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Prostate Cancer

utpatient Prostatectomy: Too Muchoo Soon or Just What the Patient Ordered

aron D. Martin, Rafael N. Nunez, Jack R. Andrews, George L. Martin,aul E. Andrews, and Erik P. Castle

BJECTIVES To evaluate the feasibility of performing a robot-assisted radical prostatectomy (RARP) as anoutpatient procedure while maintaining patient satisfaction and safety. Herein we report ourexperience, selection criteria, and discharge criteria for outpatient RARP.

ETHODS We performed a prospective study with 11 patients undergoing extraperitoneal RARP. Thesepatients were counseled before the procedure that they would go home the same evening ofthe procedure. The patients were then surveyed by a third party shortly after they returnedhome, using the Patient Judgement System-24, a previously validated instrument for patientsatisfaction. Sociodemographic data, comorbidities, and outcomes were collected for anal-ysis.

ESULTS All patients were successfully discharged the same day of surgery. Mean patient age was 62.2years with a mean body mass index of 26 kg/m2. Mean operative time was 117.6 minutes,console time was 76.7 minutes, and estimated blood loss was 168.2 mL. Mean indwellingcatheter time was 7.5 days. No complications occurred in this series of patients. Satisfactionwas unanimously high in all patients surveyed, with most scores over 90% on the PatientJudgement System-24. No patient reported any ill effects from the shortened stay or feltrushed to leave the hospital.

ONCLUSIONS The early experience with extraperitoneal RARP as a same day surgery is promising. Preoperativepatient counseling and selection is paramount. Patient satisfaction is not adversely affected bythe shortened stay. Surgeon experience, assessment of intraoperative findings, and adequate
postoperative assessment are essential. UROLOGY 75: 421–426, 2010. © 2010 Elsevier Inc.
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ising healthcare costs and managed care paymentsystems have changed the way medicine is prac-ticed. Shorter hospitalizations are encouraged for

lmost all medical and surgical conditions to decreaseosts and increase profits. Surgeons are sometimes pres-ured to discharge patients so as to keep their patient’sospitalizations to a minimum and in line with otherore aggressive surgeons. These incentives for early dis-

harge, however, must always be trumped by the patient’sest interest. Prostatectomy is one such procedure whereospital stays have shortened dramatically over the yearsespite little change in the basic procedure. Litwin et al1

as able to show that despite shortened stays, patientatisfaction remained high. It has become standard prac-ice for patients to spend only 1 night in the hospital afterobot-assisted radical prostatectomy (RARP). So thisegs the question: Would patient satisfaction remainigh if RARP were an outpatient procedure?

rom the Department of Urology, Mayo Clinic, Phoenix, ArizonaReprint requests: Aaron D. Martin, M.D., M.P.H., Department of Urology, Mayo

linic Arizona, 5777 East Mayo Blvd, Phoenix, AZ 85054. E-mail: martin.

[email protected]

Submitted: March 2, 2009, accepted (with revisions): August 7, 2009

2010 Elsevier Inc.ll Rights Reserved

ATERIAL AND METHODS

etween March 2007 and July 2007, 11 of 26 patients seen foradical prostatectomy by a single surgeon were proposed thedea of going home the evening of the surgery assuming that therocedure went without any complications. All patients wereonsented and institutional review board approval was obtainedefore beginning the study. These patients were selected be-ause of their exceptional preoperative health status with fewomorbidities, no history of bleeding diathesis, and not takinglood thinners. Mean patient age was 62.2 years, with a meanody mass index of 26 kg/m2. The patients were counseled onhe expectations of our expedited recovery pathway and theygreed to participate with the option of declining afterurgery.

All of these patients were scheduled as the first case of theay to allow for clinical assessment and review of laboratoriesefore discharge the afternoon of surgery. All cases were per-ormed or proctored by a single experienced staff surgeon whoad performed �100 RARPs (EPC). No special restrictionsere placed on resident or fellow participation. Postoperative

aboratories included a hemoglobin and basic metabolic panel.drain was left in place which was removed when minimal

utput (�100 mL over 3-4 hours) was seen in the postanesthe-ia care unit. Patients were discharged with prescriptions for an
ntibiotic to be taken while the catheter was in place, a stool
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oftener, and oxycodone/acetaminophen or hydrocodone/acet-minophen for pain. Patients living out-of-town were asked totay in town at least 1 night after leaving the hospital to be surehey felt comfortable traveling home. All 11 patients wereischarged home the evening of the procedure. Follow-up wasrranged at 1 week for catheter removal as per our routine afterARP. A cystogram was performed before catheter removal for

he purposes of the study. No follow-up call or off-site visit wasade after discharge, but any patient phone calls were dictated

nto the chart as was done routinely for all patients. Patient dataere analyzed including age, body mass index, total operative

ime, console time, blood loss, indwelling catheter time, andomplications. Discharge criteria included: uneventful opera-ive course, normal postoperative hemoglobin, minimal drainutput, and tolerating a liquid diet.Within 2 weeks postoperatively, the patient was asked to

articipate in a survey to address patient satisfaction after thexpedited pathway. We used the validated Patient Judgementystem-24 (PJS-24) which gives a global overall satisfactionith care rating and 9 multi-item satisfaction components. TheJS-24 has been validated for hospital quality assurance andhown to accurately reflect and capture issues of patients un-ergoing prostatectomy by its use in similar studies.1,2 We alsoncluded 2 general questions that have previously been vali-ated and used in similar studies to assess global satisfac-ion.1,3–5 Another question was asked to assess overall painontrol after the procedure. Our complete 27-item instrumentan be seen in the appendix. Our population consisted ofell-educated Caucasian men, which is similar to the popula-

ion in the Litwin study, which also used the PJS-24 as aeasure of satisfaction after prostatectomy. Table 1 summarizes

atient sociodemographic variables.A separate survey instrument and existing medical records

ere used to collect sociodemographic and comorbidity data.he electronic medical chart was examined to determinehether patients called the night of surgery for any issues

elated to their early discharge. Since this was a pilot studyimed mainly at determining feasibility, statistical analysisas limited by a small sample size. As a control, 10 randomly

elected patients who underwent our usual RARP pathwayith discharge within 48 hours completed the same survey.escriptive statistical methods were used to present socio-emographic and comorbidity data. Patient satisfactioncores are reported as overall and scale mean scores withtandard deviation.

ESULTSean total operative time (ie, from skin to skin) was

17.6 minutes with average of 76.7 minutes of actualonsole time. The mean estimated blood loss was 168.2L. Four patients had bilateral pelvic lymph node

issection. Mean catheter time was 7.5 days (range,-14 days). One patient had a bladder neck anasto-otic leak on cystogram which resolved with contin-

ed catheter drainage for an extra week. There were noignificant perioperative complications in this series ofatients.Eight of the 11 patients agreed to participate in the

urvey portion of the study for a 73% response rate. Threeatients declined the study questionnaire, but did not
ave any issues postoperatively on review of their medi- b
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al records. All patients left the hospital the evening ofheir surgery without complication. There was no in-rease in study patient phone calls observed in theseelected patients during the first week postoperatively.atisfaction scores were high on all scales of the PJS-24nd the global assessment questions (Table 2). Overallean total process score was 94.2 out of 100. PJS-24ean scale scores were uniformly more than 90 except forospital billing at 83.8. Most patients (75%) felt thatheir stay was just right, whereas the other 25% felt thatt was too long. No one felt that the stay was too short orushed out of the hospital. All the patients were satisfiedith pain control after the procedure and were comfort-ble at the time of discharge. Global satisfaction scoreshowed 87.5% as “extremely satisfied” with the entirexperience while 1 respondent chose only “satisfied.”he scores did not differ significantly from the controlroup.

OMMENThere continues to be growing concern over the cost ofealthcare in the United States and other countries.esources are limited and our aging population continues

o expand. With the addition of new technologies such asobotics, cost continues to rise. There have been sometudies looking at the potential economic effect of ro-

Table 1. Sociodemographics of survey respondants

Mean Age (y) 62.2Race

Caucasian 8 (100%)Relationship status

Living with spouse or partner 6 (75%)In a significant relationship, but not

living together0 (0%)

Not in a significant relationship 2 (25%)Work status

Working part/full-time 2 (25%)Unemployed, but searching 0 (0%)Retired 6 (75%)

Annual Household income*�$30 001 2 (25%)$30 001-$50 000$50 001-$75 000 1 (12.5%)�$75 000 3 (37.5%)

Education levelHigh school graduate or less 1 (12.5%)Some college, technical school, or

college degree2 (25%)

Graduate/professional degree 5 (62.5%)Medical history

Diabetes 0 (0%)Cardiovascular disease 2 (25%)Respiratory disease 1 (12.5%)Gastrointestinal disease 1 (12.5%)Renal disease 0 (0%)Depression 0 (0%)Alcohol or other drug problems 0 (0%)Cigarette smoker 3 (37.5%)

* Two patients refused to disclose income information.

otic surgery for prostate cancer.6,7 Clearly, the robot

UROLOGY 75 (2), 2010

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dds significant additional costs to the hospital, thirdarty payers, and the patient.Currently, most RARP patients stay overnight and are

ischarged on the first postoperative day. Even with aischarge as early as postoperative day 1, the cost of theobot still overshadows the savings of a shorter hospitaltay. We sought out to see whether this procedure coulde successfully performed as a same-day and/or outpatienturgical procedure, which to our knowledge has not beenublished. We found that patients could be dischargedome the same day of the surgical procedure if they methe criteria that we set without increased perioperativeomplications. We also performed follow-up satisfactionurveys and found that all the patients felt that theytayed for the appropriate amount of time in the hospital.n other words, no patient felt that they were “kicked-ut” too soon. This is consistent with previous studies,hich have tested early hospital discharge for prostatec-

omy patients.1,8

While our results are encouraging, it must be remem-ered that this is a small group of patients who volun-arily chose to participate. Also, it is well known thatatient satisfaction surveys can reveal positive resultsven in light of poor outcomes. We attempted to limithis bias by using mostly validated surveys shown to beompatible with our patient demographic administered

Table 2. Patient Judgement System-24 and global satis-faction scores (mean � SD)

Study Group(n � 8)

Control Group(n � 10)

PJS-24 scales*Total process 94.2 � 8.8 88.5 � 8.8Hospital admissions 97.5 � 7.1 95 � 10.7Daily care 93.8 � 9.2 92.5 � 17.5Patient information level 96.3 � 7.4 91.7 � 21Nursing care 94.4 � 14.0 96.9 � 5.9Physician care 96.9 � 5.9 93.8 � 9.2Ancillary hospital staff 90.8 � 13.3 95 � 9.3Atmosphere/building 95 � 9.3 97.5 � 7.1Discharge 91.3 � 21.0 93.8 � 11.9Hospital billing† 83.8 � 29.2 22.5 � 36.5

Additional globalsatisfaction scales

Satisfaction with LOS‡ 2.8 � 0.5 3.1 � 0.3Overall satisfaction§ 1.1 � 0.4 1.1 � 0.3Pain control

satisfaction¶4.5 � 0.9 4.7 � 0.5

PJS-24 � Patient Judgement System-24; LOS � length of stay.* Scores range from 0 to 100 with higher scores representinggreater satisfaction.† Many patients in the control group had not yet received billinginformation, resulting in lower scores.‡ Scores range from 1 to 5: 1 � much too short; 3 � just right;5 � much too long.§ Scores range from 1 to 5, with lower scores representing highersatisfaction.¶ Scores range from 1 to 5, with higher scores representinggreater satisfaction.

y a third party shortly after discharge. Our patients also

ROLOGY 75 (2), 2010

ad no perioperative complications, which naturally in-reases the likelihood of high satisfaction scores regard-ess of hospital stay.

Early discharge requires extra time preoperatively torepare the patient for the quick turnaround after aajor operation. It is our experience that even thoughe know it is safe to go home the same day of theperation, some patients will not be comfortable withhis transition despite preoperative counseling for var-ous reasons (eg, little home support, anxiety, precon-eived assumptions, etc). Also, these patients were aelect group in that they all had uncomplicated extra-eritoneal RARPs.The current diagnosis-related group used by most hos-

itals for prostatectomy and RARP requires a full admis-ion with full discharge. To acquire reimbursement, pa-ients cannot be admitted for a 23-hour observation or beischarged as an “outpatient.” In our cases, we performedull admits, watched the patients for 4-6 hours and thenid a “full discharge.” Whether this will provide any costenefit remains to be seen. The goal would be to seehether some or most RARPs can successfully be dis-harged the same day and possibly have the diagnosis-elated group changed so that the hospitals could beeimbursed for an “outpatient prostatectomy” and ulti-ately decrease the overall cost.

ONCLUSIONSn a very select group of patients, this feasibility studyndicates that extraperitoneal RARP can be performed astrue outpatient procedure safely and while maintainingigh patient satisfaction with proper patient education.urther investigation could shorten the current recoveryathway for prostatectomy patients and decrease overallealthcare costs.

eferences. Litwin MS, Shpall AI, Dorey F. Patient satisfaction with short stays

for radical prostatectomy. Urology. 1997;49:898-906.. Hays RD, Larson C, Nelson EC, et al. Hospital quality trends: a

short-form patient-based measure. Med Care. 1991;29:661-668.. Fowler FJ Jr, Barry MJ, Lu-Yao G, et al. Effect of radical prostatec-

tomy for prostate cancer on patient quality of life: results from aMedicare survey. Urology. 1995;45:1007-1015.

. Klein EA, Grass JA, Calabrese RN, et al. Maintaining quality of careand patient satisfaction with radical prostatectomy in the era of costcontainment. Urology. 1996;48:269-276.

. Litwin MS, Hays RD, Fink A, et al. Quality-of-life outcomes in mentreated for localized prostate cancer. J Am Med Assoc. 1995;273:129-135.

. Burgess SV, Atug F, Castle EP, et al. Cost analysis of radicalretropubic, perineal, and robotic prostatectomy. J Endourol. 2006;20:827-830.

. Lotan Y, Cadeddu JA, Gettman MT. The new economics of radicalprostatectomy: cost comparison of open laparoscopic, and robotassisted techniques. J Urol. 2004;172:1431-1435.

. Ruiz-Deya G, Davis R, Srivastav SK, et al. Outpatient radicalprostatectomy: impact of standard perineal approach on patient
outcome. J Urol. 2001;166:581-586.
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APPENDIX

JS-24 QUESTIONNAIRE AND ADDITIONAL SURVEY QUESTIONSPlease rate the following items concerning your hospital stay in terms of whether they were Excellent, Very Good, Good, Fair,

r Poor. Please only mark one answer for each statement. If something does not apply to you, mark “Doesn’t Apply.”

Patient Judgement System-24

1. Efficiency of the admitting procedure: Ease of gettingadmitted, including the amount of time it took

Excellent Very Good Good Fair Poor Doesn’t Apply

2. Attention of admitting staff to your individual needs:Their handling of your personal needs and wants


3. Sensitivity to problems: Sensitivity of hospital staff toyour special problems or concerns


4. Coordination of care: The teamwork of all the hospitalstaff who took care of you


5. Ease of getting information: Willingness of hospital staffto answer your questions


6. Instructions: How well nurses and other staff explainedabout tests, treatments, and what to expect


7. Informing family or friends: How well they were keptinformed about your condition and needs


8. Skill of nurses: How well things were done, like givingmedicine and handling IV’s


9. Attention of nurses to your condition: How often nurseschecked on you to keep track of how you were doing


10. Nursing staff response to your calls: How quick theywere to help


11. Concern and caring by nurses: Courtesy and respect youwere given, friendliness and kindness


12. Attention of doctor to your condition: How often doctorschecked on you to keep track of how you were doing


13. Concern and caring by doctors: Courtesy and respectyou were given; friendliness and kindness


14. Skill of doctors: Ability to diagnose problems,thoroughness of examinations, and skill in treating yourcondition


15. Information given by doctors: Amount of information youwere given about your illness and treatment; what to doafter leaving the hospital


16. Housekeeping staff: How well they did their jobs andhow they acted towards you


17. Laboratory staff: How well they did their jobs and howthey acted towards you


18. IV Starters: Skill of staff who started your IV Excellent Very Good Good Fair Poor Doesn’t Apply19. Restfulness of atmosphere: Amount of peace and quiet Excellent Very Good Good Fair Poor Doesn’t Apply20. Hospital building: How you would rate the hospital

building overallExcellent Very Good Good Fair Poor Doesn’t Apply

21. Discharge procedures: Time it took to be dischargedfrom the hospital and how efficiently it was handled


22. Discharge instructions: How clearly and completely youwere told what to do and what to expect when you leftthe hospital


23. Explanations about costs and how to handle yourhospital bills: The completeness and accuracy ofinformation and the willingness of hospital to answeryour questions about finances


24. Efficiency of billing: How fast you got your bill, howaccurate and understandable it was


Additional Questions25. How was the length of time spent in the

hospital after surgery?Much too short Too short Just right Too long Much too long

26. How was the pain control your receivedfollowing surgery?

Excellent Very Good Good Fair Poor

27. Overall, how satisfied are you with thetreatment you received?

ExtremelyDissatisfied

Dissatisfied Uncertain Satisfied ExtremelySatisfied

24 UROLOGY 75 (2), 2010

outpatient prostatectomy: too much too soon or just what the patient ordered

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