The shift from inpatient to ambulatory urological surgical care has been significant with increasing demands on the health care system [1]. Many surgeries including the insertion of urologic prostheses such as artificial urinary sphincters (AUS), penile prostheses (PP), and urethral slings (US) previously involved inpatient management. However, the COVID-19 pandemic led to limited access to inpatient urologic prosthesis surgeries, necessitating an outpatient/same-day surgery (DS) approach [2]. Research on the safety and feasibility of outpatient urologic prosthesis surgeries is limited. We aimed to assess the complication rates associated with urologic prosthesis DS to establish their safety and feasibility.

We conducted a retrospective review of all ambulatory and inpatient US, AUS, and PP insertions performed from January 2019 to June 2023. The resulting database comprises patient baseline demographics, comorbidities, indications and types of surgery, as well as 30-day postoperative complications, classified according to the Clavien-Dindo scale. We compared complication rates of DS and inpatient surgeries. Statistical analysis was performed using R statistical software and Microsoft Excel to identify statistical differences between rates of postoperative complications after ambulatory and inpatient urological device surgery and p-values < 0.05 were considered to be significant.

Patients who received AUS and US had short and long-standing stress urinary incontinence (SUI) due to previous prostatectomy or radiation. Patients who underwent PP implantation suffered from long-standing erectile dysfunction (ED) and previously failed pharmacologic treatments. Median age of patients in both groups was 68 years (51-89 years). Out of 110 surgeries (36 inpatients, 74 DS), post-surgical complication rates occurred in 11 inpatients and 10 DS, Tables 1,2. US insertion as DS led to significantly fewer overall complications compared to inpatient procedures (11.1% vs. 50%, p=0.006). Grade I complication rate was greater in the inpatient group than in the DS group (35.7% vs. 7.4%, p=0.02). Post-US insertion, Grade II complication rates between DS and inpatient cohorts were not significantly different (3.7% vs. 14.3%, p=0.2). Overall complication rates post-AUS were similar between DS and inpatient (19.3% vs. 21.1%, p=0.8). Grade I and II AUS complication rates did not differ significantly between the groups. Overall complication rates post-PP between DS and inpatient cohorts were not significantly different (6.2% vs. 0.0%, p=0.66). Notably, none of the 74 planned DS required unanticipated admissions immediately after surgery.

In our analysis, we found that none of the 74 planned outpatient surgeries resulted in unanticipated admissions immediately postoperatively, compared with prior inpatient stays. The minimal complication rate observed in the DS cohort is promising and encouraging. Through meticulous patient selection and due diligence, appropriate candidates could choose DS instead of hospitalization for AUS, US, and PP insertion, potentially facing equal or even reduced risks of complications. The transition of prosthetic urological surgery from an inpatient to an outpatient basis is possible, safe, and needed. The new approach can be economically beneficial and lead to a quicker recovery and more patient satisfaction. It is important to conduct a thorough patient selection, schedule a next-day follow-up, and reassess patients on a long-term basis as agreed by the patient and surgeon.

Our study demonstrates that the complication rates in the DS cohort are similar to, or significantly lower than those in the inpatient cohort. This strongly suggests that outpatient implantation of AUS, US, and PP can be safe and feasible. Given the novelty and relatively limited scale of this study, further research involving larger scale and extended duration trials is needed to assess the long-term complication rates of DS, its impact on patient satisfaction, and cost-effectiveness.

Steiner, C.A., Karaca, Z., Moore, B.J., Imshaug, M.C., Pickens, G. (2017). Surgeries in Hospital-Based Ambulatory Surgery and Hospital Inpatient Settings, 2014. HCUP Statistical Brief #223. Agency for Healthcare Research and Quality, Rockville, MD.
Teoh, J. Y.-C., Ong, W. L. K., Gonzalez-Padilla, D., Castellani, D., Dubin, J. M., Esperto, F., Campi, R., Gudaru, K., Talwar, R., Okhunov, Z., Ng, C.-F., Jain, N., Gauhar, V., Wong, M. C.-S., Wroclawski, M. L., Tanidir, Y., Rivas, J. G., Tiong, H.-Y., & Loeb, S. (2020). A Global Survey on the Impact of COVID-19 on Urological Services. European Urology, 78(2), 265–275. https://doi.org/10.1016/j.eururo.2020.05.025