Careful patient selection required for same-day discharge after BPH procedures

Michael A. Palese, MD

Same-day discharge following certain procedures for benign prostatic hyperplasia (BPH) may be highly desirable by both patients and insurance providers, but careful patient selection is required when considering this pathway, according to Michael A. Palese, MD. In this interview, Dr. Palese discusses the recent Urology study, “The utilization and safety of same-day discharge after transurethral benign prostatic hyperplasia surgery: a case-control, matched analysis of a national cohort.”¹ Dr. Palese is the chairman of the department of urology and a professor of urology at the Icahn School of Medicine, Mount Sinai, New York, New York.

Could you give an overview of this study and discuss some of the key findings?

The impetus for doing this study was to evaluate how urologists in this country deal with patients when they come in for BPH surgeries, specifically surgeries that have to be done in the hospital or ambulatory setting, such as transurethral resection of the prostate [TURP], GreenLight laser, and holmium laser enucleation of the prostate [HoLEP]. There is a lot of pressure on urologists to get these patients out of the hospital, usually the same day. We wanted to see what's really happening around the United States and how other urologists are dealing with this, not only to make sure that clinically, we're taking care of our patients, but also to deal with the headwinds that come from the insurance companies attempting to minimize costs. We have to navigate what's right and what's wrong and how we deliver the best care that we can for our patients.

We looked at the NSQIP [National Surgical Quality Improvement] data set, which allowed us to look at ambulatory and inpatient cases for TURP, GreenLight laser, and HoLEP. We looked at how many patients actually had a same-day procedure, which patients had to be admitted, and which ones required a reoperation, transfusion, or admission. There are some limitations with a study like this, of course, it's a de-identified database; we don't identify the surgeon; we don't really know the characteristics of the prostatic anatomy; we don't know exact comorbidities beyond basic Charlson comorbidities. But what this study does is give us is a big picture of what's actually being done in the United States. We were able to identify over 50,000 cases being done within a 5-year period and after case control and matching criteria we had a robust data set of about 45,000 patients.

The vast majority of patients underwent TURP, followed by GreenLight laser and then HoLEP. Each of these procedures told a different story. Between 2015-2019 approximately two-thirds of patients undergoing GL-PVP were discharged on the same day, while less than one-third and one-quarter of patients undergoing HoLEP and TURP underwent ambulatory procedures, respectively.

HoLEP is a procedure that is still in its infancy in many ways and only accounts for a small percentage of patients undergoing endoscopic treatment of their BPH. But in this subgroup, for the vast majority, we did see that the same-day admission rate went up during the study period. This may be a function of experience; as time goes on, surgeons become more comfortable with the technique, and therefore they're much more comfortable sending their patients home on the same day and surgeons are also likely selecting their patients better for same day discharge.

For TURP, the same-day discharge rate stayed about the same during the five year study period—about 30% of patients are able to have same-day surgery with TURP. That didn't change throughout the entire study period. What that tells me is that there is a certain patient selection that is taking place; urologists are doing a pretty good job of making sure that patients that can be done as a same-day surgery are being done so; the rest are being admitted appropriately and monitored appropriately.

With GreenLight laser, we didn't see much of a change during the study period. There was a slight decrease in the amount of admissions over time and subsequently a small increase in same day surgery.This subgroup of patients are more likely to undergo same day surgeries in comparison to the other techniques.

One trend we observed was that if the surgical operative time went beyond the 75th percentile in terms of time, these patients were more likely to have an admission. That makes sense; these are likely larger glands and more complicated procedures, and therefore they would lead to a higher level of postoperative care.

Overall, these findings tell us that not everyone can undergo a same-day surgery for BPH. There should be a standardized selection criteria. There are always going to be patients that need to be admitted after these types of procedures and overwhelmingly most patients do need at least an overnight admission.Clearly, a certain smaller percentage of patients can always be done as same-day surgery.

What advice would you give other providers about doing same-day discharge after transurethral BPH surgery?

You need to select your patients appropriately. Patients with larger glands, will take longer, they're more likely to have postoperative bleeding and potentially require continuous bladder irrigation. These are the patients that we're going to be keeping a little bit longer and are probably not going to be appropriate for same-day surgery. Patients with smaller glands, with no comorbidities, who are not on blood thinners, who may have had a procedure beforehand—these are all great potential candidates for same-day surgery. In my own practice, if I send a patient home the same day, I'll generally leave a catheter in them and see them in the office the next day. We tend to have quite a bit of success doing that. But again, these are carefully selected patients.

What else can be done to further lower 30-day unplanned readmission rates for surgical patients who are discharged the same day?

There are a lot of different tips and tricks, including putting patients preoperative 5 alpha reductase inhibitors such as Proscar [finasteride] or Avodart [dutasteride] in an effort to reduce the potential for postoperative bleeding. Some providers have talked about doing prostate artery embolization to minimize postoperative bleeding. These are legitimate options that could reduce the chance of postoperative bleeding and therefore increase the chance of same-day surgery viability. The jury's still out as to whether these are going to be mainstay strategies.

What would you say is the take-home message for the practicing urologist?

The take-home message is that there's no question that many patients can be done as a same-day ambulatory procedure. But you need to look at the criteria as to who you're going to keep and who you're not going to keep. Selection is absolutely the key for same-day discharge. Lining up expectations with patients is also an important part of making the correct choice. Patients need to understand that even if you tell them that you may be doing this as an ambulatory procedure, they may actually have to stay afterwards, depending on what you find in the operating room or what happens in the postoperative period. They need to know that you're doing this for their safety and for their clinical well-being. These are 2 separate issues: patient selection and managing expectations. These are common with any surgeries but particularly in the case of same-day discharge, it's very important to do address both.

Is there anything else that you feel our audience should know about the research?

This is a work in progress. As a population study with de-identified data there are going to be limitations. Future studies will be needed to further elucidate the evolution and feasibility of same day surgery with BPH surgeries. But this study does give urologists justification for pushing back on insurance companies insisting that BPH surgery should be exclusively ambulatory.

Reference

1. Garden EB, Ravivarapu KT, Levy M, et al. The utilization and safety of same-day discharge after transurethral benign prostatic hyperplasia surgery: a case-control, matched analysis of a national cohort. Urology. Published online February 6, 2022. doi:10.1016/j.urology.2022.01.037