New recommendations to reduce unnecessary blood tests after robot‐assisted radical prostatectomy

摘要

Radical prostatectomy (RP) is a standard treatment for men with localised prostate cancer. Robot-assisted RP (RARP) is associated with fewer intraoperative adverse events, reduced blood loss and lower complication rates compared to open and laparoscopic RP but delivers comparable oncological and functional outcomes [1]. Furthermore, the use of Enhanced Recovery after Surgery (ERAS) pathways for RARP, have improved patient recovery and experience, reducing costs and maintaining patient safety [2]. Despite the increased use of RARP and adoption of ERAS pathways, the historical practice of routine postoperative blood tests (POBT) remains common. No national or international guidelines exist to aid clinicians to decide whether a patient requires POBT after RARP. The aim of our present study was to evaluate the safety value of omitting routine POBT after RARP, and to propose recommendations to rationalise their use in clinical practice. The study followed established ‘Plan, Do, Study, Act’ (PDSA) quality improvement methodology [3]. The study aims were defined as above and outcomes were defined as below (‘Plan’). Baseline data were collected from a retrospective review (‘Do’) and analysed according to the plan (‘Study’). New recommendations were created based on the retrospective review and prospectively assessed (‘Act’). Routine prospectively collected perioperative data were retrospectively aggregated from 1040 consecutive patients who underwent RARP with ERAS from 2017 to 2019 in two high-volume tertiary centres in the UK. Data collected included: preoperative patient demographics (age, body mass index [BMI], American Society of Anesthesiologists [ASA] and Charlson CoMorbidity Index [CCI] score), intraoperative data (operative time, estimated blood loss [EBL], blood transfusion, nerve sparing, pelvic lymph node dissection [PLND], and complications), and postoperative data (clinical signs and symptoms, length of stay [LOS], transfusion, and 30-day Clavien–Dindo complications). Subjective intraoperative difficulties, such as difficult dissection and difficult anastomosis, were not regarded as complications. In addition, data related to the timing of discharge and ordering, taking, analysing, and reporting of POBT were collected. All patients had a minimum of 30-days of follow-up. From the retrospective review, 72% of patients were found to have no pre-, intra- or postoperative clinical concerns but still had routine POBT; no patients in this cohort developed a complication. Detailed pre-, intra- and postoperative parameters are presented in Table 1. A total of 1040 patients were used to help construct the recommendations and 300 patients were used to assess the new recommendations. Thus, 1340 patients were included in total. The median (interquartile range [IQR]) follow-up was 90 (78-98) days. Across the study population, the median age was 63 years, BMI was 28 kg/m2 and the ASA score was 2. In all, 345 (26%) patients had a CCI score of ≥1, with diabetes being the most common comorbidity in 15% of patients. There were no statistically significant differences between the two datasets for preoperative characteristics. As per European Association of Urology (EAU) intraoperative adverse incident classification, there were two Grade II events (two bowel repairs), four Grade III events (three bowel repairs and one vascular injury), and no Grade ≥IV events. Clinical concerns, defined as suspicion raised by the clinical team as per the recommendations, were reported in 221 (16%) patients, the most common concern was increasing abdominal pain in 75 patients (6%). The overall postoperative 30-day Clavien–Dindo complication rate was 5%. The most common complication was a haematoma, occurring in 21 (2%) patients. A total of 3% of patients went to HDU due to premorbid or intraoperative concerns and 4% had an intraoperative concern flagged by the operating surgeon. In 16% clinical concerns were raised by the surgical team postoperatively. The p