Radical Prostatectomy: 
Dramatically Lowered Risk of Complications               

If this were 1991 and you were about to undergo a radical prostatectomy, you would expect to be in the hospital for at least a week. Today, you will most likely go home in one to two days. This and other aspects of postoperative recovery in thousands of patients who underwent radical prostatectomy at Johns Hopkins were studied recently in a review of the changing "clinical care pathway" from surgery to discharge from the hospital. The analysis, by Phillip Pierorazio, M.D.; Jeffrey Mullins, M.D.; Ashley Ross, M.D., Ph.D.; Elias Hyams, M.D.; Alan Partin, M.D., Ph.D.; Misop Han, M.D.; Patrick Walsh, M.D.; Edward Schaeffer, M.D., Ph.D.; Christian Pavlovich, M.D.; Mohamad Allaf, M.D.; and Trinity Bivalacqua, M.D., Ph.D.; was published in the British Journal of Urology.

Radical prostatectomy in the analysis included the retropubic radical prostatectomy (RRP), known as the "Walsh Procedure," pioneered at Johns Hopkins, and a newer minimally invasive version of this procedure; laparoscopic radical prostatectomy (LRP); and robot-assisted laparoscopic radical prostatectomy (RALRP). (This study did not include men who underwent the perineal procedure and men who had previous reconstructive surgery of the urinary tract.)

" Post-operative clinical care
pathways have changed the
way we manage many diseases,
and radical prostatectomy is a
wonderful example."

"The postoperative clinical care pathway after radical prostatectomy has changed dramatically over the past 20 years at Johns Hopkins," says Bivalacqua. The decrease in length of stay has been influenced by factors including "improvements in the knowledge of prostatic anatomy and surgical technique pioneered by Walsh, which have improved blood loss during the operation, decreased the rate of blood transfusion – from between 62 and 89 percent in the 1980s to 0.8 to 3.4 percent most recently – and improved patient convalescence." Other factors include improvements in anesthesia and postoperative pain control; a move driven by both physicians and patients to get out of the hospital sooner; and the difficult economic environment and efforts to decrease costs.

Since 2005, Hopkins has had a one- to two-day clinical care pathway to discharge from the hospital, regardless of surgical approach. It begins with patient-controlled anesthesia, a clear liquid diet, walking the night of the surgery, transitioning to oral pain medications and solid food, and walking a minimum of four times on the day after surgery. All patients are educated about caring for their catheter and what they should expect over the next few weeks by trained nursing staff. For most men, surgical drains are removed before discharge.

Of 18,049 men who underwent radical prostatectomy between 1991 and 2011, nearly 84 percent (15,360) had RRP; nearly 7 percent (1,263) had the LRP; and nearly 8 percent (1,426) chose RALRP. "Interestingly, the average length of stay decreased from 7.7 days in 1991 to 3 days in 1999," says Pierorazio, "and this remained stable until 2004, when the minimally invasive radical prostatectomy emerged here." In 2005, 75 percent of all radical prostatectomies done at Hopkins were RRP; since then, that number has decreased to 60 percent, LRP has remained relatively stable at around 10 percent, and RALRP has increased from 14 percent to 30 percent of all procedures formed.

"In the overwhelming number of cases, an accelerated hospital recovery pathway of one to two days is successful regardless of surgical approach," says Bivalacqua. Only 126 men had a delayed discharge and were considered "off the pathway." The most common reasons for this included bowel obstruction, anemia, blood transfusion or bleeding, blood in the urine, and urine leakage. Most of these complications occurred in the men who underwent RALRP. African-American men also had a slightly higher risk of a longer hospitalization. "There are two important take-home messages from this analysis," says Pierorazio. "First, post-operative clinical care pathways have changed the way we manage many diseases, and radical prostatectomy is a wonderful example. Second, while RALRP had a slightly higher rate of extended hospital stay, at our hospital fewer than 1 in 50 patients were discharged ‘off-pathway.’ This may help manage patient expectations following surgery."

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