A Single Overnight Stay After Robotic Partial Nephrectomy Does Not Increase Complications

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy

Objective

We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre- and peri-operative variables associated with length of stay (LOS) greater than 3 days and readmission within 30 days.

Methods

Records from 2008 to 2018 for "laparoscopy, surgical; partial nephrectomy" for prolonged LOS and readmission cohorts were compiled. Univariate analysis with Chi-square, t-tests, and multivariable logistic regression analysis with odds ratios (ORs), p-values, and 95% confidence intervals assessed statistical associations.

Results

Totally, 20 306 records for LOS greater than 3 days and 15 854 for readmission within 30 days were available. Univariate and multivariable analysis exhibited similar results. For LOS greater than 3 days, undergoing non-elective surgery (OR=5.247), transfusion of greater than four units within 72 h prior to surgery (OR=5.072), pre-operative renal failure or dialysis (OR=2.941), and poor pre-operative functional status (OR=2.540) exhibited the strongest statistically significant associations. For hospital readmission within 30 days, loss in body weight greater than 10% in 6 months prior to surgery (OR=2.227) and bleeding disorders (OR=2.081) exhibited strongest statistically significant associations.

Conclusion

Multiple pre- and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data. Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection, optimization strategies, and patient education.

Single-port robotic partial nephrectomy: impact on perioperative outcomes and hospital stay

Single-port (SP) robotic surgery is a novel technology and is at the beginning of its adoption curve in urology. The goal of this narrative review is to provide an overview of SP-robotic partial nephrectomy (PN) 4 years after the introduction of the da Vinci SP dedicated platform, focusing on perioperative outcomes, length of stay, and surgical technique. A nonsystematic review of the literature was conducted. The research included the most updated articles that referred to SP robotic PN. Since its commercial release in 2018, several institutions have reproduced robotic PN by using the SP platform, both via a transperitoneal and a retroperitoneal approach. The published SP-robotic PN series are generally based on preliminary experiences by surgeons who had previous experience with conventional multi-arms robotic platforms. The reported outcomes are encouraging. Overall, three studies reported that SP-robotic PN cases had nonsignificantly different operative time, estimated blood loss, overall complications rate, and length of stay compared to the conventional 'multi-arms' robotic PN. However, in all these series, renal masses treated by SP had overall lower complexity. Moreover, two studies underlined decreased postoperative pain as a major pro of adopting the SP system. This should reduce/avoid the need for opioids after surgery. No study compared SP-robotic versus multi-arms robotic PN in cost-effectiveness. Published experience with SP-robotic PN has reported the feasibility and safety of the approach. Preliminary results are encouraging and at least noninferior with respect to those from the multi-arms series. Prospective comparative studies with long-term oncologic and functional results are awaited to draw more definitive conclusions and better establish the more appropriate indications of SP robotics in the field of PN.

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.

Narcotic Avoidance After Robotic Radical Cystectomy Allows Routine of Only Two-Day Hospital Stay

OBJECTIVE

To evaluate the outcomes of a narcotic-sparing clinical pathway after robotic-assisted radical cystectomy (RARC) with ileal conduit targeting discharge on postoperative day #2 and report postoperative narcotic consumption, pain scores, and the resulting length of stay (LOS).

METHODS

We reviewed a single-surgeon series of consecutive RARCs between August 2015-September 2020. Acetaminophen and ketorolac were given with thorough patient education reserving oral narcotics for breakthrough pain. Intravenous narcotics were intentionally excluded from postoperative orders. Alvimopan was given once it became available. Subcutaneous ropivacaine pain pumps were removed before discharge. Discharge criteria included diet, oral analgesia, ambulation, and bowel function. Narcotic use and pain scores were evaluated to deternine the success of the applied narcotic-avoidance strategy.

RESULTS

None of the 54 patients required intravenous narcotics postoperatively, and 19 patients (35%) never required even oral narcotics. Mean pain scores were higher in patients who required oral narcotics (4.3/11 vs 3.0/11, p=0.001, respectively). Among 35 patients who received narcotics, mean tablets taken were 4.3/day (range, 1-13) with 68% using 8 or less tablets during their entire LOS. Mean LOS was 2.1d (range 1-4). Five patients (9%) were discharged on POD#1, 37/54 (68.5%) on POD #2, 10/54 (18.5%) on POD#3 and 2/54 (4%) on POD #4. Eight patients (15%) were readmitted within 90 days.

CONCLUSION

Minimizing narcotics after RARC with conduit allowed for a 2-day LOS in the majority of patients and the shortest ever reported mean LOS after cystectomy, essentially halving hospitalization time. Patient education is critical to minimizing narcotic usage.

Application of Contrast-Enhanced Ultrasonography (CEUS) in the Assessment of Kidney Wound Recovery After Nephron-Sparing Surgery

Purpose

To investigate feasibility, repeatability and usefulness of contrast-enhanced ultrasonography (CEUS) in the assessment of kidney wound recovery after laparoscopic nephron-sparing surgery (LNSS) or robot-assisted nephron-sparing surgery (RANSS) and preliminarily research the clinical factors associated with the length of extravasation (LOE).

Patients and Methods

From April 2019 to January 2020, 130 patients that underwent LNSS or RANSS in our hospital were included, and 90 patients (90/130) received CEUS examinations each one day from the postoperative day 1. The discovery of the cessation of contrast medium extravasation from the renal wound was the primary endpoint named "ultrasonic healing", and LOE ranged from the day of surgery to "ultrasonic healing". Patient, tumor, perioperative factors and LOE were collected. Univariate analysis and multivariate linear regression analysis were applied for the determination of factors associated with LOE.

Results

The average postoperative LOE was 1.76 days (standard deviation, 1.115; 95% confidence interval: 1.52-1.99). Ultrasonic healing within three days was observed in 95.6% patients (86/90). Univariable and multivariable analyses showed that R and A components in R.E.N.A.L. nephrometry score were associated with LOE. Anterior location and R component score of 2 (tumor size>4cm) were related to longer LOE than posterior location and R score of 1 (tumor size<4cm). The incidence of complications in patients with LOE over one day was higher than those with LOE of one day.

Conclusion

CEUS was feasible, repeatable and useful in the assessment of kidney wound recovery. Tumor size and location were related to LOE after minimally invasive nephron-sparing surgery (MINSS). Length of stay after MINSS within three days might be relatively safe.

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.

Impact of the COVID-19 Crisis on Same-day Discharge After Robotic Urologic Surgery

OBJECTIVE

To assess the impact of the COVID-19 pandemic on the rate of same-day discharge (SDD) after robotic surgery METHODS: We reviewed our robotic surgeries during COVID-19 restrictions on surgery in Ohio between March 17 and June 5, 2020 and compared them with robotic procedures before COVID-19 and after restrictions were lifted. We followed our formerly described protocol in use since 2016 offering the option of SDD to all robotic urologic surgery patients, regardless of procedure type or patient-specific factors.

RESULTS

During COVID-19 restrictions (COV), 89 robotic surgeries were performed and compared with 1667 of the same procedures performed previously (pre-COV) and 42 during the following month (post-COV). Among COV patients 98% (87/89 patients) opted for same-day discharge after surgery versus 52% in the historical pre-COV group (P < .00001). Post-COV, the higher rate of SDD was maintained at 98% (41/42 patients). There were no differences in 30-day complications or readmissions between SDD and overnight patients with only 2 COV (2%) and no post-COV 30-day readmissions.

CONCLUSION

SDD after robotic surgery was safely applied during the COVID-19 crisis without increasing complications or readmissions. SDD may allow continuation of robotic surgery despite limited hospital beds and when minimizing hospital stay is important to protect postoperative patients from infection. Our experience suggests that patient attitude is a major factor in SDD after robotic surgery since the proportion of patients opting for SDD was much higher during COV and continued post-COV. Consideration of SDD long-term may be warranted for cost savings even in the absence of a crisis.

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.