Laser endoscopic enucleation of the prostate (EEP) is becoming increasingly popular worldwide for the treatment of benign prostate obstruction. In order to save medical costs and reduce the risk of nosocomial infection, the safety and effectiveness of discharge from the hospital the day after surgery have become the focus of attention. The aim of this article is to evaluate existing research on laser EEP as a treatment for day surgery (DCS). In fact, laser EEP is feasible and promising as a treatment option for DCS, which is able to provide better functional parameters compared to baseline values and reduce perioperative complications and readmission rates in some patients. Laser EEP is a safe and effective treatment with high clinical value, both for first-time and returning patients.
With the increasing popularity of laser EEP surgery worldwide, urologists have gained more experience. As the results of the surgery began to emerge, people began to wonder if this type of surgery could be performed on an outpatient basis, and while day surgery may raise patient safety concerns, the advantages are just as clear. Shorter hospital stays help reduce the risk of nosocomial infections [31], while patients may have fewer complications, which indirectly reduces the cost of treatment. Therefore, from an economic point of view, day surgery has significant advantages. In addition, this results in significant savings in post-operative human resources. To the best of our knowledge, our study is the first time in the literature that laser EEP has been looked at from the perspective of day surgery. In the studies we reviewed, functional parameters also improved as expected.
In this review, we found that the success rate of day surgery ranged from 35.3% to 100%, with an average success rate of 78.2%. In prospective studies, the readmission rate ranged from 0% to 17.8%, while the average readmission rate was 8.8%. We note that haematuria is the most common cause of hospital readdowns. Therefore, effective hemostasis is essential for patients undergoing day surgery. In addition, the color of the urine should be closely monitored and adequately flushed after surgery to prevent bleeding complications. Some of the studies in this review specifically explored GL-PVP or ThuVEP [15,26]. It is hypothesized that vaporization may reduce bleeding and postoperative hematuria and thus may have certain advantages over laser anatomical endoscopic enucleation of the prostate. However, it is important to emphasize that the comparative data provided by the currently included studies are not sufficient to substantiate this hypothesis, especially in relation to the SDD.
We assessed the complication rates of the studies and found them to range from 0% to 36.7%. Of these, the vast majority of complications were classified as Clavien-Dindo class I-II, with reported rates ranging from 3.64% to 21.8%. The complication rate of Clavien ≥ III ranges from 0.34% to 10.7%. In studies comparing SDD with non-SDD groups, we found no significant difference in the rate of complications between the two groups for Clavien III and above [18,25,26]. In addition, the complication rate of Clavien IV is extremely low, ranging from 0% to 1.8%. Laser EEG surgery has become very common, and urologists have gained experience with this type of surgery over their years of experience, which is one of the most important reasons for the low incidence of serious complications. Klein et al. observed that the success rate for SDD has increased from 70 to 87 percent over the past few years [17]. In addition, laser EEP as a day intervention is now considered a viable alternative. In the Guo et al. survey, they asked the intraoperative and postoperative surgical teams for SDD after HoLEP [32], and 96% of the health professionals involved in the study agreed that it was safe to perform SDD after HoLEP.
"Another possible reason for the lower complication rate in patients with SDD is that patients who undergo surgery on the same day belong to a specific population that is carefully selected. As far as is known, laser EEG has quite strict selection criteria for the average patient. Laser EEP can be treated with laser EEP for most patients with LUTS due to BPE, regardless of prostate size, history of previous surgery, urinary retention, impaired non-neurogenic bladder contractility, conditions requiring retreatment, and patients on anticoagulation. Laser EEP is more appropriate for patients with prostate cancer who have symptoms of obstruction, patients with benign prostatic hyperplasia who require retreatment, or patients who also require surgery for other conditions (such as bladder stones), which tend to have better functional outcomes and lower complication rates.
However, there is no consensus in the literature on which patients are best suited to make up a particular group of patients for day surgery. When assessing the success of DCS, certain characteristics of the patient, such as age, ASA status, prostate volume, and anticoagulant use, may be considered. A retrospective study in France showed that age, ASA score >2, large prostate size, and anticoagulant use were all associated with the risk of DCS for HoLEP complications. In addition, Kosiba et al. found that prostate volume and high ASA scores were important predictors of major complications after HoLEP surgery. In this study, some of the studies reviewed excluded patients with ASA>2 and/or older patients. In some studies, the use of anticoagulants was an exclusion criterion, while in others, patients with ASA>3 were not eligible for same-day surgery. Another study showed that the distance between the patient's home and the emergency ward was also a reason for exclusion.
In general, patients with high ASA scores, elderly patients, and/or patients receiving anticoagulation are excluded, a fact that may explain the association with a lower rate of complications after laser EEP DCS. In defining day surgery, the average prostate size of patients, the duration of indwelling urinary catheters, and even postoperative discharge time varied from study to study. Although the studies reviewed did not have uniform patient selection criteria, their reported low perioperative complication rates and generally low Clavien-Dindo I-II complication rates suggest that the promise of laser EEP for day surgery looks quite promising. In addition, it is noteworthy that even after some urological and general surgical procedures are performed at the same time as laser EEP, it is possible to be discharged on the same day, considering the scope of application of SDD after laser EEP. It should be emphasized, however, that there is a need for consensus on specific patient selection criteria for DCS. "
In our evaluation study, predictors of day surgery success and hospital readmissions were identified. Prostate size is one of these factors. Currently, it is unclear what the maximum prostate size to rule out SDD after laser EEP surgery. Studies have found that surgery in the morning and a prostate gland less than 40g are factors affecting the success of surgery. It has also been reported that a prostate size greater than 90ml is an important factor in SDD failure after laser EEP surgery. Other studies have confirmed that day surgery can be successful for a 175 cc prostate. The average prostate size in our review studies ranged from 35±11.4 to 229 ml. Therefore, we can conclude that medium to large prostates are suitable for SDD after laser EEP surgery. Independent predictors of hospital readmissions after laser EEP surgery were analysed: bleeding disorders (odds ratio (OR) 2.89, 95% confidence interval (CI) 1.63e5.11, P < 0.001), American Society of Anesthesiologists (ASA) score ≥3 (OR 1.80; 95% CI 1.21–2.70; P = 0.004) and high frailty burden (OR 1.67; 95% CI 1.03–2.71; P = 0.038）。 Another interesting study found that low ASA scores and advanced age were important risk factors for SDD failure. The authors of these studies explained that most of their study patients with an ASA score of 2 could not be discharged on the same day because they were receiving antiplatelet therapy and needed more attention to ensure hemostasis. On the other hand, Abdul-Muhsin et al. reported in their study significant predictors of early discharge or readmission after laser EEP surgery. In the studies we assessed, factors such as age, ASA score, prostate size, and bleeding disorder/anticoagulant use appear to be the main predictors of success in SDD.
"In addition to prostate size and ASA score, it is important to remember that, as with other types of surgery, the surgeon's experience and the hospital's caseload are general factors that affect the success of the surgery. A multicenter study by Khene et al., which included six surgeons and 992 patients who underwent GreenLight laser EEP, showed that surgical experience was associated with shorter enucleation and crushing times (P<0.001) and lower intraoperative complication rates (P<0.001) was associated with improvement in IPSS at three months postoperatively (P=0.004) [37]. Another multicenter study of 5 centers, 39 surgeons, and more than 1000 cases of HoLEP showed that greater surgical experience had a positive impact on the timing of surgery and enucleation and helped reduce postoperative urinary incontinence [38]. Therefore, we can conclude that the caseload of experienced surgeons and centers for successful perioperative DCS after laser EEP is critical for patient safety. Another important factor in the success of DCS is having a skilled and well-trained postoperative care team [12], which is critical for SDD decision-making for patients. After the patient leaves the operating room, the team monitors vital sign parameters, urine color, hematuria severity, and notifies the surgeon in charge and decides whether the patient will be discharged on the same day based on the follow-up of the postoperative care team. Post-operative care teams need to be specially trained and aware of day surgery. Ideally, day surgery nursing staff should not be changed frequently, and we recommend putting together a list of surgeries based on the number of days these trained nurses are on duty. "
There are a few points worth adding about nosocomial infections, and why SDS may be beneficial? In the studies we reviewed, there were no data showing a relationship between length of hospital stay and the risk of nosocomial infection. However, the literature shows that the risk of nosocomial infections increases with prolonged hospital stays. In addition, the 2023 UTI guidelines of the European Association of Urology clearly state that one of the most effective ways to prevent nosocomial infections/urosepsis is to shorten the length of hospital stay. Since same-day discharge also means a short hospital stay, we believe that it is advantageous in terms of preventing nosocomial infections.
"Based on the available literature, HoLEP and GreenLight vaporization are economically superior to TURP and OP because they are associated with shorter hospital stays and lower complication rates [40,41,42]. On the face of it, DCS may have a financial advantage due to the reduced length of hospital stay, lower nosocomial infection rates, and the consequent reduction in potential treatment costs. A large number of studies in this review suggest that SDS may be economically beneficial. However, only one study conducted a cost analysis comparing m-HoLEP with standard HoLEP. It is important to emphasize that this study did not conduct a cost analysis comparing patients who were discharged on the same day with those who were not discharged on the same day. Therefore, although we can hypothesize the potential cost-effectiveness associated with SDS, there is still insufficient evidence to confirm these predictions, which constitutes a significant limitation of this study. In addition, there are considerable differences in healthcare policies, systems, surgical costs, and reimbursement policies in different countries. Therefore, considering daily surgical expenses, post-operative patient readmissions and associated reimbursement will help evaluate potential cost savings. We believe that to conclusively determine the cost savings implications of DCS, it is essential to thoroughly evaluate the different reimbursement policies and readmission costs. "
"Laser endoscopic enucleation of the prostate as a day surgery has a feasibility and broad prospects. It is able to improve the functional status of some patients and reduce the risk of perioperative complications and hospital readmission. However, the question of which patients are suitable for this type of daily surgery remains unanswered. We suggest that a larger prospective study should be conducted to recruit more patients to determine the appropriate patient criteria for laser endoscopic surgery as a day surgery. In this way, we can more fully demonstrate the practicality and feasibility of laser endoscopic surgery as an outpatient procedure. "
Cite this article
Yilmaz, M., Karaaslan, M., Polat, M.E. et al. Is day-case surgery feasible for laser endoscopic enucleation of the prostate? A systematic review. World J Urol 41, 2949–2958 (2023). https://doi.org/10.1007/s00345-023-04594-7
