Prostate cancer is the most common cancer diagnosed in men in the United States.[1] Robot-assisted laparoscopic prostatectomy (RALP) is the gold standard surgical treatment for localized prostate cancer, and is frequently performed by urologic oncologists at UCSF, with over 300 cases performed annually.[2]     

Typically, patients undergoing RALP are admitted postoperatively for one night for monitoring and postoperative education. Over the past 15 years, there has been increased interest from the urologic community in performing RALP with same-day discharge (SDD).[3] The COVID-19 pandemic accelerated uptake of RALP SDD, as surgeons and hospitals attempted to conserve critically needed hospital beds and minimize hospital-acquired infections. Indeed, SDD is no longer a novelty, with high-volume surgeons and institutions performing up to 59% of their RALP cases with SDD.[4]    

The argument for RALP with SDD from a healthcare value perspective is simple: RALP with SDD can reduce health care costs and increase surgical efficiency. Two studies to date have estimated the cost savings associated with SDD in the United States. Cheng et al. demonstrated a $2,106 (19%) overall cost reduction per patient who underwent SDD versus inpatient RALP at two academic medical centers.[5] Abaza et al. estimated the cost of an overnight admission at $2,109 per patient in a community setting.[6] Of note, neither of these studies were performed at outpatient surgery centers, and do not account for additional potential cost-savings associated with performing RALP with SDD at an outpatient center.  Similarly, neither study accounted for additional indirect cost savings derived from freeing the use of inpatient beds and personnel for other patients, which has previously been estimated to be $1,652 per patient at our institution. 

There is ample evidence that RALP with SDD can be performed safely. A meta-analysis by Uy et al. of 14 studies found no differences in ≥grade 3 Clavien-Dindo complications (RR: 0.4, 95% CI 0.2, 1.1, p 0.07), 90-day readmission rates (RR: 0.6, 95% CI 0.3, 1.1, p 0.10) or ED visits (RR: 1.0, 95% CI 0.3, 3.1, p 0.97) amongst patients undergoing SDD versus inpatient RALP.[7] Similarly, a recent systematic review by Najdawi et al. of 16 studies published between 2020-2024 assessing outcomes after SDD versus inpatient multi-port RALP demonstrated that complication rates, ED visits, and readmission rates were not negatively impacted by same-day discharge.[8] (To the contrary, two studies reported favorable outcomes in the SDD cohorts.)[6,9]   

Patient satisfaction with RALP SDD has been shown to be high, with satisfaction rates between 87.5% and 100%.[3,5,8] Early mobilization and return to “normal” life/work are priorities amongst patients undergoing RALP, and SDD may facilitate meeting these goals.[10] Patient quality and safety will be a priority and these outcomes will be tracked during this project to ensure safe implementation. 

Historically, the UCSF Department of Urology has taken a thoughtful and conservative approach towards adopting RALP SDD. The department recently performed RALP SDD for a small minority of patients in 2024. Contemporary evidence on the favorable cost-savings, safety, patient satisfaction, and feasibility of RALP SDD, combined with new SDD capacity at the Bayfront Outpatient Surgery Center, offers a unique opportunity to maximize healthcare value in our department. We propose development of an evidence-based RALP SDD pathway, with a goal of increasing the proportion of RALP procedures performed with SDD to 30%.    

Key target: to increase the proportion of RALP procedures performed with SDD to 30% within 1 FY. This is an attainable goal based on published experiences at other institutions: at Brigham and Women’s, the proportion of SDD cases increased from 4.4% to 45% over the course of 1.75 years; amongst a single surgeon at OhioHealth Dublin Methodist Hospital, the proportion of SDD cases increased to 49.2% 21 months after introduction of a SDD pathway; amongst a French surgeon’s patient cohort the proportion of SDD was 59% one year after introduction of a SDD pathway.[11,6,4] We further aim to ensure that patient safety, equity, and satisfaction are not compromised as a result of our intervention.   

To track and promote progress towards our goals, we plan to measure the following performance indicators over time for each target:    

Percentage of all patients undergoing RALP who are eligible for SDD per our selection criteria   

Percentage of patients who are eligible for SDD per our selection criteria who are offered SDD by their surgeon   

Percentage of all patients undergoing RALP who elect to undergo SDD   

Percentage of all patients undergoing RALP who successfully undergo SDD   

For patients who are offered and elect to undergo SDD, we will track their progress through each phase of the SDD pathway, thereby identifying any roadblocks to success.   

We will explore patient motivations for electing SDD versus inpatient RALP   

Rates of Clavien-Dindo complications amongst patients undergoing SDD versus inpatient RALP   

Rates of 30-day readmissions amongst patients undergoing SDD versus inpatient RALP   

Rates of emergency department visits amongst patients undergoing SDD versus inpatient RALP    

Amongst patients who “fail” the SDD pathway (elect to undergo SDD but ultimately are admitted), we will examine the reasons for failure to ensure that there are no major safety events and use this as a feedback mechanism to refine the pathway.   

Rates of SDD versus inpatient RALP, by race/ethnicity, language, and insurance   

We will explore patient satisfaction with SDD with a patient experience questionnaire.     

Cultural gaps: Historically, a barrier to implementation of a RALP SDD pathway was surgeon concerns regarding patient selection and safety of SDD. As described above, since RALP SDD was introduced 15 years ago, studies have repeatedly demonstrated that SDD is safe, and does not negatively impact rates of complications, readmissions, or ED visits. We have partnered with surgeons performing RALP in our department to design a safe and feasible SDD pathway, based on existing successful protocols from peer institutions/surgeons. We will partner with surgeons performing RALP in our department over the course of the project to further refine and finalize our pathway.   

Educational gaps: Another historical barrier to RALP SDD involves developing the resources needed to ensure timely and safe discharge. We will modify our existing high-quality preoperative educational materials for patients (written and audiovisual) to include information about the RALP SDD pathway and postoperative care topics (i.e., foley catheter management) typically covered during the inpatient stay.    

Systems gaps: The Mission Bay PACU has the capacity to recover patients who undergo RALP SDD, but there are challenges, including pressure to clear beds and staffing shortages as evening hours approach. These challenges can be addressed, for example, by scheduling patients undergoing RALP SDD as the first case of the day and including patients who live nearby. The new Bayfront Outpatient Surgery Center offers additional SDD capacity for appropriate patients. We may also be able to temporarily admit patients for observation prior to SDD. 

Technological gaps: Development of a RALP SDD pathway has the potential to significantly change our practice at UCSF. Technological support with EHR innovations through the Caring Wisely program will allow us to track numerous performance and safety metrics (described in “Target” section), empowering us to make iterative improvements to our pathway and outcomes over the project year and into the future.   

We aim to design and implement an evidence-based RALP SDD pathway based on existing successful protocols from peer institutions, and expert input from our own urologic oncologists.    

Stakeholder engagement: We will meet with key stakeholders (including faculty in the Departments of Urology and Anesthesia, and PACU directors at Mission Bay and Bayfront) to solicit input, ensure that all parties are aligned on the proposed SDD RALP pathway, and anticipate/troubleshoot roadblocks to successful implementation. We are excited to have secured the enthusiastic support of Sharon Gleeson and Lina Bandera, Directors of Perioperative Services at Mission Bay and Bayfront, respectively. The support of the Caring Wisely Core Leadership Team and Executive Committee will further empower us to address any barriers that arise and successfully reach our targets.   

Practice setting: The RALP SDD pathway will be implemented at Mission Bay and Bayfront (for appropriate patients). Both sites offer 23-hour observation in the event that a planned SDD cannot occur.   

Target population: All patients undergoing RALP who meet the selection criteria will be eligible for the SDD pathway. We would like to highlight that the surgeon remains the ultimate decision-maker with regard to whether to offer SDD to patients who otherwise meet selection criteria. Eligible patients will then receive education regarding the SDD pathway, and can elect to aim for SDD or next day discharge.   

RALP SDD pathway elements: Review of the literature underscores the importance of SDD programs that incorporate patient selection, preoperative preparation for SDD, intraoperative measures to prevent postoperative pain and nausea/vomiting, and enhanced recovery protocols.[7,8] We have incorporated these elements into our RALP SDD pathway (Appendix 1). This pathway will be fine-tuned over the coming months with feedback from our key stakeholders prior to implementation.      

We will build a RALP SDD dashboard that tracks patient candidacy for and progress through the pathway. This will allow surgeons to easily evaluate patient candidacy for SDD, and if enrolled in the pathway, their readiness for SDD from a clinical perspective. We will also track applicable outcome metrics (per “Target” section) to allow for iterative improvement through PDSA cycles and ensure patient safety is maintained.   

We will build smart order sets for the RALP SDD pathway.   

We will build a smart data element that populates preoperative SDD counseling materials into the AVS.   

Sustainability: Once developed, implemented, and refined during the funding year, sustaining the RALP SDD pathway will require minimal effort/resources. Project co-lead and Department of Urology faculty Max Bowman will provide longitudinal oversight of the pathway.The urologic oncology faculty at UCSF is a relatively small group, and as they will be involved in development of the pathway, we expect that maintaining adherence to the pathway in future years will be straightforward. The patient education resources developed will continue to be utilized and can be easily refined as needed in the future. The APeX infrastructure including order sets, counseling materials, and dashboard to monitor performance will continue to be available to providers.   

Scalability: There are numerous other urologic procedures (for example, robot-assisted partial nephrectomy, laparoscopic nephrectomy) that are currently performed with an overnight stay, but are potentially well-suited for SDD in the appropriate patient. Thus, the intervention developed and lessons learned from this project can be applied in the future to other surgeries, leading to future cost savings.    

Salary support for project co-leads for project implementation: $40,000-$45,000   

Development of educational materials, data analytics, and IT support: $5,000-$10,000