Briggs, T

Cleaveland, P

Collins, J

Flora, K

Fricker, M

Hanna, N

Hines, J

Kasivisvanathan, V

Kelkar, A

Kelly, J

Lamb, BW

Miah, S

Nathan, A

Nathan, S

Patel, S

Phuah, Y

Rajan, P

Rashid, A

Shah, N

Shaw, G

Sooriakumaran, P

Sridhar, A

Williams, N

English

UCL Discovery

New recommendations to reduce unnecessary bloodtests after robot-assisted radical prostatectomyRadical prostatectomy (RP) is a standard treatment for menwith localised prostate cancer. Robot-assisted RP (RARP) isassociated with fewer intraoperative adverse events, reducedblood loss and lower complication rates compared to openand laparoscopic RP but delivers comparable oncological andfunctional outcomes [1]. Furthermore, the use of EnhancedRecovery after Surgery (ERAS) pathways for RARP, haveimproved patient recovery and experience, reducing costs andmaintaining patient safety [2].Despite the increased use of RARP and adoption of ERASpathways, the historical practice of routine postoperativeblood tests (POBT) remains common. No national orinternational guidelines exist to aid clinicians to decidewhether a patient requires POBT after RARP.The aim of our present study was to evaluate the safety valueof omitting routine POBT after RARP, and to proposerecommendations to rationalise their use in clinical practice.The study followed established ‘Plan, Do, Study, Act’ (PDSA)quality improvement methodology [3]. The study aims weredefined as above and outcomes were defined as below(‘Plan’). Baseline data were collected from a retrospectivereview (‘Do’) and analysed according to the plan (‘Study’).New recommendations were created based on theretrospective review and prospectively assessed (‘Act’).Routine prospectively collected perioperative data wereretrospectively aggregated from 1040 consecutive patients whounderwent 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] andCharlson CoMorbidity Index [CCI] score), intraoperative data(operative time, estimated blood loss [EBL], blood transfusion,nerve sparing, pelvic lymph node dissection [PLND], andcomplications), and postoperative data (clinical signs andsymptoms, length of stay [LOS], transfusion, and 30-dayClavien–Dindo complications). Subjective intraoperativedifficulties, such as difficult dissection and difficult anastomosis,were not regarded as complications. In addition, data related tothe timing of discharge and ordering, taking, analysing, andreporting of POBT were collected. All patients had a minimumof 30-days of follow-up. From the retrospective review, 72% ofpatients were found to have no pre-, intra- or postoperativeclinical concerns but still had routine POBT; no patients in thiscohort developed a complication.The study team, composed of experienced, high-volumeconsultant robotic surgeons at both tertiary centres, reviewedthe outcomes from the retrospective data. Expert opinion wasused to recommend the following criteria for POBT:• All patients admitted to high-dependency units (HDUs)postoperatively.• Patients with intraoperative concerns such as difficultdissection or adhesions, EBL >750 mL, urine leak, bowel,bladder or port-site injury, known coagulopathy andsalvage procedures.• Patients with postoperative concerns such as cardiovasculardysfunction, raised NHS England National Early WarningScore (NEWS) or pyrexia, increasing abdominal pain,tenderness or guarding, nausea or vomiting, high drainoutput, low urine output or haematuria and woundconcern.Detailed pre-, intra- and postoperative parameters arepresented in Table 1. A total of 1040 patients were used tohelp construct the recommendations and 300 patients wereused to assess the new recommendations. Thus, 1340 patientswere 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 themost common comorbidity in 15% of patients. There were nostatistically significant differences between the two datasetsfor preoperative characteristics. As per European Associationof Urology (EAU) intraoperative adverse incidentclassification, there were two Grade II events (two bowelrepairs), four Grade III events (three bowel repairs and onevascular injury), and no Grade ≥IV events. Clinical concerns,defined as suspicion raised by the clinical team as per therecommendations, were reported in 221 (16%) patients, themost common concern was increasing abdominal pain in 75patients (6%).The overall postoperative 30-day Clavien–Dindo complicationrate was 5%. The most common complication was ahaematoma, occurring in 21 (2%) patients. A total of 3% ofpatients went to HDU due to premorbid or intraoperativeconcerns and 4% had an intraoperative concern flagged bythe operating surgeon. In 16% clinical concerns were raisedby the surgical team postoperatively. The perioperativetransfusion rate was 0.9% (nine patients) and median LOS© 2021 The AuthorsBJU Internationalpublished by John Wiley & Sons Ltd on behalf of BJU International. www.bjui.org wileyonlinelibrary.comThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use anddistribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.BJU Int 2021; 128: 681–684 doi:10.1111/bju.15511Research Communicationwas 1 day. No patients died within the short 30-day follow-up period.Implementation of the recommendations resulted in adecrease of POBT requested from 100% to 27% (P = 0.001).The new recommendations were associated with a reductionin POBT related discharge delays from 6% to 0% (P = 0.008).No complications were missed, and one patient had anunplanned re-admission within 90-days for urinary sepsis.Postoperative blood tests should be used to assess variation inhaematological or biochemical parameters after surgery wherevariation is likely to occur and when it is likely to reflectadverse events [4]. The results of our present study show thatroutine POBT in patients with no adverse clinical findings donot reveal any complications that are not suspected byclinical judgement. POBT alone without clinical assessment,would only be useful in helping to diagnose 43% of allcomplications. Intra- and postoperative clinical assessmentTable 1 Pre-, intra- and postoperative variables.Variable Total Derivation dataset Validation dataset PN 1340 1040 300PreoperativeAge, years, median (IQR) 63 (61–65) 63 (61–65) 63 (60–66) 0.364BMI, kg/m2, median (IQR) 28 (27–29) 28 (27–30) 28 (27–31) 0.462ASA score, median 2 2 2 0.98CCI score ≥1, n (%) 345 (26) 283 (27) 62 (23) 0.31IntraoperativeOperation time, min, median (IQR) 120 (100–140) 120 (100–150) 120 (90–150) 0.126EBL, mL, median (IQR) 250 (200–300) 250 (200–300) 260 (180–350) 0.371Transfusion, n (%) 3 (0.2) 3 (0.3) 0 (0) 1Nerve sparing, n (%)Nil 253 (19) 178 (17) 75 (25) 0.515Unilateral 543 (41) 432 (42) 111 (37)Bilateral 543 (41) 429 (41) 114 (38)PLND, n (%) 467 (35) 374 (36) 93 (31) 0.236Concerns and complications, n (%) 51 (4) 36 (3) 15 (5) 0.762EBL >750 mL 29 (2) 21 (2) 7 (2)Anastomotic leak 11 (1) 6 (0.6) 5 (2)Bowel injury 6 (0.4) 5 (0.5) 1 (0.3)Vascular injury 3 (0.2) 2 (0.2) 1 (0.3)Bladder injury 2 (0.1) 1 (0.1) 1 (0.3)Port-site injury 1 (0.1) 1 (0.1) 0 (0)PostoperativeClinical concerns, n (%) 221 (16) 161 (15) 60 (20) 0.25Increasing abdominal pain 75 (6) 59 (6) 16 (5)High drain output/leak 42 (3) 33 (3.2) 9 (3)Cardiovascular dysfunction 39 (3) 25 (2) 14 (5)Nausea/vomiting 26 (2) 17 (1.6) 9 (3)Low urine output 20 (1) 15 (1) 5 (2)Wound concern 5 (0.3) 4 (0.4) 1 (0.3)Oxygen desaturations 5 (0.3) 4 (0.4) 1 (0.3)Bleeding 5 (0.3) 3 (0.3) 2 (0.6)Calf pain 1 (0.1) 1 (0.1) 0 (0)Confusion 3 (0.2) 0 (0) 3 (1)Transfusion, n (%) 6 (0.4) 6 (0.6) 0 (0) 1Complications (30-day), n (%) 68 (5) 48 (5) 20 (7) 0.615Haematoma 21 (2) 15 (1) 6 (2)Anastomotic urine leak 9 (0.6) 7 (0.7) 2 (0.6)UTI 11 (0.8) 6 (0.6) 5 (2)Ileus 7 (0.5) 5 (0.5) 2 (0.6)Bowel injury 5 (0.4) 4 (0.4) 1 (0.3)Wound breakdown 5 (0.4) 4 (0.4) 1 (0.3)Acute kidney injury 7 (0.5) 4 (0.4) 3 (0.9)Renal/ureteric injury 2 (0.1) 2 (0.2) 0 (0)Deep vein thrombosis 1 (0.1) 1 (0.1) 0 (0)Clavien-Dindo complications, n (%) 68 (5) 48 (5) 20 (7) 0.73Grade I–II 64 (5) 44 (4) 20 (7)Grade III–V 4 (0.2) 4 (0.4) 0 (0)LOS, days, median (IQR) 1 (1–2) 1 (1–2) 1 (1–2) 0.934Discharge delays, n (%) 62 (5) 62 (6) 0 (0) 0.008*Re-admission (90-day), n (%) 14 (1) 12 (1) 2 (0.6) 0.943*P < 0.05.682© 2021 The AuthorsBJU International published by John Wiley & Sons Ltd on behalf of BJU InternationalResearch Communicationcorroborated with postoperative complications in 99.9% ofpatients. Therefore, routine POBT should not be a surrogatefor thorough clinical assessment.In the retrospective review, 6% of patients experienced adischarge delay of ≥1 day due to missed venepuncture, mis-labelled, mis-resulted or delayed reporting of POBT. Ravindraet al. [5] found in 170 patients that >90% of all blood testsrequested for Grade I–III urological procedures were availableafter 11:00 hours, which resulted in delayed discharge. Afterissuing local guidelines there was a 75% reduction in POBTrequested with no change to patient safety. Over 1.2 millionbed-days were lost in the NHS during 2013 due to delayeddischarges, with an associated cost of £820 million [6]. Ourrecommendations may help reduce the costs associated withdischarge delays and POBT.Our recommendations resulted in a 73% reduction in POBTafter RARP and show that procedure specificrecommendations may significantly reduce POBT requestsacross a variety of surgical procedures. A review of 532patients undergoing elective laparoscopic cholecystectomyfound that routine POBT do not predict complications butmay be of benefit in technically challenging cases [7].Furthermore, other surgical specialities such as gynaecologyand general surgery are transitioning from open surgicaltechniques to minimally invasive surgery, which has beenproven to lower EBL, transfusion and complication rates, andreduce LOS [8]. Therefore, we would recommend that othersurgical specialities undertake an evaluation of their use ofroutine POBT.Our recommendations capture data from two high-volumecentres with experienced surgeons. Further multicentreresearch is required to provide a more comprehensive picturewith specific cost analysis.To conclude, routine POBT, without a clinical indication, arenot necessary after RARP. Intra- and postoperative clinicaljudgement is highly accurate in predicting and diagnosingcomplications. Our recommendations can avoid POBT innearly three out of four patients undergoing RARP.Perioperative transfusion rates are extremely low andhospitals could remove the need for two group and screensamples. Furthermore, our recommendations may reducedischarge delays and increase patient turnover to help thefinancial, logistical and resource burden on NHS Trusts. Ourmethodology and recommendations may be applicable toother surgical procedures.AcknowledgementsUro-oncology Department University College LondonHospitals NHS Foundation Trust. Urology DepartmentAddenbrooke’s Hospital, Cambridge University HospitalsNHS Foundation Trust.FundingArjun Nathan was supported by the National Institute forHealth Research (NIHR) through an Academic ClinicalFellowship.Conflict of InterestAll authors confirm they have no disclosure of interest.Ethical ApprovalAll patients were registered as part of BAUS nationaloutcomes audit and registered with both institutional auditdepartments [Ref: 2631 and 11896]. Ethical guidance wasfollowed in-line with the NHS Research Ethics Committeeand institutional clinical governance protocols.Arjun Nathan1,2 , Nancy Hanna3,4, Amir Rashid3,4,Sonam Patel2, Yuzhi Phuah2, Kiran Flora2, Monty Fricker5,Paul Cleaveland1, Veeru Kasivisvanathan1,2, NormanWilliams1, Saiful Miah3, Justin Collins1, Anand Kelkar1,Ashwin Sridhar1, John Hines1, Tim Briggs1, John Kelly1,Nimish Shah3, Greg Shaw1, Prasanna Sooriakumaran1,6,Prabhakar Rajan1,7, Benjamin W Lamb3,8 andSenthil Nathan11Department of Uro-oncology, University College LondonHospitals NHS Foundation Trust, London, 2University CollegeLondon, London, 3Department of Urology, CambridgeUniversity Hospitals NHS Foundation Trust, Cambridge,4University of Cambridge, Cambridge, 5Newcastle University,Newcastle Upon Tyne, 6Nuffield Department of SurgicalSciences, University of Oxford, Oxford, 7Barts Cancer Institute,CR-UK Barts Centre, Queen Mary University of London,London and 8Faculty of Health, Education, Medicine andSocial Care, Anglia Ruskin University, Cambridge, UKReferences1 Tewari A, Sooriakumaran P, Bloch DA, Seshadri-Kreaden U, Hebert AE,Wiklund P. Positive surgical margin and perioperative complication ratesof primary surgical treatments for prostate cancer: a systematic review andmeta-analysis comparing retropubic, laparoscopic, and roboticprostatectomy. Eur Urol 2012; 62: 1–152 Ploussard G, Almeras C, Beauval JB et al. Same-day discharge surgeryfor robot-assisted radical prostatectomy in the era of ERAS andprehabilitation pathways: a contemporary, comparative, feasibility study.World J Urol 2020 (Online ahead of print). https://doi.org/10.1007/s00345-020-03119-w3 NHS Improvement. Plan, Do, Study, Act (PDSA) cycles and the model forimprovement 2018. Available at: https://improvement.nhs.uk/documents/2142/plan-do-study-act.pdf. Accessed November 20204 Reissfelder C, Rahbari NN, Koch M et al. Postoperative course andclinical significance of biochemical blood tests following hepatic resection.Br J Surg 2011; 98: 836–445 Ravindra P, Lam G, Miller MA. Post-operative blood tests in patientsundergoing urological surgery. Int J Surg 2016; 36: S1226 NHS. National tariff payment system 2020. Available at: https://improvement.nhs.uk/resources/national-tariff/. Accessed November 2020© 2021 The AuthorsBJU International published by John Wiley & Sons Ltd on behalf of BJU International 683Research Communication7 Ben-Ishay O, Zeltser M, Kluger Y. Utility of routine blood tests afterelective laparoscopic cholecystectomy for symptomatic gallstones. World JGastrointest Surg 2017; 9: 149–528 Nelson H, Sargent D, Wieand HS et al. A comparison of laparoscopicallyassisted and open colectomy for colon cancer. N Engl J Med 2004; 350:2050–9Correspondence: Arjun Nathan, University College LondonDivision of Surgery and Interventional Sciences, Charles BellHouse, 43-45 Foley Street, London W1W 7JN, UK.e-mail: arjun.nathan.11@ucl.ac.ukAbbreviations: ASA, American Society of Anesthesiologists;BMI, body mass index; CCI, Charlson Comorbidity index;EBL, estimated blood loss; ERAS, Enhanced Recovery afterSurgery; HDU, high-dependency unit; IQR, interquartilerange; LOS, length of stay; PLND, pelvic lymph nodedissection; POBT, postoperative blood tests; (RA)RP, (robot-assisted) radical prostatectomy.684© 2021 The AuthorsBJU International published by John Wiley & Sons Ltd on behalf of BJU InternationalResearch Communication

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

https://discovery.ucl.ac.uk/id/eprint/10129535/7/Kasivisvanathan_BJU%20International%20-%202021%20-%20Nathan%20-%20New%20recommendations%20to%20reduce%20unnecessary%20blood%20tests%20after%20robot%E2%80%90assisted%20radical.pdf

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

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