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.
  
  
  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'.
authors.affiliation: The James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD, USA.
authors.forename: Phillip M
authors.initials: PM
authors.lastname: Pierorazio
authors.forename: Jeffrey K
authors.initials: JK
authors.lastname: Mullins
authors.forename: Ashley E
authors.initials: AE
authors.lastname: Ross
authors.forename: Elias S
authors.initials: ES
authors.lastname: Hyams
authors.forename: Alan W
authors.initials: AW
authors.lastname: Partin
authors.forename: Misop
authors.initials: M
authors.lastname: Han
authors.forename: Patrick C
authors.initials: PC
authors.lastname: Walsh
authors.forename: Edward M
authors.initials: EM
authors.lastname: Schaeffer
authors.forename: Christian P
authors.initials: CP
authors.lastname: Pavlovich
authors.forename: Mohamad E
authors.initials: ME
authors.lastname: Allaf
authors.forename: Trinity J
authors.initials: TJ
authors.lastname: Bivalacqua
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005500:Follow-Up Studies; D006785:Hospitals, University / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008396:Maryland / Q000453:epidemiology; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D009017:Morbidity / Q000639:trends; D010351:Patient Discharge / Q000639:trends*; D059035:Perioperative Period; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D011379:Prognosis; D011468:Prostatectomy / Q000379:methods*; D012189:Retrospective Studies; D012371:Robotics; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014549:Urinary Incontinence / Q000453:epidemiology / Q000209:etiology*