Pain is the most common clinical barrier to same-day discharge after percutaneous nephrolithotomy

ABSTRACT

INTRODUCTION AND OBJECTIVE: The COVID-19 pandemic has provided an impetus to reconsider traditional urologic practices and adapt to the unprecedented healthcare burden. Reducing length of stay after minimally invasive procedures is now more important than ever. Using percutaneous nephrolithotomy (PCNL) as a model, we sought to evaluate clinical barriers to same-day discharge in order to better understand the feasibility of outpatient surgery. METHODS: Prospective data collected from 500 inpatient PCNLs performed at our institution between 2016 and 2020 was analyzed via the Registry for Surgery of the Kidney and Ureter (ReSKU). Preadmissions and aborted procedures were excluded. We analyzed clinical problems and complications that warranted postoperative admission. Major categories included infection, bleeding, and excessive pain, which was defined as either a documented pain complication or administration of intravenous opioids within 24 hours after discharge from the recovery room. Multivariate statistics were used to assess risk factors for each outcome. RESULTS: Excessive pain was the most common postoperative problem (40.9%). ASA score was inversely correlated with odds of having increased pain (OR 0.64, 95% CI 0.42-0.98) and was the only statistically significant predictor in our multivariate model that included dilated tract number, diameter, and location. The postoperative SIRS/sepsis rate within 7 days was 9.7%, and higher ASA score (OR 3.6, 95% CI 1.8-7.6) and incomplete stone clearance (OR 2.7, 95% CI 1.2-6.3) were significant predictors. Age, sex, body mass index (BMI), stone burden, and positive preoperative urine cultures were not associated with overall infection rate. In patients who had a postoperative infection, 34.1% of infections were detected intraoperatively or in the recovery room, and 48.8% were associated with the nephrostomy tube removal process on postoperative day 1. Patients who had a postoperative double-J stent rather than a nephrostomy tube had a lower overall infection rate (1.8%, p = 0.047). Finally, only 1.9% of patients had a bleeding complication, and 1.1% required a blood transfusion. CONCLUSIONS: Excessive pain is the most common clinical barrier to same-day discharge after PCNL and affects nearly half of all patients. Bleeding is infrequent, and most infections can be recognized perioperatively or avoided with alternative tube management strategies. Rigorous patient selection for same-day discharge does not appear to be necessary. Optimizing pain control may be the key to performing outpatient surgery on a large scale.