MIRP has several advantages over traditional procedures, including reduced blood loss and transfusion rates, decreased postoperative pain, and a shorter duration of hospitalization in more recent cases [19]. The current findings suggest that discharge on the day of surgery is both safe and feasible for a subset of patients undergoing MIRP. Our analysis also indicated that a Gleason score of 3 + 3 is the main factor that significantly increases the success of discharge on the day of surgery. Notably, all patients in our study were satisfied with the procedure and the length of stay.
Historically, the duration of hospitalization following open RP has decreased with increasing surgical experience over the last 100 years, as noted by Klein et al. [1]. In their study, reducing the median length of stay from 7 to 2 days following open radical prostatectomy (RP) did not significantly change mortality or new hospitalization/complication rates, although nearly 90% of patients reported overall satisfaction. A few years later, Martin et al. [2] were the first to report the results of a feasibility study involving 11 patients undergoing outpatient open retropubic RP. Pure laparoscopic and robot-assisted RP have also been associated with decreases in postoperative length of stay, pain, and blood loss when compared with traditional open procedures [3]. Dudderidge et al. reported that 78% of patients who underwent conventional laparoscopic RP were discharged after one night of hospitalization, while 7% of patients were discharged on the same day [20].
Several high-volume surgical centers have described their initial experience regarding the safety and viability of outpatient robot-assisted laparoscopic radical prostatectomy (RARP), reporting similar complication and outcome rates [6, 12, 21, 22]. Research has further indicated that RARP increases patient satisfaction and reduces postoperative pain levels when compared with open procedures. In addition to reducing recovery time, these improvements allow patients to resume their general activities more quickly and enhance their perception of their own general health [23]. Another important factor would be the type of surgery. It is well known that the preservation of peritoneal cavity integrity may ensure an earlier recovery of intestinal activity, a more rapid return to diet and, consequently, a shorter length of stay. However, the protocol of our center is the transperitoneal route [24], and still did not impact negatively our results.
Berger et al. [12] conducted a prospective study involving 30 patients, 87% of whom were discharged on the day of surgery. In their study, they observed no significant differences in demographic or perioperative variables between the outpatient and hospitalization groups. In our study, 12 patients were not discharged according to randomization due to mild pain, nausea/vomiting, or hematuria and related insecurities. These results indicate that, even when early discharge is considered clinically safe, patients must have the option to stay if they do not feel safe. In the study by Berger et al. [12], four patients were not discharged on the day of surgery, three of whom elected to forego early discharge despite having no clinical problems.
These data reinforce the notion that patient selection and motivation are important factors influencing same-day discharge from the hospital following surgery. Similarly, the support network provided at hospital discharge is also important success in the immediate postoperative period. The use of an intermediate care hospital, established in a municipality, reduced length of stay without increasing readmissions, admissions, mortality, activities of daily living, primary health care utilization or total care days [25]. Ensuring initial assistance in a support home monitored by a technical nursing assistant may help to improve acceptance and success of early discharge. However, it is well known that support homes and/or nursing facilities are not present worldwide. Therefore, convenient access to the medical team via electronic communication, and early outpatient follow up may decrease postoperative anxiety among postsurgical patients. In our study, we had no post-surgical complications nor readmission, showing that these selected patients were safe with an early discharge.
Khalil et al. [10] analyzed postoperative data for patients undergoing RARP using the database of the American College of Surgeons National Surgical Quality Improvement Program. The data were used to identify patients who had been discharged from the hospital on the day of surgery (n = 258) and those who had stayed in the hospital for more than 1 day (n = 1,290). Global morbidity, reoperation, and readmission rates were low and did not significantly differ between the two groups. Abboudi et al. [13] analyzed data for 32 patients who underwent laparoscopic RP and were discharged on the day of surgery. Postoperative complications were observed in six patients, including intensive care unit (ICU) admission, lymphocele infection, and re-catheterization secondary to a defective catheter balloon. Hospitalization was necessary in four of these six cases. Berger et al. [12] reported no differences in perioperative or functional outcomes between individuals undergoing outpatient RARP and a compatible inpatient group. Banapour et al. [21] reviewed data for 51 patients who underwent RARP, 51% of whom underwent an ambulatory procedure. No differences in operative time, blood loss, or complication rates were observed between patients discharged early and those requiring a standard hospital stay. Several other centers have reported their experience with early discharge, noting that same-day discharge following RARP does not appear to increase postoperative complication or readmission rates when compared with a standard overnight stay [6, 10, 12, 21]. Together, these studies have provided no clear evidence that reducing the duration of hospitalization leads to increases in complication rates following RP. Our data support this notion, as we observed excellent short-term results without cases of readmission or decreases in patient satisfaction.
Despite promising evidence, relevant studies have included well-selected patient populations with limited comorbidities, an ideal BMI, and adequate social support. Most patients included in the study of outpatient RARP by Khalil et al. [10] were young, were not current smokers, had a low ASA class, and did not have obesity. The authors also reported a shorter operative time and a reduced need for pelvic lymphadenectomy in patients undergoing RARP. Our study included patients without obesity and those with localized disease not requiring pelvic lymphadenectomy. Notably, researchers have highlighted the relationship of obesity and comorbidities with an increased risk of complications and prolonged recovery time after RARP [26]. The present study found, in these well-selected patients, that Gleason score was the main variable that should be considered during the decision of discharging patient in the same day of surgery. Besides another Brazilian study [11], that found prostate volume as a factor, our univariable logistic regression pointed to Gleason score as more important, and prostate volume was a potential confusing variable. It is well known that prostate volume can impact in perioperatory results, such as blood loss and surgery time [27,28,29,30]. In fact, higher Gleason scores increase the chance to surgical margins involvement, extracapsular invasion and/or seminal vesicle involvement, leading to the need of a more complex surgery and/or involving bigger surgical margins [31, 32].
In addition to the feasibility and safety of early discharge of this selected population, we found that satisfaction of the patients was high, independently on discharge time. This result corroborates several reports [2, 5, 13, 33] that applied satisfaction questionnaires to patients (11, 129, 32 and 100 patients, respectively) after early discharge, and found that satisfaction was uniformly high.
As surgeons have become more experienced with RARP, some of the initially restrictive criteria used for patient selection, such as BMI or the need for lymph node dissection, have been expanded in more recent series [6, 10]. Khalil et al. [10] reported that > 70% of outpatient surgery cases occurred after 2012. All single-center studies on laparoscopic RP or outpatient RARP were published after 2010 [2, 10, 12, 21]. This may be related to the learning curve, confidence in the methodology, and standardization of MIRP, which has progressed with increasingly lower blood transfusion and complication rates [34, 35]. In fact, Ploussard et al. [36] performed a countrywide study of the RARPs performed in France in 2020 and found association of same-day discharge and higher-volume centers, which gives the notion that, besides very well solid criteria of patient selection, the experience of surgeon is fundamental for early day discharge success. In the current study, all surgical procedures were performed by surgeons experienced in minimally invasive surgery at high-volume oncological centers.
This study had several strengths when compared with previous investigations. To the best of our knowledge, this is the first prospective, randomized study of early discharge after RP conducted at one of the largest cancer hospitals in Latin America. Our findings expand the body of knowledge regarding safety and patient satisfaction in cases of same-day discharge after surgery and provide insight into factors that may predict success following early discharge.
Despite these strengths, our study also had some limitations. Although the calculation of the number of patients was performed under very well delimited parameters, the sample size is not extensive. It is well known that patient satisfaction surveys can suggest positive results even when the results are poor. To limit the influence of such bias, we utilized a validated satisfaction instrument (SATIS-BR), which was administered shortly after discharge by a third researcher blinded to the patient groups. Furthermore, given that procedures were performed by surgical experts at high-volume centers, no patients in our study experienced perioperative complications, which naturally increased the likelihood of high satisfaction scores regardless of hospitalization time. Additionally, some questions possibly were not well-understood by the patients, which could have biased some results. For example, one patient of the same-day discharge group answered that felt that the length of his stay was long. Lastly, while the study was conducted at a public hospital, participants exhibited significant differences in socioeconomic status.
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