01, 95% CI: 1.0-1.2, P=0.001), and occurrence of a postoperative complication (OR=2.2, 95% CI: 2.0-2.5, P<0.001).

CONCLUSIONS

Our findings confirm that a single overnight stay after RAPN is feasible and safe. In our experience, and within the limitations of the present analysis, prolonged operative time and occurrence of immediate postoperative complications translate into higher risk of prolonged hospital stay. Besides adopting a minimally invasive approach, surgeons should also implement perioperative care pathways facilitating early discharge without increasing the risk of readmission.

Xanthogranulomatous pyelonephritis: a comparison of open and minimally-invasive surgical approaches

To compare perioperative outcomes between patients undergoing minimally-invasive (MIS) and open surgical approaches for the treatment of Xanthogranulomatous Pyelonephritis (XGP). Between 2007 and 2017 we retrospectively identified 40 patients undergoing nephrectomy at our institution for pathologically confirmed XGP. Patients whose operations were ultimately completed with open technique were analyzed with the open cohort, whereas patients whose operations were completed in entirety using any laparoscopic approach were analyzed with the MIS group. Twenty-three patients were analyzed in the open cohort, compared to seventeen in the MIS group. Three patients in the open cohort were converted intraoperatively from MIS to open approach. Compared to the open group, the MIS group less often had an abscess on preoperative CT (11.8% vs 54.5%; p = 0.006). The MIS group also had lower intraoperative blood loss (100 vs 400 mL; p < 0.001), lower rate of blood transfusion (0% vs 45.5%; p = 0.002), lower postoperative intensive care admission (0% vs 34.8%; p = 0.013), and shorter hospital stay (4 vs 7 days; p = 0.013). However, there was no significant difference in high-grade complications between these groups (5.9% vs 34.8%; p = 0.054). Preoperative CT scan may be an important factor when considering operative approach for treatment of XGP. Patients who are able to undergo MIS approach have less blood loss, shorter hospitalization, and are less likely to require intensive care admission, which may be related to the disease process, the surgical technique, or both.

Pre- and intra-operative predictors of postoperative hospital length of stay in patients undergoing radical prostatectomy for prostate cancer in China: a retrospective observational study

Background

Hospital length of stay (LOS) has recently been receiving increasing attention as a marker of medical resource consumption. Identifying predictors of longer LOS can better equip doctors to counsel patients and facilitate more efficient patient flow and utilization of medical resources. The objective of this study was to identify pre- and intra-operative risk factors for postoperative hospital LOS in patients who had undergone radical prostatectomy in China.

Methods

We retrospectively analyzed data of 793 eligible patients with prostate cancer who had undergone radical prostatectomy in our institution between January 2011 and March 2016. Relevant preoperative variables, including patient characteristics, medical comorbidities, prostate cancer disease-specific variables, urinary tract symptoms, preoperative laboratory values, and intraoperative variables including operation type, operation duration, and blood loss, were analyzed. The outcome was postoperative length of stay which was calculated as the time from the date of operation to the date of discharge. Multiple linear regression analysis was used to identify predictors of this outcome.

Results

The mean postoperative LOS was 11.7 days (±4.6 days) and the median 10 days (range, 5–46 days). According to univariate and multivariate analysis, operation type (open or laparoscopic), blood loss, Gleason score (≥8) and preoperative laboratory values of white blood count (WBC) were found to be the main explanatory predictors of postoperative LOS of patients with prostate cancer in our institution. Additionally, open surgery was the strongest significant predictor of longer LOS according to the standardized coefficients in this model.

Conclusions

Our findings indicate that significant predictors of longer postoperative LOS in patients who have undergone radical prostatectomy in China include both preoperative variables of Gleason score, WBC and intraoperative variables of operation type (open or laparoscopic), blood loss. To shorten hospital LOS in patients with prostate cancer and optimize utilization of Chinese medical resources, efforts should be made to improve the intraoperative process and reduce the prevalence of preoperative risk factors.