Cancer and Prostatic Diseases (2004) 7, 50–53 & 2004 Nature Publishing Group All rights reserved 1365-7852/04 $25.00 www.nature.com/pcan Current trends in the management of radical retropubic prostatectomy: is short-stay RRP feasible in the United Kingdom?

AR Ramsden1*, R Thurairaja2, R Persad2 & GW Chodak1,3 1Midwest Urology Research Foundation, University of Chicago, Chicago, Illinois, USA; 2Department of Urology, Bristol Royal Infirmary, UK; 3Midwest Prostate and Urology Health Center, University of Chicago, Chicago, Illinois, USA

Background: Our aim was to review UK practice in the management of radical retropubic prostatectomy and identify opportunities to reduce LOS to American levels. Methods: A survey was conducted of BAUS members regarding LOS and postoperative management. Results: Out of 551 surveys 126 were returned. Mean LOS in the UK is 5.2 days. Opiate analgesia, PCA and postoperative epidural may delay discharge. Diet and mobilization are commenced at 1.7 and 2.1 days, respectively. Conclusion: Care pathways can safely reduce LOS to 2 days. Protocols to reduce LOS in the UK should be assessed and their impact on cost and quality-of-life evaluated. and Prostatic Diseases (2004) 7, 50–53. doi:10.1038/sj.pcan.4500698

Keywords: prostatectomy; hospital stay; care pathways

Introduction ment. Koch et al2 reduced cost by 44% and decreased the mean length of stay from 5.7 to 3.6 days. In the management of localized prostate cancer, radical Between 1996 and 2000, this department developed a retropubic prostatectomy (RRP) remains the surgical care pathway (Figure 1), which has resulted in the treatment of choice. Attempts to improve standard- shortest reported LOS of just 1.34 days with 74.2% of of-care have focused on perioperative management and patients being discharged on the first postoperative day.8 quality of life outcomes. Concerns about healthcare costs The key feature of this pathway is the use of Spinal and have provided the stimulus for American physicians, in Epidural anaesthesia instead of General Anaesthetic. The particular, to cut their costs while simultaneously epidural is removed in recovery and a single dose of IM maintaining (or improving) standards of patient care. Methadone given. Oral Paracetamol and NSAIDs are Length of hospital stay has been identified as the main started at 4 h postoperatively and oral fluids commenced determinant of cost1 and as a result, critical-care path- as soon as they are tolerated. Patients start to mobilize on ways have been developed in the United States, geared the evening of . They are then discharged on the towards earlier discharge.1–7 following morning, provided they are tolerating oral During the 1990 s, various groups were able to reduce diet, walking unassisted and are apyrexial. hospital stay by taking an aggressive approach to diet, Patient satisfaction surveys have reported good fluids and mobilization and by eliminating the use of results and there is no increase in complications or epidural anaesthesia for postoperative pain manage- readmissions.8,9 Same day discharge has also been evaluated. Hajjar et al4 have conducted a pilot study in which 10 patients underwent Radical Retropubic Prostatectomy as day *Correspondence: A Ramsden, Midwest Urology Research cases without an increase in complications. Foundation, 4646 N. Marine Drive, Suite A5500, Chicago, IL 60640, In the United Kingdom, there has been less of an USA. E-mail: [email protected] imperative to economise and hospital stays remain Received 10 July 2003; revised 16 October 2003; accepted 23 October longer. In our pilot study in 2002, this was typically 5–8 10 2003 days (mean 5.2). Management of RRP in UK AR Ramsden et al

The aim of this study was to assess current UK practice and was excluded. This left a study group of 82 51 in the perioperative management of RRP and to raise questionnaires. questions about how Short-Stay Radical Retropubic The mean number of RRPs performed per annum was Prostatectomy could be achieved in the United Kingdom. 27.0 with a range of 6–120 and s.d. of 19.4. Mean op time was 143.0 min (range 75–300, s.d. 37.7). Mean read- mission rate was 3.4%. There were no statistically Method significant correlations between the number of cases performed per annum, the operating time and the A postal survey was sent to all full members of the readmission rate. British Association of Urological Surgeons, as listed in Mean length of stay in the UK was 5.24 days (range 2– the BAUS Member’s Handbook 2002/2004, asking about 12, s.d. 1.60, median 5) (Figure 2). All but one surgeon current practice in the management of RRP. A total of 551 made use of either epidural or PCA for postoperative surveys were sent out and surgeons were asked to return pain control (for a mean of 2.14 days). The one surgeon them by post or facsimile. Responses were anonymous who did not make use of these modalities had the earliest although the name of the hospital was recorded. discharge (2 days). The survey (Appendix 1) comprised 23 questions In addition to epidural anaesthesia or PCA, 42 of 82 about: the number of cases performed per annum; the (51%) surgeons used paracetamol or NSAIDs for post- average length of stay; anaesthetic use; postoperative operative analgesia with the remaining 40 (49%) using analgesia; preoperative counselling; drain and oral or parenteral opiates as well. The use of nonopiate protocols; diet and fluids; mobilisation; LN dissection; analgesia was associated with a shorter hospital stay blood transfusion and readmission rate. (4.97 vs 5.52 days) although this did not quite reach statistical significance (P ¼ 0.09). Patients mobilised at a mean of 2.1 days (range 0–4, Results median 2), commenced oral fluids at a mean of 1.1 days (range 0–2, median 1) and solid diet at a mean of 1.7 days Out of 551, 126 (23%) urologists returned completed (range 0–4, median 2) — where 0 denotes the day of surveys. Of these, 44 performed no RRPs and were surgery. excluded from further analysis. One urologist had retired A surgical drain was used in 97% of cases and was removed at a mean of 2.16 days with 50 ml being the average volume for directing its removal. The urethral catheter was removed at a mean of 16 days and a median of 14 days (range 7–28 days). Only 16% of surgeons make use of cystograms in directing catheter removal and there was no correlation between length of catheterisation and the use of cystograms. Criteria for performing (LN) dissection varied widely with 36% of surgeons performing LN dissection on all patients and 7% LN sampling only if nodes were palpable intraoperatively. The PSA level above which LN dissection was performed ranged from 6 to 20 (mode ¼ 10) and the Gleason score ranged from 6 to 8 (mode ¼ 7). All patients received verbal counselling by either a doctor or specialist nurse or both. In addition, 44/82 (54%) urologists offered written information about the procedure.

Figure 1 Short-stay care pathway for RRP. Figure 2 Distribution of length of hospital stay in UK.

Prostate Cancer and Prostatic Diseases Management of RRP in UK AR Ramsden et al

52 Patients received blood transfusion in 33.4% of cases this is a primary association as a feature of a more (range 0–96%). Only 12 surgeons (14.6%) used auto- traditional approach to postoperative management, or logous blood transfusion. whether the elimination of opiates speeds recovery. The need for cystography in assessing the integrity of the vesico-urethral anastomosis prior to catheter removal remains an area of practice in which there is much Discussion disparity. While some surgeons routinely perform cystography at 28 days before removing the catheter, This study provides valuable information about others remove the catheter at day 7 without radiographic current clinical practice in the United Kingdom in the evidence of anastomotic integrity. Best-practice in this postoperative management of Radical Retropubic issue is yet to be elucidated. Prostatectomy. Preoperative counselling has an important role in One outcome is that the response rate from BAUS preparing patients for short-stay surgery. In this practice, members appears to be very low. A possible explanation patients undergo a 1-h counselling session with a for this is that, although the questionnaire was sent to specialist nurse as well as with the surgeon. In addition individual urologists, many were returned for entire they are provided with detailed written information on departments. In addition, it is likely that many urologists the procedure and the course of their hospital stay and who do not perform RRP failed to respond to the recovery. We believe that this is integral to the patients’ questionnaire. In 1999/2000, 62% of urologists did not acceptance of what remains an unusual approach to this perform any RRPs.11 If we presume this figure to be scale of surgery. reasonably stable, that would suggest that there are now Undertaking short-stay RRP in the UK would require a in the region of 340 urologists in the UK not performing significant change in the traditional values upheld by RRP. Thus, their failure to respond would have little or both doctors and patients. It requires training and no impact on the results. education of anaesthetic staff, theatre staff, nurses and Similarly, we estimate that there are around 210 physiotherapists. Furthermore, there are obstacles at a urologists in the UK who are performing RRP. Although management level; concerns about ‘losing’ empty beds, we received only 83 responses from this group, we additional costs of increased bed turnover, allocation of believe that the majority of prostatectomies are ac- theatre time and a potentially higher demand on counted for; the total estimated number of cases per community medicine. The cost reduction per procedure, annum in this study was 2215 which compares well with however, is significant and the net result could be Ravichandran’s figure of 1465 for 1999/2000.11 Some of beneficial to the British healthcare system. this increase may be the result of surgeons overestimat- As a result of the growing use of PSA screening in the ing their case-load. Some, however, may be a true United Kingdom, there is already an upward trend in the reflection of the growing popularity of RRP as PSA incidence of prostate cancer in the UK and conjecture screening becomes more widespread and disease is that incidence may reach levels seen in the USA. The identified at an earlier stage. NICE Guidance on Cancer Services, estimates that the In 2000, Ravichandran et al11 reported that less than rise in incidence of prostate cancer, between 2001 and 18% of urologists undertaking Radical Prostatectomy 2004, will result in additional costs ranging between perform more than 20 per year. In contrast, 53/82 (65%) d15.4 and d43.8 million.12 Although there is a paucity of of this study group were performing more than 20 per evidence definitively supporting radical treatment year and the mean number performed was 27.0. The over active monitoring, RRP remains a mainstay of mean is higher than expected and may be an indication treatment and will be a significant constituent of these that surveys are more likely to be returned by surgeons costs. To make use of a strategy for undertaking RRP in who are performing the most surgery. It may also an economically efficient way is a logical means of represent pooling of departmental results. containing these rising expenses. Before early discharge becomes feasible, existing The implications of a shorter hospital stay run further trends will need to be modified, in particular, attitudes than merely reducing expenditure. Patient satisfaction, towards anaesthesia and analgesia. General anaesthesia complications and readmission rates are comparable to remains the standard of care in the UK, either alone conventional stays. It has been suggested that recovering (42.7%) or in combination with epidural (51.2%), spinal at home prompts patients to mobilise sooner, eat better (1.2%) or caudal (1.2%) anaesthesia. The use of combined and be less dependant on analgesics.4 In addition, there epidural and spinal anaesthetic, without GA, has been is less exposure to the risks of hospital-acquired shown to be effective in this setting, however, and offers infection. Furthermore, reducing hospital stay might advantages over General Anaethesia in the recovery prove an effective means of meeting the new targets set period.3 Pain control is excellent, incidence of ileus is low out in the national cancer guidelines. and commencement of oral intake earlier. This allows early introduction of oral analgesia and removal of the epidural. By eliminating the use of epidural or PCA for postoperative pain management, patients are able to Conclusion mobilise sooner thus expediting what is a rate-limiting step for discharge. The single surgeon in this study who In spite of evidence from the United States that short-stay did not use postoperative epidural or PCA had the prostatectomy is a safe and cost-effective practice, with a shortest LOS. high level of patient satisfaction, it has not been adopted The use of nonopiate analgesia was associated with a in the UK. Hospital stays remain longer, diet, fluids and shorter LOS than opiate analgesia. It is unclear whether mobilisation are delayed and anaesthesia and analgesia

Prostate Cancer and Prostatic Diseases Management of RRP in UK AR Ramsden et al 53 impose limitations on the rate of recovery. To implement 6 Keetch DW, Buback D. A clinical-care pathway for decreasing a short-stay protocol requires the Urological team to hospital stay after radical prostatectomy. BJU 1998; 81: 398–402. significantly readdress traditional paradigms but by 7 Palmer J et al. Same day surgery for radical retropubic reducing stay, resources can be optimised, waiting lists prostatectomy: is it an attainable goal? Urology 1996; 47: 23–28. reduced and a high standard of care delivered to 8 Kirsh EJ, Worwag EM, Sinner M, Chodak GW. Using outcome patients. A short-stay pathway is being developed in data and patient satisfaction surveys to develop policies regarding minimum length of hospitalization after radical Bristol and our experience with its implementation will prostatectomy. Urology 2000; 56: 101–107. be reported once it has been evaluated. 9 Litwin MS, Shpall AI, Dorey F. Patient satisfaction with short stays for radical retropubic prostatectomy. Urology 49: 898–906. References 10 Ramsden AR, Thurairaja R, Persad R, Chodak GW. Is short stay radical retropubic prostatectomy feasible in the United King- 1 Licht MR, Klein EA. Early hospital discharge following radical dom? (Abstract). Prostate Cancer Prostatic Diseases, In press. retropubic prostatectomy: impact on cost and rate. 11 Ravichandran S, Dasgupta P, Booth CM. Radical prostatectomy Urology 1994; 44: 700–704. in Britain and Ireland at the Millennium. BJUI 2000; 90: 420–423. 2 Koch MO, Smith JA, Hodge EM, Brandell RA. Prospective 12 Guidance on Cancer Services. Improving Outcomes in Urological development of a cost-efficient program for radical retropubic Cancer. The Manual. National Institute for Clinical Excellence, prostatectomy. Urology 1994; 44: 311–318. September 2002. 3 Worwag E, Chodak GW. Overnight hospitalistion after radical prostatectomy: the impact of two clinical pathways on patient satisfaction, length of hospitalization and morbidity. Anaes Analg 1998; 87: 62–67. 4 Hajjar JH, Budd HA, Wachtel Z, Howhannesian A. Ambulatory Appendix 1: radical retropubic prostatectomy. Urology 1998; 51: 443–448. 5 Litwin M et al. Cost-efficient radical prostatectomy with a Condensed questionnaire on RRP management clinical care path. JUrol1996; 155: 989–993.

Hospital Name______

1 How many Radical Retropubic Prostatectomies to you perform per year on average? 2 What is the average hospital stay for RRP? 3 What type of anaesthetic do you typically use? 4 What proportion of patients receive spinal/epidural anaesthesia? 5 When a patient receives an epidural, for how many days is this normally left in place? 6 What other post-op analgesia do you normally use? [Please tick all that apply] & Paracetamol & NSAIDS & Oral Opioids & IM Opiates & IV Opiates 7 What type of pre-operative counseling do your patients receive? & Verbal & Written & Both 8 Who conducts pre-operative counseling? [Please tick all that apply] & Specialist Nurse & Junior doctor & Consultant 9 Do you routinely place a surgical drain? Yes & No & 10 On average, on what post-operative day is the drain removed? 11 What are your criteria for removing the drain? 12 On average, on what post-operative day is the catheter removed? 13 Do you make use of cystography in your decision to remove the catheter? Yes & No & 14 On what post-operative day do you normally commence oral fluids? 15 On what post-operative day do you normally commence diet? 16 On what post-operative day do your patients fully mobilize? 17 At what PSA level do you routinely perform Lymph Node Dissection? 18 At what Gleason Score do you routinely perform Lymph Node Dissection? 19 Do you have any other criteria for performing Lymph Node Dissection? 20 What proportion of your patients receive blood transfusion during surgery? 21 Do you make any use of autologous blood transfusion? Yes & No & 22 What is your readmission rate? 23 What is your average Op. time [knife-to-skin to wound-closure]?

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