Prolonged Length of Stay After Robotic Prostatectomy: Causes and Risk Factors

Feasibility, safety and effectiveness of robot-assisted radical prostatectomy with a new robotic surgical system: a prospective, controlled, randomized clinical trial

BACKGROUND

Robot-assisted radical prostatectomy (RARP) gains increasing popularity in the surgical management of prostate cancer (PCa) but is challenged by its prohibitive expense. A domestic robotic system has been developed to address this issue, but data comparing the self-developed robot with the widely used robot is lacking. We performed a randomized clinical trial to compare KD-SR-01® and DaVinci® robots in terms of perioperative, short-term oncological and functional outcomes in RARP.

MATERIALS AND METHODS

We prospectively enrolled patients with clinically localized PCa. Patients were randomized to undergo either KD-SR-01®-RARP (K-RARP) or DaVinci®-RARP (D-RARP) by the same surgical team. The baseline, perioperative, short-term oncologic and urinary functional data were collected and compared.

RESULTS

We enrolled 39 patients, including 20 patients undergoing K-RARP and 19 undergoing D-RARP. Demographic and tumor characteristics were comparable between groups. All surgeries were performed successfully with no conversion to open. The operative time was similar (P = 0.095) and K-RARP offered less volume of intraoperative bleeding (P < 0.001). Four patients in the K-RARP group and three in the D-RARP group developed postoperative complications (P = 0.732). Patients undergoing K-RARP had less volume of drainage (P = 0.022). Positive surgical margins were observed in three patients undergoing K-RARP and five undergoing D-RARP (P = 0.451). During the follow up, one patient receiving K-RARP group and two receiving D-RARP group had measurable prostate specific antigen (P = 0.605). Urine leakage, urinary control and pad usage were comparable between groups at six weeks post-surgery.

CONCLUSIONS

The two surgical robots yielded similar results in feasibility, safety and short-term oncologic and functional efficacy for RARP.

TRIAL REGISTRATION

The trial has been registered at www.chictr.org.cn with a registration number of ChiCTR2200057000 on 25th February 2022.

Evaluation of neuraxial analgesia on outcomes for patients undergoing robot assisted abdominal surgery

STUDY OBJECTIVE

Following robot assisted abdominal surgery, the pain can be moderate in severity. Neuraxial analgesia may decrease the activity of the detrusor muscle, reduce the incidence of bladder spasm and provide effective somatic and visceral analgesia. In this systematic review, we assessed the role of neuraxial analgesia in robot assisted abdominal surgery.

DESIGN

Systematic review.

SETTINGS

Robot assisted abdominal surgery.

PATIENTS

Adults.

INTERVENTIONS

Subsequent to a search of the electronic databases, observational studies and randomized controlled trials that assessed the effect of neuraxial analgesia instituted at induction of anesthesia or intraoperatively in adult and robot assisted abdominal surgery were considered for inclusion. The outcomes of observational studies as well as randomized controlled trials which were not subjected to meta-analysis were presented in descriptive terms. Meta-analysis was conducted if an outcome of interest was reported by two or more randomized controlled trials.

MAIN RESULTS

We included 19 and 11 studies that investigated spinal and epidural analgesia in adults, respectively. The coprimary outcomes were the pain score at rest at 24 h and the cumulative intravenous morphine consumption at 24 h. Spinal analgesia with long acting neuraxial opioid did not decrease the pain score at rest at 24 h although it reduced the cumulative intravenous morphine consumption at 24 h by a mean difference (95%CI) of 14.88 mg (-22.13--7.63; p < 0.0001, I2 = 50%) with a low and moderate quality of evidence, respectively, on meta-analysis of randomized controlled trials. Spinal analgesia with long acting neuraxial opioid had a beneficial effect on analgesic indices till the second postoperative day and a positive influence on opioid consumption up to and including the 72 h time point. The majority of studies demonstrated the use of spinal analgesia with long acting neuraxial opioid to lead to no difference in the incidence of postoperative nausea and vomiting, and the occurrence of pruritus was found to be increased with spinal analgesia with long acting neuraxial opioid in recovery but not at later time points. No difference was revealed in the incidence of urinary retention. The evidence in regard to the quality of recovery-15 score at 24 h and hospital length of stay was not fully consistent, although most studies indicated no difference between spinal analgesia and control for these outcomes. Epidural analgesia in robot assisted abdominal surgery was shown to decrease the pain on movement at 12 h but it had not been studied with respect to its influence on the pain score at rest at 24 h or the cumulative intravenous morphine consumption at 24 h. It did not reduce the pain on movement at later time points and the evidence related to the hospital length of stay was inconsistent.

CONCLUSIONS

Spinal analgesia with long acting neuraxial opioid had a favourable effect on analgesic indices and opioid consumption, and is recommended by the authors, but the evidence for spinal analgesia with short acting neuraxial opioid and epidural analgesia was limited.

Cardiovascular Disease in Total Knee Arthroplasty: An Analysis of Hospital Outcomes, Complications, and Mortality

Background

Cardiovascular comorbidities have been identified as a significant risk factor for adverse outcomes following surgery. The purpose of this study was to investigate its prevalence and impact on postoperative outcomes, hospital metrics, and mortality in patients undergoing total knee arthroplasty (TKA). Our hypothesis was that patients with cardiovascular comorbidities would have worse outcomes, greater postoperative complication rates, and increased mortality compared to patients without cardiovascular disease.

Methods

In this retrospective study, data from the National Inpatient Sample database from 2011 to 2020 were queried for patients who underwent TKA with preexisting cardiac comorbidities, including congestive heart failure (CHF), coronary artery disease (CAD), valvular dysfunction, and arrhythmia. Multivariate logistic regression analyses compared hospital metrics (length of stay, costs, and adverse discharge disposition), postoperative complications, and mortality rates while adjusting for demographic and clinical variables. All statistical analyses were performed using R studio 4.2.2 and Stata MP 17 and 18 with Python package.

Results

A total of 385,585 patients were identified. Those with preexisting CHF, CAD, valvular dysfunction, or arrhythmias were found to be older and at higher risk of adverse outcomes, including prolonged length of stay, increased hospital charges, and increased mortality (p < 0.001). Additionally, all preexisting cardiac diagnoses led to an increased risk of postoperative myocardial infarction, acute kidney injury (AKI), and need for transfusion (p < 0.001). The presence of valvular dysfunction, arrhythmia, or CHF was associated with an increased risk of thromboembolic events (p < 0.001). The presence of CAD and valvular dysfunction was associated with an increased risk of urologic infection (p < 0.001).

Conclusions

This study demonstrated that CHF, CAD, valvular dysfunction, and arrhythmia are prevalent among TKA patients and associated with worse hospital metrics, higher risk of perioperative complications, and increased mortality. As our use of TKA rises, a lower threshold for preoperative cardiology referral in older individuals and early preoperative counseling/intervention in those with known cardiac disease may be necessary to reduce adverse outcomes.

Epidemiology of and Risk Factors in Postoperative Complications from Robotically Assisted Laparoscopic Radical Prostatectomy in Contemporary National Surgical Quality Improvement Program Data

Introduction: For localized clinically significant prostate cancer (csPCa), robotically assisted laparoscopic radical prostatectomy (RALP) is the gold standard surgical treatment. Despite low overall complication rate, continued quality assurance (QA) efforts to minimize complications of RALP are important, particularly given movement toward same-day discharge. In 2019, National Surgical Quality Improvement Program (NSQIP) began collecting RALP-specific data. In this study, we assessed pre- and perioperative factors associated with postoperative complications for RALP to further QA efforts. Materials and Methods: Surgical records of csPCa patients who underwent RALP were retrieved from the 2019 to 2021 NSQIP database, including new RALP-specific data. Multivariate logistic regression evaluated the association between risk factors and outcomes specific to RALP and pelvic lymph node dissection (PLND). Input variables included American Society of Anesthesiologists (ASA) class, age, operative time, and body mass index (BMI). Variables from the extended dataset with PLND information included number of nodes evaluated, perioperative antibiotics, postoperative venous thromboembolism (VTE) prophylaxis, history of prior pelvic surgery, and history of prior radiotherapy (RT). Outcomes of interest were any surgical complication, infection, pulmonary embolism, deep venous thrombosis, acute kidney injury, pneumonia, lymphocele, and urinary/anastomotic leak (UAL). Results: A total of 11,811 patients were included with 6.1% experiencing any complication. Prior RT, prior pelvic surgery, older age, higher BMI, lack of perioperative antibiotic therapy, longer operative time, PLND, and number of lymph nodes dissected were associated with higher risk of postoperative complications. Regarding procedure-specific complications, there were increased odds of UAL with prior RT, prior pelvic surgery, longer operative time, and higher BMI. Odds of developing lymphocele increased with prior pelvic surgery, performance of PLND, and increased number of nodes evaluated. Conclusion: In contemporary NSQIP data, RALP is associated with low complication rates; however, these rates have increased compared with historical studies. Attention to and counseling regarding risk factors for peri- and postoperative complications are important to set expectations and minimize risk of unplanned return to a health care setting after discharge.

Developing and validating utility parameters to establish patient-reported outcome-based perioperative symptom management in patients undergoing prostatectomy: a multicentre, prospective, observational cohort study protocol

INTRODUCTION

Symptom monitoring and alerting based on patient-reported outcomes have proven valuable in a postoperative setting. However, the parameters of the implemented patient-centred symptom management system for patients with prostate cancer (PC) remain unclear. This study aims to develop a perioperative symptom scale (PSS) to monitor symptoms, determine the appropriate timing for symptom assessment and establish intervention criteria for physicians.

METHODS AND ANALYSIS

We will prospectively recruit 387 patients undergoing PC surgery in 3 hospitals. The Chinese version of the MD Anderson Symptom Inventory (MDASI) will be used for longitudinal symptom data collection, presurgery and 1, 2, 3, 5, 7, 14, 21, 28, 42 and 90 days post surgery. A PSS will be generated when symptoms change significantly over time. A linear mixed model will be used to determine appropriate follow-up time points. The functional status determined by MDASI interference can then be used to establish alarm thresholds.

ETHICS AND DISSEMINATION

This study was approved by the Lishui Municipal Central Hospital Ethics Committee on 13 April 2022 (No. LSMCHEC-2022-54) and the Ethics Committee of Huzhou Central Hospital on 5 July 2023 (No. HZCHEC-202306017-01), the Ethics Committee of the First Affiliated Hospital of Huzhou Normal College on 20 June 2023 (No. HZYYEC-2023KYLL055). The latest protocol used in this study was V.2.0, dated on 25 February 2023. Before publication in a peer-reviewed journal, our findings will be presented and discussed at relevant medical conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2200059110.

Effect of Early Postoperative Rehabilitation on Length of Hospital Stay after Robot-assisted Radical Prostatectomy

Objectives

: This study assessed how early postoperative rehabilitation interventions affected the duration of hospital stay in patients with prostate cancer who had radical prostatectomy with robotic assistance.

Methods

: From the Japanese Diagnosis Procedure Combination database, we extracted case data for patients discharged between April 2014 and March 2020. Patients were recognized by code C61 from the International Classification of Diseases, 10th Edition. We ran a multilevel linear regression analysis to investigate the impact of early rehabilitation on the duration of hospital stay.

Results

: There were 2151 participants in the trial. In patients with prostate cancer who had resection utilizing robotic-assisted devices, early rehabilitation was related to a substantial decrease in duration of hospital stay (coefficient, -0.86; 95% CI, -1.64 to -0.07; P=0.032).

Conclusions

: Early postoperative rehabilitation may contribute to shorter hospital stays in patients with prostate cancer at high risk of both postoperative complications and a decline in their ability to perform activities of daily living.

How May Longer Console Times Influence Outcomes after Robot-Assisted Radical Prostatectomy (RARP)?

Longer operating time in radical prostatectomy may increase the risk of perioperative complications. Various factors such as cancer extent, the procedure's level of difficulty, habitus and previous surgeries may lengthen robot-assisted radical prostatectomy (RARP) and therefore compromise outcomes.

OBJECTIVE

this study investigates the influence of operating time on outcomes after RARP in real life settings in a monocentric single surgeon study.

METHODS

a total of 500 sequential patients who were operated on between April 2019 and August 2022 were involved. Men were allocated to three groups short (n = 157; 31.4%), under or equal to 120 min; average (n = 255; 51%), between 121 and 180 min; long (n = 88; 17.6%), above 180 min console time. Demographic, baseline and perioperative data were analyzed and compared between groups. Univariate logistic regression was completed to investigate the association between console time and outcomes and to predict factors which may prolong surgery.

RESULTS

hospital stay and catheter days were significantly longer in group 3 with medians of 6 and 7 days (p < 0.001 and <0.001, respectively). Those findings were confirmed in univariate analysis, with p = 0.012 for catheter days and p < 0.001 for hospital stay. Moreover, major complications were higher in patients with longer procedures, at p = 0.008. Prostate volume was the only predictor of a prolonged console time (p = 0.005).

CONCLUSION

RARP is a safe procedure and most patients will be discharged uneventfully. Yet, a longer console time is associated with a longer hospital stay, longer catheter days and major complications. Caution has to be taken in the large prostate to avoid longer procedures, which may prevent postoperative adverse events.

Severe systemic disease of the American Society of Anesthesiologists' (ASA) physical status system classification associated with delayed length of hospital stay in 1329 consecutive patients treated with radical prostatectomy for clinical prostate cancer

BACKGROUND

The investigate the associations of the ASA physical status system with clinical, pathological, and perioperative features of prostate cancer (PCa) patients treated with radical prostatectomy (RP) that eventually associated with pelvic lymph node dissection (PLND).

METHODS

We performed a retrospective analysis of prospective collected data from January 2013 to October 2020, including1329 patients. The ASA system was preoperatively assessed for each patient. Evaluated clinical factors were grouped as preoperative, perioperative, and pathological and were statistically associated with the ASA system. Continuous variables were represented as medians with relative interquartile ranges (IQR) and categorical factors were assessed as frequencies (percentages). Associations and risk of each ASA Class with population features were assessed by the multinomial logistic regression model (univariate and multivariate analysis). All tests were two-sided with P<0.05 considered to indicate statistical significance.

RESULTS

Postoperative complications at discharge occurred in 27.2%. The distribution of the ASA physical status system was as follows: ASA I 108 patients (8.1%), ASA II 1081 subjects (81.3%) and ASA III 140 cases (10.5%). Median length of hospital state (LOHS) was the same for ASA groups I and II (4 days), but longer (5 days) for the ASA group III. On MVA, the risk of delayed hospital stay was associated only with ASA III patients and was independent from age and BMI. Clavien-Dindo complications greater than 2 did not show any independent association with the ASA system.

CONCLUSIONS

The ASA preoperative physical status system predicted the likelihood of longer LOHS.

Modified apical dissection improves early continence in robot-assisted laparoscopic radical prostatectomy: Comparative study between modified apical dissection and anterior suspension stitch

PURPOSE

Recently, the modified apical dissection (MAD) technique in robot-assisted laparoscopic radical prostatectomy (RARP) has shown excellent functional outcomes but has never been rigorously validated at various institutions. This study aimed to evaluate the effect of MAD on early continence and potency compared with the anterior suspension stitch (SS) technique.

MATERIALS AND METHODS

A total of 100 patients who underwent RARP with SS and 100 who underwent RARP with MAD by a single surgeon were propensity score matched and retrospectively compared for continence and potency recovery at 1 week and 1, 3, 6, 9, and 12 months.

RESULTS

Continence was reached in 20.6%, 33.3%, 67.2%, 74.1%, 81.1%, and 83.0% of patients in the SS group, compared with 49.2%, 73.3%, 86.8%, 96.6%, 100.0%, and 100.0% in the MAD group at postoperative 1 week and 1, 3, 6, 9, and 12 months, respectively. In the SS group, potency rates were 0.0%, 20.0%, 50.0%, 66.7%, 75.0%, and 83.3%; in the MAD group, the rates were 50.0%, 90.0%, 88.9%, 100.0%, 100.0%, and 100.0%. Recovery of continence was higher in the MAD group within the first 6 months (p=0.005, <0.010, 0.041, 0.016 at 1 week, 1, 3, and 6 months). There were no significant differences in potency recovery rates between the two groups (all p≥0.05).

CONCLUSIONS

The MAD technique results in earlier recovery of continence compared with the SS technique.

Long-term comparative outcome analysis of a robot-assisted laparoscopic prostatectomy with retropubic radical prostatectomy by a single surgeon

We aimed to report a comprehensive outcome analysis of robot-assisted laparoscopic prostatectomies (RALP) performed by a single surgeon and compared it to retropubic radical prostatectomies (RRP) done by the same surgeon in a high-volume center. Preoperative, perioperative, and postoperative data were collected prospectively and compared with retrospective retropubic radical prostatectomy data. Perioperative, oncological data, and functional results in the first year were compared between the two groups. There were 547 RARPs between 4th August 2011 and 31st December 2018, and 428 RRPs between 1st January 1996 and 31st December 2009 which were included in this review. While the operation time was in favour of the open group (196 vs 160 min, p < 0.01), the estimated blood loss (188 vs 316 ml, p < 0.01), blood transfusion rate (3% vs 7%, p = 0.021), hospital stay (4 days vs 7 days), and mean catheter duration (12 vs 15 days) were in favour of the robotic group. Majority of the complications belonged to Clavien-Dindo group II in both groups and the rates were not significantly different (p = 0.33). The 12-month continence rate was in favour of the RALP group (98.3% vs 99.2%, p < 0.01). Overall survival of the RALP cohort at 24 months was 99.8%, 60 months 96.1%, 84 months 87.3%, 96 months 81.3%), and 108 months was 79.5%. Overall survival at 24 months was 99.8%, 60 months 96.1%, 84 months 87.3%, 96 months 81.3%, and 108 months 79.5%. RALP is a safe, minimally invasive, technically feasible procedure with comparable functional and oncological outcomes. Our study showed superior perioperative and continence outcomes in RALP. However, despite its growing popularity, RRP still remains the gold standard in India due to its affordability and accessibility.

A Retrospective Comparative Analysis of Perioperative Complications in Navigated versus Conventional Thoracolumbar Fusion in the Setting of Adult Spinal Deformity

OBJECTIVE

Stereotactic intraoperative computer-assisted navigation has been shown to improve pedicle screw accuracy in spinal fusion surgery, but evidence of impact of navigation on clinical outcomes is lacking. The aim of this study is to compare rates of perioperative complications between navigated and nonnavigated procedures for deformity correction.

METHODS

An administrative database was queried for adult patients undergoing thoracolumbar fusion procedures for deformity. Nonelective cases and those involving malignancy, infection, or trauma were excluded. Individuals were divided into 2 cohorts based on the use of stereotactic intraoperative navigation and paired 1:1 for comparison based on a propensity score matching algorithm. Rates of unplanned reoperation and other perioperative complications were compared between matched groups. A multivariable Cox regression model was constructed to identify the impact of navigation on specific subgroups.

RESULTS

A total of 6150 patients met eligibility criteria for the study; after propensity score matching, 456 patients who underwent conventional fusion were matched to 456 patients receiving intraoperative navigation. Navigated cases took an average of 30 minutes longer than nonnavigated cases. There were no significant differences in rates of complications between cohorts. A subgroup analysis revealed that use of navigation was associated with decreased hazard for reoperation in individuals undergoing interbody fusion.

CONCLUSIONS

Despite increased surgical duration, the use of navigation does not seem to significantly impact rates of perioperative complications outside of procedures involving interbody fusion. Surgeons should elect to use navigation in cases expected to be of high operative complexity at their own discretion.

Factors Affecting Postoperative Length of Stay in Patients Undergoing Anterior Lumbar Interbody Fusion

BACKGROUND

With hospital leaders and policy makers increasingly seeking ways to improve resource use, there has been heightened interest in reducing hospital length of stay (LOS) and performing spine procedures on an outpatient basis. We aimed to determine which risk factors correlated with prolonged LOS after anterior lumbar interbody fusion (ALIF).

METHODS

Medical records for patients who underwent ALIF were retrospectively reviewed. Patients were divided into those who had extended (≥3 days) versus nonextended (<3 days) LOS, and patient demographics, medical comorbidities, and preoperative medications were analyzed. Univariate and multivariate regression were then used to determine preoperative risk factors for extended LOS.

RESULTS

A total of 166 patients were included (mean age, 48.7 years). Medical comorbidities included hypertension (31.9%), diabetes (8.4%), and obesity (body mass index >30 kg/m²) (48.8%). LOS was not extended in 121 patients and extended in 45. Mean LOS was 2.2 days (95% confidence interval, 1.9-2.5). On multivariate logistic analysis, age ≥65 years (P = 0.001), preoperative benzodiazepine use (P = 0.014), 12-item Short Form mental component score (P = 0.008), estimated blood loss (P = 0.015), time to mobilization (P < 0.001), and total operative time (P = 0.020) were independent predictors for extended LOS.

CONCLUSIONS

As attempts are made to perform more spine procedure in ambulatory surgical centers, strict patient selection criteria are all critical in making this possible. Our results suggest that age, preoperative benzodiazepine use, higher intraoperative blood loss, delayed mobilization, and lower 12-item Short Form mental component score were correlated with increased LOS. Therefore, inpatient ALIF may be more suitable for patients with these risk factors.

Predictors of Extended Hospitalization and Early Reoperation After Elective Lumbar Disc Arthroplasty

BACKGROUND

Lumbar disc arthroplasty (LDA) has emerged as a motion-sparing alternative to lumbar fusion. Although LDA may be amenable to the ambulatory surgical setting, to date no study has identified the factors predisposing patients to extended hospital stay.

METHODS

A national surgical quality improvement database was queried from 2011 to 2019 for patients undergoing elective, single-level, primary LDA. Univariate and multivariate logistic regression analyses were performed to elucidate predictors of length of stay (LOS) at or above the 90th percentile of the study population (3 days). Secondary study endpoints included rates of complications, as well as predictors and reasons for unplanned reoperation within 30 days.

RESULTS

A total of 630 patients met eligibility criteria for the study, of whom 517 (82.1%) had LOS <3 days and 113 (17.9%) had LOS ≥3 days. Multivariate logistic regression revealed associations between prolonged hospitalization and postoperative diagnosis of degenerative disk disease, obesity, Hispanic identity, and operation length >120 minutes. Before discharge, patients with LOS ≥3 days were more likely to have venous thromboembolisms, pneumonia, surgical site infections, and reoperations. Independent predictors of reoperation were wound infections, diabetes, and smoking.

CONCLUSIONS

Complications following elective single-level LDA are relatively rare, with few extended hospitalizations being attributable to any specific complication. Risk factors for prolonged LOS appear to be related to diagnosis and surgical time rather than to modifiable preoperative comorbidities. Conversely, unplanned reoperations within 30 days are associated with optimizable perioperative factors such as smoking, diabetes, and surgical site infection.

How reliable are surgeon-reported data? A comparison of the British Association of Urological Surgeons radical prostatectomy audit with the National Prostate Cancer Audit Hospital Episode Statistics-linked database

OBJECTIVES

To evaluate the accuracy and completeness of surgeon-reported radical prostatectomy outcome data across a national health system by comparison with a national dataset gathered independently from clinicians directly involved in patient care.

PATIENTS AND METHODS

Data submitted by surgeons to the British Association of Urological Surgeons (BAUS) radical prostatectomy audit for all men undergoing radical prostatectomy between 2015 and 2016 were assessed by cross linkage to the National Prostate Cancer Audit (NPCA) database. Specific data items collected in both databases were selected for comparison analysis. Data completeness and agreement were assessed by percentages and Cohen's kappa statistic.

RESULTS

Data from 4707 men in the BAUS and NPCA databases were matched for comparison. Compared with the NPCA, dataset completeness was higher in the BAUS dataset for type of nerve-sparing procedure (92% vs 42%) and postoperative margin status (89% vs 48%) but lower for readmission (87% vs 100%) and Charlson score (80% vs 100%). For all other variables assessed completeness was comparable. Agreement and data reliability were high for most variables. However, despite good agreement, the inter-cohort reliability was poor for readmission, M stage and Charlson score (κ < 0.30).

CONCLUSIONS

For the first time in urology we show that surgeon-reported data from the BAUS radical prostatectomy audit can reliably be used to benchmark peri-operative radical prostatectomy outcomes. For comorbidity data, to assist with risk analysis, and longer-term outcomes, NPCA routinely collected data provide a more comprehensive source.

Predictors for prolonged length of stay after laparoscopic appendectomy for complicated acute appendicitis in adults

BACKGROUND

Appendicitis-related hospitalizations linked with peritonitis or postoperative complications result in longer lengths of stay and higher costs. The aim of the present study was to assess the independent association between potential predictors and prolonged hospitalization after laparoscopic appendectomy (LA) for complicated acute appendicitis (CAA).

METHODS

A retrospective cohort study was conducted on adult patients diagnosed with CAA in which LA was attempted. The primary outcome was a prolonged length of stay (LOS) after surgery, defined as hospitalizations longer than or equal to the 75th percentile for LOS, including the day of discharge. Hierarchical regression models were run to elucidate the independent predictors for the variable of interest.

RESULTS

The present study involved 160 patients with a mean age of 50.71 years. The conversion rate was 1.9%, and the overall postoperative morbidity rate was 23.8%. The median length of stay (LOS) was 5 days (75th percentile: 7 days). Multivariate analyses included nine variables that are statistically and/or clinically relevant to assess its relationship with a prolonged LOS: three preoperative (age, sex, and comorbidity), four intraoperative (appendix gangrene, perforation, degree of peritonitis, and drain placement), and two postoperative (immediate ICU admission and complications). The development of postoperative complications (OR 6.162, 95% CI 2.451-15.493; p = 0.000) and the placement of an abdominal drain (OR 3.438, 95% CI 1.107-10.683; p = 0.033) were found to be independent predictors for prolonged LOS. For patients not presenting postoperative complications, drain placement was the only independent predictor for the outcome (OR 7.853, 95% CI 1.520-40.558; p = 0.014). Sensitivity analyses showed confirmatory results.

CONCLUSION

The intraoperative process of care has a clear impact on LOS after LA for CAA in adults; therefore, the decision of whether to drain in these situations should be made more restrictively yet with judicious caution.