Hypothesis / aims of study
Enhanced recovery after surgery protocols and increased attention to value-based care have led to the reconsideration of routine post-operative admission in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) cases. Recent studies have shown same-day discharge is safe and feasible in apical prolapse repair. [1,2] We aimed to assess trends in same-day discharge (SDD) and associated readmissions and emergency room visits across the FPMRS spectrum in a single-surgeon 10-year experience.
Study design, materials and methods
A retrospective review was performed of cases done by a single FPMRS-certified urologist between 6/1/2010 and 8/30/2020 at a single institution. The medical record was queried for patient baseline demographics and comorbidities, length of stay, and 30-day outcomes associated with each case (readmission, emergency department (ED) visits). Non-FPMRS specialty cases were excluded, as well as cases where a hysterectomy was performed by a gynecologist, because these admissions were dictated by their team. To facilitate clinically meaningful comparisons of 30-day outcomes based on SDD status, a subset cohort of cases traditionally involving next-day discharge was created (i.e., robotic transabdominal, apical prolapse repair). We termed this group “the traditionally admitted cohort”. Simple logistic regression modeling was performed to assess probability of SDD and 30-day readmission or ED visit over time. Patient characteristics and 30-day outcomes were compared based on SDD status for the overall cohort as well as the traditionally admitted cohort.
Results
1793 surgeries were identified and analyzed, including 357 apical prolapse repairs, 370 slings, 392 neuromodulation, and 247 genitourinary reconstructive cases. The majority (79.1%) of cases had SDD. For patients admitted postoperatively, mean length of stay was 1.5 ±1.3 days. Among the 601 cases in the traditionally admitted cohort, rates of SDD were significantly higher in 2020 than 2010 (84% versus 32%, p<0.001), while 30-day readmission and ED visits did not change (p=0.22) (Figure). Overall rates of 30-day readmission and ED visits were low (1.9% and 2.6%, respectively) and did not differ based on SDD status (p=0.76). Readmissions occurred at mean 11.6 (7.0) days, most commonly for urinary tract infection (13/34). For the traditionally admitted cohort, most complications associated with readmission or ED visits were minor (25/28 Clavien-Dindo ≤2) (Table). No ED visits or readmissions for SDD patients would have been prevented by postoperative admission.
Interpretation of results
This large ten-year single-surgeon retrospective review demonstrates that a wide breadth of FPMRS surgeries can be safely performed on an outpatient basis. While SDD increased significantly over time, 30-day post-operative readmissions and ED visits remained low and did not differ based on SDS status. The overwhelming majority of associated complications were low-grade, and presentations were most often a week or more after surgery. Of the few serious complications in the SDD cohort, none would have been prevented with a post-operative admission. Our findings underscore the feasibility and safety of routine SDD for the majority of FPMRS cases.