A combination of enhanced recovery after surgery and prehabilitation pathways improves perioperative outcomes and costs for robotic radical prostatectomy

Ploussard, Guillaume; Alméras, Christophe; Beauval, Jean-Baptiste; Gautier, Jean-Romain; Garnault, Valérie; Frémont, Natacha; Dallemagne, Stéphanie; Loison, Guillaume; Salin, Ambroise; Tollon, Christophe

doi:10.1002/cncr.33061

Cited by 47 publications

(45 citation statements)

References 23 publications

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“…Furthermore, Ploussard et al illustrate that ERAS and prehabilitation pathways, in synergy, can result in improved short-term surgical outcomes and reduced costs after RARP, without an increase in re-admission rate. 62 The consideration of longer time-scales of medical attention (i.e., extended follow-up and preoperative prehabilitation) should not be excluded in designing QI initiatives, and hence the primacy of one dedicated staff responsible for addressing minor complications before patients require re-admission is central.…”

Section: Discussionmentioning

confidence: 99%

A systematic review and meta-analysis of unplanned hospital visits and re-admissions following radical prostatectomy for prostate cancer

Mukkala¹,

Song²,

Lee³

et al. 2021

CUAJ

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Introduction: Unplanned visits (UPV) — re-admissions and emergency room (ER) visits — are markers of healthcare system quality. Radical prostatectomy (RP) is a commonly performed cancer procedure, where variation in UPV represents a gap in care for prostate cancer patients. Here, we systematically synthesize the rates, reasons, predictors, and interventions for UPV after RP, to inform evidence-based quality improvement (QI) initiatives. Methods: A systematic review was performed for studies from 2000–2020 using keywords: “re-admission,” “emergency room/department,” “unplanned visit,” and “prostatectomy.” Studies that focused on UPV following RP and that reported rates, reasons, predictors, or interventions, were included. Data was extracted via a standardized form. Meta-analysis was completed. Results: Sixty studies, with 406 107 RP patients, were eligible; 16 028 UPV events (~5%) were analyzed from 317 050 RP patients. UPV rates after RP varied between studies (ER visit range 6–24%; re-admissions range 0–56%). The 30-day and 90-day ER visit rates were 12% and 14%, respectively; the 30-day and 90-day re-admission rates were 4% and 9%, respectively. A total of 55% of all re-admissions after RP are directly due to postoperative genitourinary (GU)-related complications such as strictures, obstructions, fistula, bladder-related, incontinence, urine leak, renal problems, and other unspecified urinary complications. The next most common re-admission reasons were anastomosis-related, infection-related, cardiovascular/pulmonary events, and wound-related issues. Thirty-four percent of all ER visits after RP are directly due to urine-related issues such as retention, urinoma, obstruction, leak, and catheter problems. The next most common ER visit reasons were abdominal/gastrointestinal issues, infection-related, venous thromboembolic events, and wound-related issues. Predictors for increased re-admission included: open RP, lymph node dissection, Charlson comorbidity index≥2, low surgeon/hospital case volume, and socioeconomic determinants of health. Of the 10 interventions evaluated, a 3.4% average reduction in UPV rate was observed, highlighting an approximate two-fold decrease. Meta-analysis demonstrated a significant benefit of interventions over controls with odds ratio 0.62 (95% confidence interval 0.46–0.84). Interventions that used multidisciplinary, nurse-centered, programs, with patient self-care/empowerment were more beneficial than algorithmic patient care pathways and preoperative patient education. Conclusions: Twenty years of international, retrospective, experience suggests UPV after RP are often related to GU complications, infection- or wound-related factors. QI interventions to reduce UPV should target these factors. While many re-admissions after RP appear to be unavoidable, ER visits have more opportunity for volume reduction by QI. The interventions evaluated herein have potential to reduce UPV after RP.

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Section: Discussionmentioning

confidence: 99%

A systematic review and meta-analysis of unplanned hospital visits and re-admissions following radical prostatectomy for prostate cancer

Mukkala¹,

Song²,

Lee³

et al. 2021

CUAJ

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“…In addition, enhanced recovery after surgery (ERAS) regimens have led to continuous improvements regarding peri-operative outcomes in oncourology surgery, even after robot-assisted radical prostatectomy (RARP) [4][5][6][7][8]. Recently, prehabilitation pathway along with ERAS and robotic surgery has also been suggested to synergistically participate in improving patient perception and post-operative outcomes after RARP [9]. All of these improvements may generate a reduction of length of stay and a wider acceptance of same day surgery (SDD).…”

Section: Introductionmentioning

confidence: 99%

Same Day Discharge versus Inpatient Surgery for Robot-Assisted Radical Prostatectomy: A Comparative Study

Rahota

Salin

Gautier

et al. 2021

JCM

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(1) Background: no study has compared outcomes of same day discharge (SDD) versus inpatient robot-assisted radical prostatectomy (RARP) in homogenous cohorts. Our aim was to compare perioperative outcomes and urinary continence recovery between SDD and inpatient RARP in contemporary, comparable patients. (2) Methods: we included consecutive patients undergoing RARP between 2018 and 2020 (n = 376). Only patients eligible for SDD (no oral anticoagulant, distance home-hospital <150 km) and having >6-month follow-up were included (n = 180). All patients underwent RARP with or without lymph node dissection. Comparisons were performed between SDD (n = 42) and inpatient RARP (n = 138). Primary outcomes were 90-day complication and readmission rates and continence rates at 1 and 6 months. (3) Results: median patient age was 66.7 years. Median duration of surgery and blood loss was 134 min and 200 mL, respectively. Lymph node dissection and nerve-sparing procedures were performed in 76.7% and 82.2% of cases, respectively. Median follow-up was 19.5 months. No difference was seen regarding patient features, peri-operative outcomes, and pathology parameters between both groups. The proportion of SDD RARP was stable over time (23.5%). The 90-day unplanned visits, readmission and complication rates were 9.5%, 7.1%, and 19.0% in SDD patients versus 14.5% (p = 0.407), 10.1% (p = 0.560), 28.3% (p = 0.234) for inpatient RARP, respectively. Trends favoring SDD were not statistically significant. Continence rates at 1-(p = 0.589) and 6-months (p = 0.674) were comparable between SDD and inpatient RARP. The main limitation was the lack of randomization. (4) Conclusions: this multi-surgeon comparative study confirms the safety of routine SDD RARP in terms of perioperative and functional outcomes. Trends favoring SDD in terms of complications, emergency visits and readmission have to be confirmed.

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“…The results of prehabilitation are promising thus far in other cancer types (39)(40)(41). Since one of the primary aims of our study is to determine the feasibility -the main perceived barrier for application -of our multimodal prehabilitation programme, a study design based on randomisation was deemed suboptimal.…”

Section: Discussionmentioning

confidence: 99%

Multimodal Prehabilitation in Patients with Non-Small Cell Lung Cancer Undergoing Anatomical Resection: Protocol of a Non-Randomised Feasibility Study

Molenaar

Meyenfeldt

Betue

et al. 2020

Preprint

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BackgroundThe preoperative period can be used to enhance a patient’s functional capacity with multimodal prehabilitation and, consequently improve and fasten postoperative recovery. Especially non-small cell lung cancer (NSCLC) surgical patients may benefit from this intervention, since the affected and resected organ is an essential part of the cardiorespiratory fitness. Drafting a prehabilitation programme is a challenge, since many disciplines are involved, and time between diagnosis of NSCLC and surgery is limited. We designed a multimodal prehabilitation programme prior to pulmonary surgery and conduct a study to assess feasibility and efficacy of the programme. Publication of this protocol may help other health care facilities to implement such a programme. MethodsThe multimodal prehabilitation programme consists of an exercise programme, nutritional support, mental support, smoking cessation programme, patient empowerment and respiratory optimisation. In two Dutch teaching hospitals, 40 adult patients with proven or suspected NSCLC will be included. In a non-randomised fashion, 20 patients follow the multimodal prehabilitation programme and 20 will be assessed in the control group, according to patient preference. Assessments take place at four time points: baseline, week before surgery, six weeks postoperatively and three months postoperatively. Feasibility and efficacy of the prehabilitation programme will be assessed as primary outcomes. DiscussionSince the time between diagnosis of NSCLC and surgery is limited, it is a challenge to implement a prehabilitation programme. This study will assess whether this is feasible and effective. The non-randomised fashion of the study might result in a selection bias. However, the control group is necessary, to put the prehabilitation group in perspective and to assess feasibility further. By publishing this protocol of our feasibility study, we aim to facilitate others to evaluate and implement a multimodal prehabilitation programme for surgical lung cancer patients.Trial registrationThis feasibility study is registered as NL8080 in the Netherlands Trial Register on the 10th of October 2019, https://www.trialregister.nl/trial/8080. Secondary identifiers: CCMO (Central Committee on Research Involving Human Subjects) number NL70578.015.19, reference number of the Medical Ethical Review Committee of Máxima MC W19.045.

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A combination of enhanced recovery after surgery and prehabilitation pathways improves perioperative outcomes and costs for robotic radical prostatectomy

Cited by 47 publications

References 23 publications

A systematic review and meta-analysis of unplanned hospital visits and re-admissions following radical prostatectomy for prostate cancer

A systematic review and meta-analysis of unplanned hospital visits and re-admissions following radical prostatectomy for prostate cancer

Same Day Discharge versus Inpatient Surgery for Robot-Assisted Radical Prostatectomy: A Comparative Study

Multimodal Prehabilitation in Patients with Non-Small Cell Lung Cancer Undergoing Anatomical Resection: Protocol of a Non-Randomised Feasibility Study

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