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

Phillip Martin Pierorazio, Jeffrey K. Mullins, Ashley E. Ross, Elias S. Hyams, Alan Wayne Partin, Misop Han, Patrick Walsh, Edward M. Schaeffer, Christian Pavlovich, Mohamad E Allaf, Trinity Bivalacqua

Research output: Contribution to journalArticle

Abstract

What's known on the subject? and What does the study add? Standard clinical care pathways to discharge have been established for a number of 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). This study adds evidence that the emergence of MIRP is associated with a decrease in LOS for all patients undergoing RP. In addition, it catalogues the development of the clinical care pathway over 20 years at a large, tertiary care hospital with extensive experience in RP. Finally, it defines the common reasons patients fall 'off-pathway' (ileus, urine leak, anaemia and re-exploration for bleeding) and defines the immediate perioperative morbidity profile of RP. Specifically, it addresses approach-specific morbidities and indicates that MIRP is associated with higher rates of 'off-pathway' discharge, most often due to ileus. Objective 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 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 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 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'.

Original languageEnglish (US)
Pages (from-to)45-53
Number of pages9
JournalBJU International
Volume112
Issue number1
DOIs
StatePublished - Jul 2013

Fingerprint

Prostatectomy
Morbidity
Critical Pathways
Ileus
Length of Stay
Anemia
Urine
Hemorrhage
Tertiary Healthcare
Tertiary Care Centers
Blood Transfusion
Anesthesia
Databases

Keywords

  • clinical care pathway
  • morbidity
  • outcomes
  • prostate cancer
  • radical prostatectomy

ASJC Scopus subject areas

  • Urology

Cite this

@article{1cec994ea1dd4334ac073297063177b3,
title = "Trends in immediate perioperative morbidity and delay in discharge after open and minimally invasive radical prostatectomy (RP): A 20-year institutional experience",
abstract = "What's known on the subject? and What does the study add? Standard clinical care pathways to discharge have been established for a number of 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). This study adds evidence that the emergence of MIRP is associated with a decrease in LOS for all patients undergoing RP. In addition, it catalogues the development of the clinical care pathway over 20 years at a large, tertiary care hospital with extensive experience in RP. Finally, it defines the common reasons patients fall 'off-pathway' (ileus, urine leak, anaemia and re-exploration for bleeding) and defines the immediate perioperative morbidity profile of RP. Specifically, it addresses approach-specific morbidities and indicates that MIRP is associated with higher rates of 'off-pathway' discharge, most often due to ileus. Objective 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 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 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 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'.",
keywords = "clinical care pathway, morbidity, outcomes, prostate cancer, radical prostatectomy",
author = "Pierorazio, {Phillip Martin} and Mullins, {Jeffrey K.} and Ross, {Ashley E.} and Hyams, {Elias S.} and Partin, {Alan Wayne} and Misop Han and Patrick Walsh and Schaeffer, {Edward M.} and Christian Pavlovich and Allaf, {Mohamad E} and Trinity Bivalacqua",
year = "2013",
month = "7",
doi = "10.1111/j.1464-410X.2012.11767.x",
language = "English (US)",
volume = "112",
pages = "45--53",
journal = "BJU International",
issn = "1464-4096",
publisher = "Wiley-Blackwell",
number = "1",

}

TY - JOUR

T1 - Trends in immediate perioperative morbidity and delay in discharge after open and minimally invasive radical prostatectomy (RP)

T2 - A 20-year institutional experience

AU - Pierorazio, Phillip Martin

AU - Mullins, Jeffrey K.

AU - Ross, Ashley E.

AU - Hyams, Elias S.

AU - Partin, Alan Wayne

AU - Han, Misop

AU - Walsh, Patrick

AU - Schaeffer, Edward M.

AU - Pavlovich, Christian

AU - Allaf, Mohamad E

AU - Bivalacqua, Trinity

PY - 2013/7

Y1 - 2013/7

N2 - What's known on the subject? and What does the study add? Standard clinical care pathways to discharge have been established for a number of 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). This study adds evidence that the emergence of MIRP is associated with a decrease in LOS for all patients undergoing RP. In addition, it catalogues the development of the clinical care pathway over 20 years at a large, tertiary care hospital with extensive experience in RP. Finally, it defines the common reasons patients fall 'off-pathway' (ileus, urine leak, anaemia and re-exploration for bleeding) and defines the immediate perioperative morbidity profile of RP. Specifically, it addresses approach-specific morbidities and indicates that MIRP is associated with higher rates of 'off-pathway' discharge, most often due to ileus. Objective 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 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 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 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'.

AB - What's known on the subject? and What does the study add? Standard clinical care pathways to discharge have been established for a number of 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). This study adds evidence that the emergence of MIRP is associated with a decrease in LOS for all patients undergoing RP. In addition, it catalogues the development of the clinical care pathway over 20 years at a large, tertiary care hospital with extensive experience in RP. Finally, it defines the common reasons patients fall 'off-pathway' (ileus, urine leak, anaemia and re-exploration for bleeding) and defines the immediate perioperative morbidity profile of RP. Specifically, it addresses approach-specific morbidities and indicates that MIRP is associated with higher rates of 'off-pathway' discharge, most often due to ileus. Objective 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 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 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 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'.

KW - clinical care pathway

KW - morbidity

KW - outcomes

KW - prostate cancer

KW - radical prostatectomy

UR - http://www.scopus.com/inward/record.url?scp=84879108720&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84879108720&partnerID=8YFLogxK

U2 - 10.1111/j.1464-410X.2012.11767.x

DO - 10.1111/j.1464-410X.2012.11767.x

M3 - Article

C2 - 23759008

AN - SCOPUS:84879108720

VL - 112

SP - 45

EP - 53

JO - BJU International

JF - BJU International

SN - 1464-4096

IS - 1

ER -