Trends in immediate perioperative morbidity and delay in discharge after open and minimally invasive radical prostatectomy (RP): a 20-year institutional experience

摘要

Objective class="unordered" style="list-style-type:disc" id="L1">To investigate the development of the clinical care pathway to discharge after radical prostatectomy (RP) at a large, academic medical centre over the past 20 years, focusing on the rates and reasons for deviation.Patients and methods class="unordered" style="list-style-type:disc" id="L2">In all, 18 049 men were identified from the Johns Hopkins RP database who had undergone surgery since 1991.Patients in whom the length of stay (LOS) was ≤ 95th percentile, defined the clinical care pathway to discharge and those in whom LOS was ≥ 98th percentile were termed ‘off-pathway’.Results class="unordered" style="list-style-type:disc" id="L3">The mean LOS decreased from 7.7 days in 1991 to 1.6 days in 2010.Of 7126 patients undergoing RP since 2005, 1803(25.3%), 4881(68.5%) and 312 (4.4%) were discharged on postoperative day (POD) 1, 2 and 3, respectively; 126 (1.8%) patients, discharged on POD4–21 were ‘off-pathway’.The most common reasons for delay of discharge were ileus (44, 0.615%), urine leak (12, 0.17%), anaemia requiring blood transfusion (nine, 0.126%) and bleeding requiring re-exploration (six, 0.08%).The proportion of patients ‘off-pathway’ was 1.20%, 1.06% and 4.01% for retropubic RP (RRP), laparoscopic RP (LRP) and robot-assisted laparoscopic RP (RALRP), respectively (P < 0.001).Ileus delayed discharge in 0.28%, 0.37% and 1.9% of patients undergoing RRP, LRP and RALRP, respectively (P < 0.001).Conclusions class="unordered" style="list-style-type:disc" id="L4">The clinical care pathway to discharge after RP has changed dramatically at our institution over the past 20 years.RALRP appears to result in a higher proportion of ‘off-pathway’ patients, primarily due to ileus, compared with RRP and LRP. However, very few patients were discharged ‘off-pathway’. class="kwd-title">Keywords: prostate cancer, radical prostatectomy, clinical care pathway, outcomes, morbidity class="head no_bottom_margin" id="S1title">IntroductionIn an effort to improve patient care, patient satisfaction and the cost-effectiveness of large scale surgeries, standard clinical care pathways to discharge have been established for several operations including radical prostatectomy (RP) [, ]. The pathway after RP has changed dramatically over the past two decades due to improvements in surgical technique, anaesthesia and most recently, the introduction of minimally invasive RP (MIRP). In 2000, Gardner et al. [] described a clinical care pathway to discharge after RP of 5 days; more recent publications report reductions in the pathway to 3 and 2 days with the introduction of robot-assisted laparoscopic RP (RALRP) [, ].Prior studies defined the postoperative pathway based on institutional data, evaluated predictors of increased length of stay (LOS), complication and readmission rates, and compared open and MIRP [–]. Therefore, it was not the goal of this analysis either to repeat the work of prior studies by investigating complications or readmissions after RP. Rather, the primary goal of the present analysis was to examine the changes in the care pathway after RP over 20 years at a major academic centre renowned for RP, and to investigate the causes of immediate, perioperative morbidity and their influence on ‘off-pathway’ prolonged hospitalisation.