- Email: [email protected]
Anterior Urethroplasty Has Transitioned to an Outpatient Procedure Without Serious Rise in Complications: Data From the National Surgical Quality Improvement Program
Accepted Manuscript Title: Anterior Urethroplasty Has Transitioned to an Outpatient Procedure Without Serious Rise in Complications: Data From NSQIP Author: Susan MacDonald, Devin Haddad, Abraham Choi, Marc Colaco, Ryan Terlecki PII: DOI: Reference:
S0090-4295(16)30693-8 http://dx.doi.org/doi: 10.1016/j.urology.2016.09.043 URL 20061
To appear in:
Urology
Received date: Accepted date:
7-7-2016 21-9-2016
Please cite this article as: Susan MacDonald, Devin Haddad, Abraham Choi, Marc Colaco, Ryan Terlecki, Anterior Urethroplasty Has Transitioned to an Outpatient Procedure Without Serious Rise in Complications: Data From NSQIP, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2016.09.043. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Anterior urethroplasty has transitioned to an outpatient procedure without serious rise in complications: Data from NSQIP
Susan MacDonald1, Devin Haddad2, Abraham Choi3, Marc Colaco3,4, Ryan Terlecki3,4 Author Affiliations: 1
Department of Urology, Penn State Hershey Medical Center, Hershey, PA 17033 Ohio State University Wexner Medical Center, Columbus, OH 43210 3 Wake Forest School of Medicine, Winston-Salem, NC 27157 4 Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC 27157 2
Susan MacDonald, M.D. Department of Urology Penn State Hershey Medical Center 500 University Dr Hershey, PA 17033 Phone: 717-531-8848 Fax: 717-531-4475 Email: [email protected]
(Corresponding Author)
Devin Haddad, M.D. Ohio State University Wexner Medical Center 395 West 12th Avenue Columbus, OH 43210 Phone: 614-442-2200 Fax: 614-293-6656 Email: [email protected] Abraham Choi, B.A. Wake Forest School of Medicine Medical Center Blvd Winston Salem, NC 27157 Phone: 336-716-5690 Fax: 336-716-0656 Email: [email protected] Marc Colaco, M.D. Department of Urology Wake Forest Baptist Health Medical Center Blvd Winston Salem, NC 27157 Phone: 336-716-5690 Fax: 336-716-0656 Email: [email protected] Ryan Terlecki, M.D. Department of Urology Wake Forest Baptist Health Medical Center Blvd Winston Salem, NC 27157 Phone: 336-716-5690 Fax: 336-716-0656 Email: [email protected]
Keywords: Anterior Urethroplasty, Outpatient, Ambulatory Surgery, Complications, NSQIP
Page 1 of 12
2
Word Count: 1510 Conflicts of Interest: None Source(s) of Funding: None
Abstract Objective: To analyze the trend in inpatient versus outpatient performance of anterior urethroplasty and examine outcomes using data from the National Surgical Quality Improvement Program database (NSQIP). Methods: A retrospective cross sectional analysis was performed using the NSQIP database. Cases of single stage anterior urethroplasty from 2006-2013 were identified using the ICD-9 procedure code 53410. Univariate analysis was performed to compare 30-day complication rates for inpatient and outpatient cases. A linear regression model was created for all years with greater than 50 reported cases. Results: A total of 326 anterior urethroplasties were reported; 222 (68.1%) were inpatient procedures, and 104 (31.9%) were outpatient procedures. The most common complication, urinary tract infection, was consistent between inpatient (2.7%) and outpatient (2.9%) procedures. The rate of wound dehiscence was significantly higher among outpatient cases (1.92% vs 0%, p = 0.03). There were no significant differences in the rates of wound infection, bleeding, graft failure, deep vein thrombosis, pneumonia, or sepsis. The linear regression model shows a significant increase in outpatient procedures (R2=0.91) and equivalent decrease in inpatient procedures (R2=0.91) for the last 3 years of the study period. Resident involvement was associated with a decreased rate of reoperation (0% vs 8.3% p<0.001). Conclusions: There has been a shift in the performance of anterior urethroplasty toward outpatient management. Overall, complication rates appear low. Future research is necessary to
Page 2 of 12
3
determine how to decrease overall cost of single stage urethroplasty without compromising quality of care.
Introduction: Due to the economic burden of health care within the United States, measures to contain and reduce cost are warranted. Decreasing hospital stays after surgery and adaptation of surgical procedures to outpatient management is a seemingly worthwhile strategy. Utilization of ambulatory surgical centers increased by 300% between 1996 and 2006.1 Apart from decreased use of inpatient resources and reduced cost for patients, outpatient surgery has also been associated with shorter preoperative wait times, less time off work, and a reduced risk of nosocomial infections.2 For the reconstructive urologist, anterior urethroplasty is a case that seems amenable to outpatient performance for select patients. This has been demonstrated in small series with limited follow up.3,4 It seems valuable, therefore, to determine the current trends in site-selection for performance of anterior urethroplasty and to evaluate if there is any impact upon reported outcomes. With a hypothesis of increasing outpatient management, we chose to query national data to shed light on these items.
Methods: A retrospective cross sectional analysis was performed using data reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, a risk adjusted database comprised of over 500 hospitals across different setting that voluntarily submit data as part of a quality improvement initiative sponsored by the American College of Surgeons.5 Data is either automatically populated or collected by trained research
Page 3 of 12
4
nurses depending on institution, and has been demonstrated to have high interrater reliability in case reporting. This database has been validated and used for population based studies in a number of surgical fields including urology.6,7,8 Cases of single stage anterior urethroplasty were identified using the ICD-9 procedure code 53410. The database was queried for all cases between the years of 2006 and 2013 and all identified cases were included in this study. Univariate analysis was performed to determine differences in 30-day complication rates between inpatient and outpatient cases. Categorical variables were compared using the Chi square test, while integral variables were analyzed using Student’s t-test. A linear regression model was created for all years with greater than 50 reported cases. A secondary goal was to determine the effect of resident involvement on outcomes. Thus, an analysis was performed to examine differences in overall complications, need for reoperation, and readmission rates among anterior urethroplasties involving residents versus those that did not. Results: A total of 326 single stage anterior urethroplasties were reported over the study period; 222 (68.1%) were performed as inpatient procedures, and 104 (31.9%) were performed as outpatient procedures. No stringent guidelines are published defining inpatient vs.outpatient procedures in the NSQIP database, however the mean length of stay for an inpatient procedure was 1.9 days vs. 0.43 days for an outpatient procedure. A linear regression model was created for 2010-2012, years with greater than 50 cases reported, which demonstrated a significant decrease in inpatient procedures (R2=0.91) and a significant increase in outpatient procedures (R2=0.91). (Figure 1)
Page 4 of 12
5
Patient demographics for those managed inpatient versus outpatient are shown in Table 1. The mean operative time for inpatient procedures exceeded that of outpatient procedures by 59 minutes (p <0.01). There was no significant difference in ASA scores, BMI, smoking status, or proportion of patients with diabetes between groups. Patients receiving inpatient management were significantly younger. A comparison of 30-day complication rates is shown in Table 2. The most common complication was urinary tract infection, which was consistent between inpatient (2.7%) and outpatient (2.9%) procedures. There was a trend towards increased superficial wound infection in outpatient urethroplasty that did not reach significance. (0.45% vs. 1.92% p = 0.19). The rate of wound dehiscence, however, was significantly higher for outpatient procedures (1.92% vs. 0%, p = 0.03), although the overall incidence was low. There were no significant differences in the rates of bleeding, deep vein thrombosis, graft failure, pneumonia, MI, or sepsis. Reoperation rates and readmission rates were higher for inpatient urethroplasty, though these differences did not reach statistical significance. For cases with available data, 136 involved residents, whereas 48 did not. Resident involvement was associated with a significantly decreased rate of reoperation (0% vs 8.3% p<0.001). Although cases involving residents had an increase in mean operative time of 42 minutes, there was no significant difference in any complication. Discussion: Performance of outpatient surgical procedures is rising nationwide.1,9 Increased utilization of ambulatory surgical centers theoretically affords the potential to improve efficiency and outcomes, and possibly reduce the cost of care relative to inpatient management. National data suggests that there has been a significant shift in site-selection for anterior urethroplasty.
Page 5 of 12
6
Although outpatient management was associated with a higher rate of wound dehiscence, the overall rate was low and this was the only complication with a statistically significant association. The existing data to support outpatient anterior urethroplasty is limited. Following review of 54 such cases, including those with up to a 23-hour hospital stay, Lewis et al reported 93% success with short follow-up.3 In that series, outpatient cases were associated with shorter operative times and patients were younger and had shorter strictures compared to those that received inpatient management. In 2005, MacDonald et al reported a “minimal impact surgery” protocol including local anesthetic, a COX-2 inhibitor, and cold compresses postoperatively that shortened mean hospital stay to seven hours.4 In the second half of their study period, 85% of anterior urethroplasties were performed outpatient, and success was reported as 97% at a mean follow-up of 27 months. Similar to the previously mentioned series, patients admitted to the hospital had a mean age increase of 7 years. Based on questionnaires given to patients discharged less than 24 hours after urethroplasty, 89% felt this was appropriate.10 However, 56% reported moderate difficulty with mobility and 24% reported severe problems with usual care. To date, this represents the largest comparison of site-selection for anterior urethroplasty and associated outcomes. This study has a high level of external validity, as the data is from a nationwide database reported by multiple different surgeons. However, it is not without several limitations. Anterior urethroplasties are quite heterogenous and specific details that would attest to complexity are not captured within the NIQIP database. Stricture length, location, etiology, and the number of prior procedures are all relevant to surgeon decision-making. It has not been shown, however, that any of these specific items should dictate whether or not a patient can be discharged home from the recovery room. At our center, for example, all patients undergoing
Page 6 of 12
7
posterior or anterior (anastomotic or substitution) urethroplasty are kept for 23-hour observation. This is regardless of the nature or number of prior surgeries, length of graft, or operative time. Operative time could be considered a surrogate marker for case complexity, and in this review inpatient cases, on average, took an hour longer but with no significant increase in complications. Admittedly, there was a trend towards an increased rate of reoperation and readmission, however these did not reach significance. The only statistically significant difference in 30-day complications was for wound dehiscence (1.92% outpatient vs 0% inpatient, p = 0.03). It is unclear if this could be related to the level of postoperative activity since those cases managed inpatient had an average stay of 1.9 days. Also, the clinical significance of dehiscence is unclear since none of the outpatient cases required reoperation within 30 days and no long-term data is available to determine rate of subsequent fistula formation or stricture recurrence. Resident involvement was associated with a significantly decreased rate of reoperation (0% vs 8.3% p<0.001) and no difference in complications. There was an increase in mean operative time of 42 minutes for cases involving residents. Similarly Löppenberg et al noted that resident involvement increased the operative time for hydrocele surgery, without increasing rates of complications.11 Looking at outpatient plastic surgical procedures, Massenburg et al. also found no association between resident participation and complications.12 One could speculate that increased operative time may be related to teaching, or possibly increased complexity, as occasionally seen in cases referred to tertiary care centers. Clearly, there are patient factors that can guide the need for admission apart from details specific to their urethral stricture disease and type of repair. Anesthesia providers may encourage longer observation for patients based on comorbidities and hemodynamic parameters during or
Page 7 of 12
8
after surgery. Based on this study of national data, there was no significant difference in the patient populations by ASA scoring. It is unknown, however, if some of these patients were selected for efforts targeting preoperative optimization. Additional data analysis may allow development of a model to predict the need for postoperative admission.
Conclusions: Nationally, performance of anterior urethroplasty is shifting toward outpatient management. Although the overall 30-day complication rates are low in both the inpatient and outpatient setting, the statistically significant elevation in wound dehiscence after outpatient urethroplasty could be clinically significant when applied to the total number of cases nationwide. Resident involvement is associated with longer operative times, but no increase in adverse outcomes and, actually, a decreased rate of reoperation. While further research may offer additional clarity to this issue, the available evidence seems to strongly support that outpatient management is appropriate for single stage anterior urethroplasty.
Page 8 of 12
9
References 1) Cullen KA, Hall M, Golosinskiy A. Ambulatory Surgery in the United States, 2006. Natl
Health Stat Rep. 2009; (Number 11). 2) Mandal A, Imran D, McKinnell T, Rao GS. Unplanned admissions following ambulatory plastic surgery--a retrospective study. Ann R Coll Surg Engl. 2005; 87(6): 466-468. doi:10.1308/003588405X60560. 3) Lewis JB, Wolgast KA, Ward JA, Morey AF. Outpatient Anterior Urethroplasty: Outcome Analysis and Patient Selection Criteria. J Urol. 2002; 168(3):1024-1026. doi:10.1016/S0022-5347(05)64566-1. 4) MacDonald MF, Al-Qudah HS, Santucci RA. Minimal impact urethroplasty allows sameday surgery in most patients. Urology. 2005; 66(4):850-853. doi:10.1016/j.urology.2005.04.057. 5) National Surgical Quality Improvement Program [home page on the Internet] Chicago, IL: American College of Surgeons; 2005. [cited 2016 May 17]. Available from: www.acsnsqip.org. 6) Bastiampillai R, Lavallee LT, Cnossen S, et al. Laparoscopic nephroureterectomy is associated with higher risk of adverse events compared to laparoscopic radical nephrectomy. Can Urol Assoc J. 2016; 10(3-4):126-31. 7) Packiam VT, Cohen AJ, Nottingham CU, Pariser JJ, Faris SF, Bales GT. Open Versus Minimally Invasive Adult Ureteral Reimplantation: Analysis of 30-Day Outcomes in the National Surgical Quality Improvement Program (NSQIP) Database. Urology. 2016; (16)30221-7. pii: S0090-4295(16)30221-7. doi: 10.1016/j.urology.2016.05.025 8) Semerjian A, Zettervall SL, Amdur R, Jarrett TW, Vaziri K. 30-Day morbidity and mortality outcomes of prolonged minimally invasive kidney procedures compared with shorter open procedures: national surgical quality improvement program analysis. J Endourol. 2015; 29(7):830-7. 9) Kaye KW. Changing trends in urology practice: increasing outpatient surgery. Aust NZ J Surg. 1995; 65(1):31-34. 10) Okafor H, Nikolavsky D. Impact of Short-Stay Urethroplasty on Health-Related Quality of Life and Patient’s Perception of Timing of Discharge. Adv Urol. 2015;2015:806357. doi:10.1155/2015/806357. 11) Löppenberg B, Cheng PJ, Speed JM et al. The effect of resident involvement on surgical outcomes for common urologic procedures: A case study of uni- and bilateral hydrocele repair. Urology. 2016; pii: S0090-4295(16)30097-8. doi: 10.1016/j.urology.2016.03.045. 12) Massenburg BB, Sanati-Mehrizy P, Jablonka EM, Taub PJ. The impact of resident participation in outpatient plastic surgical procedures. Aesthetic Plastic Surg. 2016; 40(4):584-91.
Page 9 of 12
10
Figure 1 – Trends in Urethroplasty
Page 10 of 12
11
Table 1 – Characteristics of Procedures Inpatient Procedure Time
Outpatient
p value
178.91
119.22
<0.001
1.9
0.43
<0.001
Average Age
46.9
52.2
0.009
BMI
30.5
30.7
0.066
ASA 1
18.47%
11.54%
0.113
ASA 2
47.30%
50.00%
0.649
ASA 3
31.53%
37.50%
0.287
ASA 4
2.70%
0.00%
0.09
Days to Discharge
Page 11 of 12
12
Table 2 – 30 Day Complication Rates Inpatient
Outpatient
p value
Wound Infection
0.45%
1.92%
0.194
Dehiscence*
0.00%
1.92%
0.038
UTI
2.70%
2.88%
0.925
MI
0.45%
0.96%
0.581
DVT
0.45%
0.00%
0.493
Readmission
2.25%
0.96%
0.419
Reoperation
1.80%
0.00%
0.168
Page 12 of 12
S0090-4295(16)30693-8 http://dx.doi.org/doi: 10.1016/j.urology.2016.09.043 URL 20061
To appear in:
Urology
Received date: Accepted date:
7-7-2016 21-9-2016
Please cite this article as: Susan MacDonald, Devin Haddad, Abraham Choi, Marc Colaco, Ryan Terlecki, Anterior Urethroplasty Has Transitioned to an Outpatient Procedure Without Serious Rise in Complications: Data From NSQIP, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2016.09.043. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Anterior urethroplasty has transitioned to an outpatient procedure without serious rise in complications: Data from NSQIP
Susan MacDonald1, Devin Haddad2, Abraham Choi3, Marc Colaco3,4, Ryan Terlecki3,4 Author Affiliations: 1
Department of Urology, Penn State Hershey Medical Center, Hershey, PA 17033 Ohio State University Wexner Medical Center, Columbus, OH 43210 3 Wake Forest School of Medicine, Winston-Salem, NC 27157 4 Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC 27157 2
Susan MacDonald, M.D. Department of Urology Penn State Hershey Medical Center 500 University Dr Hershey, PA 17033 Phone: 717-531-8848 Fax: 717-531-4475 Email: [email protected]
(Corresponding Author)
Devin Haddad, M.D. Ohio State University Wexner Medical Center 395 West 12th Avenue Columbus, OH 43210 Phone: 614-442-2200 Fax: 614-293-6656 Email: [email protected] Abraham Choi, B.A. Wake Forest School of Medicine Medical Center Blvd Winston Salem, NC 27157 Phone: 336-716-5690 Fax: 336-716-0656 Email: [email protected] Marc Colaco, M.D. Department of Urology Wake Forest Baptist Health Medical Center Blvd Winston Salem, NC 27157 Phone: 336-716-5690 Fax: 336-716-0656 Email: [email protected] Ryan Terlecki, M.D. Department of Urology Wake Forest Baptist Health Medical Center Blvd Winston Salem, NC 27157 Phone: 336-716-5690 Fax: 336-716-0656 Email: [email protected]
Keywords: Anterior Urethroplasty, Outpatient, Ambulatory Surgery, Complications, NSQIP
Page 1 of 12
2
Word Count: 1510 Conflicts of Interest: None Source(s) of Funding: None
Abstract Objective: To analyze the trend in inpatient versus outpatient performance of anterior urethroplasty and examine outcomes using data from the National Surgical Quality Improvement Program database (NSQIP). Methods: A retrospective cross sectional analysis was performed using the NSQIP database. Cases of single stage anterior urethroplasty from 2006-2013 were identified using the ICD-9 procedure code 53410. Univariate analysis was performed to compare 30-day complication rates for inpatient and outpatient cases. A linear regression model was created for all years with greater than 50 reported cases. Results: A total of 326 anterior urethroplasties were reported; 222 (68.1%) were inpatient procedures, and 104 (31.9%) were outpatient procedures. The most common complication, urinary tract infection, was consistent between inpatient (2.7%) and outpatient (2.9%) procedures. The rate of wound dehiscence was significantly higher among outpatient cases (1.92% vs 0%, p = 0.03). There were no significant differences in the rates of wound infection, bleeding, graft failure, deep vein thrombosis, pneumonia, or sepsis. The linear regression model shows a significant increase in outpatient procedures (R2=0.91) and equivalent decrease in inpatient procedures (R2=0.91) for the last 3 years of the study period. Resident involvement was associated with a decreased rate of reoperation (0% vs 8.3% p<0.001). Conclusions: There has been a shift in the performance of anterior urethroplasty toward outpatient management. Overall, complication rates appear low. Future research is necessary to
Page 2 of 12
3
determine how to decrease overall cost of single stage urethroplasty without compromising quality of care.
Introduction: Due to the economic burden of health care within the United States, measures to contain and reduce cost are warranted. Decreasing hospital stays after surgery and adaptation of surgical procedures to outpatient management is a seemingly worthwhile strategy. Utilization of ambulatory surgical centers increased by 300% between 1996 and 2006.1 Apart from decreased use of inpatient resources and reduced cost for patients, outpatient surgery has also been associated with shorter preoperative wait times, less time off work, and a reduced risk of nosocomial infections.2 For the reconstructive urologist, anterior urethroplasty is a case that seems amenable to outpatient performance for select patients. This has been demonstrated in small series with limited follow up.3,4 It seems valuable, therefore, to determine the current trends in site-selection for performance of anterior urethroplasty and to evaluate if there is any impact upon reported outcomes. With a hypothesis of increasing outpatient management, we chose to query national data to shed light on these items.
Methods: A retrospective cross sectional analysis was performed using data reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, a risk adjusted database comprised of over 500 hospitals across different setting that voluntarily submit data as part of a quality improvement initiative sponsored by the American College of Surgeons.5 Data is either automatically populated or collected by trained research
Page 3 of 12
4
nurses depending on institution, and has been demonstrated to have high interrater reliability in case reporting. This database has been validated and used for population based studies in a number of surgical fields including urology.6,7,8 Cases of single stage anterior urethroplasty were identified using the ICD-9 procedure code 53410. The database was queried for all cases between the years of 2006 and 2013 and all identified cases were included in this study. Univariate analysis was performed to determine differences in 30-day complication rates between inpatient and outpatient cases. Categorical variables were compared using the Chi square test, while integral variables were analyzed using Student’s t-test. A linear regression model was created for all years with greater than 50 reported cases. A secondary goal was to determine the effect of resident involvement on outcomes. Thus, an analysis was performed to examine differences in overall complications, need for reoperation, and readmission rates among anterior urethroplasties involving residents versus those that did not. Results: A total of 326 single stage anterior urethroplasties were reported over the study period; 222 (68.1%) were performed as inpatient procedures, and 104 (31.9%) were performed as outpatient procedures. No stringent guidelines are published defining inpatient vs.outpatient procedures in the NSQIP database, however the mean length of stay for an inpatient procedure was 1.9 days vs. 0.43 days for an outpatient procedure. A linear regression model was created for 2010-2012, years with greater than 50 cases reported, which demonstrated a significant decrease in inpatient procedures (R2=0.91) and a significant increase in outpatient procedures (R2=0.91). (Figure 1)
Page 4 of 12
5
Patient demographics for those managed inpatient versus outpatient are shown in Table 1. The mean operative time for inpatient procedures exceeded that of outpatient procedures by 59 minutes (p <0.01). There was no significant difference in ASA scores, BMI, smoking status, or proportion of patients with diabetes between groups. Patients receiving inpatient management were significantly younger. A comparison of 30-day complication rates is shown in Table 2. The most common complication was urinary tract infection, which was consistent between inpatient (2.7%) and outpatient (2.9%) procedures. There was a trend towards increased superficial wound infection in outpatient urethroplasty that did not reach significance. (0.45% vs. 1.92% p = 0.19). The rate of wound dehiscence, however, was significantly higher for outpatient procedures (1.92% vs. 0%, p = 0.03), although the overall incidence was low. There were no significant differences in the rates of bleeding, deep vein thrombosis, graft failure, pneumonia, MI, or sepsis. Reoperation rates and readmission rates were higher for inpatient urethroplasty, though these differences did not reach statistical significance. For cases with available data, 136 involved residents, whereas 48 did not. Resident involvement was associated with a significantly decreased rate of reoperation (0% vs 8.3% p<0.001). Although cases involving residents had an increase in mean operative time of 42 minutes, there was no significant difference in any complication. Discussion: Performance of outpatient surgical procedures is rising nationwide.1,9 Increased utilization of ambulatory surgical centers theoretically affords the potential to improve efficiency and outcomes, and possibly reduce the cost of care relative to inpatient management. National data suggests that there has been a significant shift in site-selection for anterior urethroplasty.
Page 5 of 12
6
Although outpatient management was associated with a higher rate of wound dehiscence, the overall rate was low and this was the only complication with a statistically significant association. The existing data to support outpatient anterior urethroplasty is limited. Following review of 54 such cases, including those with up to a 23-hour hospital stay, Lewis et al reported 93% success with short follow-up.3 In that series, outpatient cases were associated with shorter operative times and patients were younger and had shorter strictures compared to those that received inpatient management. In 2005, MacDonald et al reported a “minimal impact surgery” protocol including local anesthetic, a COX-2 inhibitor, and cold compresses postoperatively that shortened mean hospital stay to seven hours.4 In the second half of their study period, 85% of anterior urethroplasties were performed outpatient, and success was reported as 97% at a mean follow-up of 27 months. Similar to the previously mentioned series, patients admitted to the hospital had a mean age increase of 7 years. Based on questionnaires given to patients discharged less than 24 hours after urethroplasty, 89% felt this was appropriate.10 However, 56% reported moderate difficulty with mobility and 24% reported severe problems with usual care. To date, this represents the largest comparison of site-selection for anterior urethroplasty and associated outcomes. This study has a high level of external validity, as the data is from a nationwide database reported by multiple different surgeons. However, it is not without several limitations. Anterior urethroplasties are quite heterogenous and specific details that would attest to complexity are not captured within the NIQIP database. Stricture length, location, etiology, and the number of prior procedures are all relevant to surgeon decision-making. It has not been shown, however, that any of these specific items should dictate whether or not a patient can be discharged home from the recovery room. At our center, for example, all patients undergoing
Page 6 of 12
7
posterior or anterior (anastomotic or substitution) urethroplasty are kept for 23-hour observation. This is regardless of the nature or number of prior surgeries, length of graft, or operative time. Operative time could be considered a surrogate marker for case complexity, and in this review inpatient cases, on average, took an hour longer but with no significant increase in complications. Admittedly, there was a trend towards an increased rate of reoperation and readmission, however these did not reach significance. The only statistically significant difference in 30-day complications was for wound dehiscence (1.92% outpatient vs 0% inpatient, p = 0.03). It is unclear if this could be related to the level of postoperative activity since those cases managed inpatient had an average stay of 1.9 days. Also, the clinical significance of dehiscence is unclear since none of the outpatient cases required reoperation within 30 days and no long-term data is available to determine rate of subsequent fistula formation or stricture recurrence. Resident involvement was associated with a significantly decreased rate of reoperation (0% vs 8.3% p<0.001) and no difference in complications. There was an increase in mean operative time of 42 minutes for cases involving residents. Similarly Löppenberg et al noted that resident involvement increased the operative time for hydrocele surgery, without increasing rates of complications.11 Looking at outpatient plastic surgical procedures, Massenburg et al. also found no association between resident participation and complications.12 One could speculate that increased operative time may be related to teaching, or possibly increased complexity, as occasionally seen in cases referred to tertiary care centers. Clearly, there are patient factors that can guide the need for admission apart from details specific to their urethral stricture disease and type of repair. Anesthesia providers may encourage longer observation for patients based on comorbidities and hemodynamic parameters during or
Page 7 of 12
8
after surgery. Based on this study of national data, there was no significant difference in the patient populations by ASA scoring. It is unknown, however, if some of these patients were selected for efforts targeting preoperative optimization. Additional data analysis may allow development of a model to predict the need for postoperative admission.
Conclusions: Nationally, performance of anterior urethroplasty is shifting toward outpatient management. Although the overall 30-day complication rates are low in both the inpatient and outpatient setting, the statistically significant elevation in wound dehiscence after outpatient urethroplasty could be clinically significant when applied to the total number of cases nationwide. Resident involvement is associated with longer operative times, but no increase in adverse outcomes and, actually, a decreased rate of reoperation. While further research may offer additional clarity to this issue, the available evidence seems to strongly support that outpatient management is appropriate for single stage anterior urethroplasty.
Page 8 of 12
9
References 1) Cullen KA, Hall M, Golosinskiy A. Ambulatory Surgery in the United States, 2006. Natl
Health Stat Rep. 2009; (Number 11). 2) Mandal A, Imran D, McKinnell T, Rao GS. Unplanned admissions following ambulatory plastic surgery--a retrospective study. Ann R Coll Surg Engl. 2005; 87(6): 466-468. doi:10.1308/003588405X60560. 3) Lewis JB, Wolgast KA, Ward JA, Morey AF. Outpatient Anterior Urethroplasty: Outcome Analysis and Patient Selection Criteria. J Urol. 2002; 168(3):1024-1026. doi:10.1016/S0022-5347(05)64566-1. 4) MacDonald MF, Al-Qudah HS, Santucci RA. Minimal impact urethroplasty allows sameday surgery in most patients. Urology. 2005; 66(4):850-853. doi:10.1016/j.urology.2005.04.057. 5) National Surgical Quality Improvement Program [home page on the Internet] Chicago, IL: American College of Surgeons; 2005. [cited 2016 May 17]. Available from: www.acsnsqip.org. 6) Bastiampillai R, Lavallee LT, Cnossen S, et al. Laparoscopic nephroureterectomy is associated with higher risk of adverse events compared to laparoscopic radical nephrectomy. Can Urol Assoc J. 2016; 10(3-4):126-31. 7) Packiam VT, Cohen AJ, Nottingham CU, Pariser JJ, Faris SF, Bales GT. Open Versus Minimally Invasive Adult Ureteral Reimplantation: Analysis of 30-Day Outcomes in the National Surgical Quality Improvement Program (NSQIP) Database. Urology. 2016; (16)30221-7. pii: S0090-4295(16)30221-7. doi: 10.1016/j.urology.2016.05.025 8) Semerjian A, Zettervall SL, Amdur R, Jarrett TW, Vaziri K. 30-Day morbidity and mortality outcomes of prolonged minimally invasive kidney procedures compared with shorter open procedures: national surgical quality improvement program analysis. J Endourol. 2015; 29(7):830-7. 9) Kaye KW. Changing trends in urology practice: increasing outpatient surgery. Aust NZ J Surg. 1995; 65(1):31-34. 10) Okafor H, Nikolavsky D. Impact of Short-Stay Urethroplasty on Health-Related Quality of Life and Patient’s Perception of Timing of Discharge. Adv Urol. 2015;2015:806357. doi:10.1155/2015/806357. 11) Löppenberg B, Cheng PJ, Speed JM et al. The effect of resident involvement on surgical outcomes for common urologic procedures: A case study of uni- and bilateral hydrocele repair. Urology. 2016; pii: S0090-4295(16)30097-8. doi: 10.1016/j.urology.2016.03.045. 12) Massenburg BB, Sanati-Mehrizy P, Jablonka EM, Taub PJ. The impact of resident participation in outpatient plastic surgical procedures. Aesthetic Plastic Surg. 2016; 40(4):584-91.
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Figure 1 – Trends in Urethroplasty
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Table 1 – Characteristics of Procedures Inpatient Procedure Time
Outpatient
p value
178.91
119.22
<0.001
1.9
0.43
<0.001
Average Age
46.9
52.2
0.009
BMI
30.5
30.7
0.066
ASA 1
18.47%
11.54%
0.113
ASA 2
47.30%
50.00%
0.649
ASA 3
31.53%
37.50%
0.287
ASA 4
2.70%
0.00%
0.09
Days to Discharge
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Table 2 – 30 Day Complication Rates Inpatient
Outpatient
p value
Wound Infection
0.45%
1.92%
0.194
Dehiscence*
0.00%
1.92%
0.038
UTI
2.70%
2.88%
0.925
MI
0.45%
0.96%
0.581
DVT
0.45%
0.00%
0.493
Readmission
2.25%
0.96%
0.419
Reoperation
1.80%
0.00%
0.168
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