VAIL, CO USA (UroToday.com) - Introduction: Since Clayman performed the first laparoscopic nephrectomy in 1991, laparoscopy has revolutionized operative urology and allowed for marked reductions in postoperative pain and duration of hospital stay.
Laparoscopic prostatectomy, however, remained a specialized and technically challenging operation with long operative times and a very steep learning curve. The introduction of robotic-assisted surgery in the early 2000s allowed for widespread and feasible minimally invasive radical prostatectomy, with shorter hospital stays and less operative blood loss compared to traditional open surgery. Increasing experience has yielded excellent results. In this large suburban practice with greater then 5 000 RALPs performed, less than 1/200 patients have experienced hospital stays greater than 24 hours, and less than 1/400 patients have required a blood transfusion. This begs the question, “is outpatient robotic-‐assisted prostatectomy safe and feasible?”
Methods: 12 patients were selected to undergo outpatient RALP at a single freestanding ambulatory surgery centers over a six-‐month period. All patients were typed and crossmatched for two units of packed red blood cells pre-‐operatively. A full-service hospital was available within a five-‐minute drive. The American Society of Anesthesiologists (ASA) score was 2 or less in all cases. A transversus abdominis plane (TAP) block was performed preoperatively.
Results: 12 patients underwent successful outpatient RALP. The average patient age was 56. Mean prostate specific antigen (PSA) was 5.91 and the Gleason score was 7 or less. The average operative time was 125 minutes and mean estimated blood loss was 67cc. There were no intraoperative complications, and all patients were discharged within 12 hours of surgery. All Jackson-‐Pratt drains were removed within 4 hours postoperatively. No hospital admissions were required. Final pathology revealed one patient with a focally positive margin, one patient with T3b disease, and all others with T2c disease. To date, 11/12 patients are fully continent. One patient requires one pad use daily less than three months postoperatively. The all-‐inclusive procedure cost at this ambulatory surgical center totaled $9,500 including pathology and anesthesia. A sample of three other local hospitals revealed out-‐of-‐pocket costs for RALP of $8,500, $13,000, and $23,500 all without anesthesia or pathology fees.
Conclusions: We have demonstrated the safety and efficacy of outpatient RALP in a small sample of patients. For properly selected healthy men in the hands of an experienced robotic surgeon outpatient RALP may offer the next advancement in minimally invasive prostatectomy, with advantages of convenience and cost reduction by eliminating the inpatient stay. Further study with an increased sample of patients will be necessary, however, before the approach is commonly adopted.
Presented by Thomas M. Facelle, MD; Gregory Lovallo, MD; Christopher Wright, MD; Michael Esposito, MD; Nitin N. Patel, MD; and Mutahar Ahmed, MD at the 24th International Prostate Cancer Update - February 19 - 22, 2014 - Cascade Conference Center - Vail, Colorado USA
Rutgers New Jersey Medical School, Newark, N.J.
Hackensack University Medical Center, Hackensack, NJ USA
New Jersey Center for Prostate Cancer and Urology, Maywood, NJ USA