title: Evolution of care pathway for laparoscopic radical prostatectomy.
abstract: OBJECTIVE
  We report results of the introduction of a laparoscopic radical prostatectomy (LRP) care pathway. This included the introduction of a transversus abdominis plane (TAP) local anesthetic block and other measures to reduce the impact of factors known to delay postoperative recovery. Outcomes including pain, analgesic requirements, complications, and length of stay are reported.
  
  
  METHODS
  Two hundred consecutive patients undergoing LRP from 2008 to 2010 were prospectively studied. A detailed perioperative care pathway was developed and implemented. The pathway was modified after a pain audit to include bilateral transversus abdominis plane regional anesthetic blockade. Same day discharge criteria were applied to suitable patients. Demographics and perioperative and follow-up data were prospectively collected and recorded on a database.
  
  
  RESULTS
  Overall, 78% of cases were discharged after 1 night stay; 14 patients were managed as true day cases without overnight stay. Operative time (P<0.0001), intraoperative blood loss (P=0.018), %≤ 1 day stay (P=0.0091), transfusion, and conversion rate (nil in latter 100 cases) all improved significantly in the second 100 group of patients compared with the first 100 cases. The introduction of TAP blocks led to significant reductions of mean intraoperative and postoperative opiate use (17.3 mg to 1.3 mg and 1.9 mg to 0.2 mg morphine, respectively) without any significant effect on perceived pain. True day cases did not experience a significantly different rate of complications than the whole cohort.
  
  
  CONCLUSIONS
  Through a structured care pathway incorporating the TAP block, 1 night stay laparoscopic prostatectomy can be safely delivered with reduced inpatient stay costs. In selected patients, day-case prostatectomy is feasible.
authors.affiliation: Department of Urology, Royal Marsden Hospital NHS Trust, Imperial College Healthcare NHS Trust, London, United Kingdom. timdudderidge@doctors.org.uk
authors.forename: Tim J
authors.initials: TJ
authors.lastname: Dudderidge
authors.forename: Patrick
authors.initials: P
authors.lastname: Doyle
authors.forename: Erik K
authors.initials: EK
authors.lastname: Mayer
authors.forename: Jen
authors.initials: J
authors.lastname: Taylor
authors.forename: Sachin
authors.initials: S
authors.lastname: Agrawal
authors.forename: Jens Uwe
authors.initials: JU
authors.lastname: Stolzenburg
authors.forename: Mathias H
authors.initials: MH
authors.lastname: Winkler
mesh_terms: D000701:Analgesics, Opioid / Q000627:therapeutic use; D000758:Anesthesia; D054869:Clinical Audit; D015331:Cohort Studies; D019091:Critical Pathways; D003710:Demography; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000188:drug therapy; D010351:Patient Discharge; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods*
chemical_list: D000701:Analgesics, Opioid