ABSTRACT
INTRODUCTION AND OBJECTIVE: Research demonstrates the benefits of robotic-assisted prostatectomies (RARP) in regard to blood loss and post-operative recovery, there is a paucity in the literature regarding RARP as an outpatient procedure. With minimal operating room capacity during COVID-19, advances in minimally invasive surgical techniques and a relatively healthy patient population, outpatient RARP may be feasible. The aim of our study was to demonstrate the safety and feasibility of RARP as a same day outpatient procedure. METHOD(S): A retrospective cohort study at a single institution was performed by four fellowship trained surgeons who routinely perform RARP. Patients were identified through billing records who underwent RARP between January 2019 and December 2021. Patients were divided into two cohorts, inpatient (one stay past midnight) and outpatient (defined as same day surgery with no stay past midnight). Individual surgeons admission necessity during COVID-19 limitations. We then extracted data using the electronic health record (EHR). The two groups were then compared using standard statistical methods for cohort studies. Statistical significance was defined as p<0.05. RESULT(S): Over a two-year period, a total of 497 RARP were performed with 139 (28%) outpatient cases. There was no difference in baseline demographics between the cohorts. There was a statistically significant difference in estimated blood loss (142 vs 102 mLs, p>=0.001) and operative time (193 vs 180 mins, p=0.004) in the inpatient vs outpatient cohorts, respectively. There was no significant difference in cancer stage, prostate size, or node/margin positivity between cohorts. There was a higher rate of readmissions (5% vs 0%, p=0.007) and number of ED presentations (0.15 vs 0.05, p=0.019) in the inpatient group. There was no difference in complication rates between the groups. Importantly, there was no significant difference in burden on the clinical staff demonstrated by no difference in number of phone calls to clinic, number of EHR messages, or opioid prescriptions on discharge. CONCLUSION(S): Overall, our data suggests that in a well selected patient group, RARP can safely be performed as an outpatient procedure with no significant differences on clinic staff workload or oncologic outcomes. While there was no pre-defined "algorithm" to determine outpatient vs inpatient surgery, the similarity in demographics and pre-operative characteristics between the groups lends support to performing this procedure as an outpatient with inpatient admission being reserved for select patients.
ABSTRACT
Rationale: Asthma affects 20 million adults in the United States resulting in up to 500,000 hospitalizations each year. Patients admitted to the intensive care unit (ICU) for asthma exacerbations requiring invasive ventilation have a mortality of ∼7%. Extracorporeal membrane oxygenation (ECMO) is a salvage technique used in patients with respiratory failure to increase delivery of oxygen, remove CO2 and allow time for recovery. Case series and uncontrolled registry studies have examined benefits of ECMO for asthma exacerbations with respiratory failure, but no studies have examined outcomes associated with use of ECMO for asthma exacerbations compared to standard care. Objective: To assess outcomes associated with use of ECMO during asthma exacerbations requiring invasive ventilation compared to standard care. Methods: Patients were extracted from the Premier Database from 2010-2020 if they had a primary diagnosis of asthma, or a primary diagnosis of respiratory failure with a secondary diagnosis of asthma, and were treated with invasive ventilation. Patients were excluded for age < 18y, no ICU admission, chronic lung disease other than asthma, COVID-19, or if they were not treated with corticosteroids. Hospital mortality was the primary study outcome. Key secondary outcomes included ICU length of stay (LOS), hospital LOS, length of invasive ventilation and hospital costs. Differences in outcomes were assessed using propensity score matching at a 1:2 ratio of ECMO versus no ECMO, and by covariate adjustment of the entire study group. Results: A total of 20,494 patients with asthma exacerbations requiring invasive ventilation were included in the study, of which 130 were treated with ECMO and 20,364 were not. After propensity matching, ECMO (N=103) versus no ECMO (N=206) was associated with reduced mortality (11.4% vs. 23.3%, p = 0.017) and increased hospital costs, but no difference in ICU LOS, hospital LOS or length of mechanical ventilation (Table). The covariate-adjusted model replicated these findings (Table). When individual patients were assigned a probability of being treated with ECMO equal to the hospital rate where they were admitted, each 10% increase in the hospital rate of ECMO was associated with no change in the odds of mortality (OR, 1.12: 95% CI, 0.82-1.52), p=0.48). ECMO was also associated with increased renal replacement therapy (P = 0.02), shock (P=0.02) and 30-day all-cause readmission (P = 0.01). Conclusion: ECMO was associated with reduced mortality at the cost of increased morbidity in asthmatics requiring invasive ventilation, indicating that ECMO has the potential to save thousands of lives.