Transcript Day case TURP – is it feasible?

Day case TURP – is it feasible?
• Limited service capacity
•Low priority
delays
•Good argument for day case TURP
•Audit – not about comparison of techniques but about feasibility
Ijabla Raymond1 Sarah M. Lloyd2 Stuart N. Lloyd3
1
Clinical Fellow in Urology 2 Consultant Anaesthetist 3 Consultant Urologist
St James’s University Hospital Leeds LS9 7TF
Audit of 3 years inpatient TURPs in Leeds 2003-2005
ELECTIVE
EMERGENCY
Number of Average Total Average Pre- Average PostProcedures
Stay days op Stay days op Stay days
COMBINED
Number of Average Total Average Pre- Average PostProcedures
Stay days op Stay days op Stay days
Number of Average Total Average Pre- Average PostProcedures
Stay days op Stay days op Stay days
Gyrus
230
4.97
1.48
3.5
126
9.39
5.35
4.04
356
6.54
2.85
3.69
Mono
Polar
536
5.33
1.87
3.46
361
9.65
5.55
4.1
897
7.07
3.35
3.72
Totals
766
5.23
1.75
3.47
487
9.58
5.5
4.08
1253
6.92
3.21
3.71
No difference between techniques
Inpatient culture affects duration of stay - TWOC
Acutes - delay in theatre date, or medical reasons
Justification for separate Day Case list
Gyrus (Saline) TURP
First performed in Leeds
by SNL 1999
1st Day case procedure 2001
171 cases since then
•
Pre-assessment: catheter advice, DVT,
aspirin/clopidogrel, DM medicines, Bloods,
ECG
•
On day of surgery: consent, first on am list,
GA/Spinal (avoid morphine), 3-way 18Fg foley
with slow irrigation for approx 1-2hrs, no post
op bloods needed
•
Aim home within 6hrs
Recent decline due to increased need for DC ureteroscopy &
TURBT
loop TURP
130
loop TURP + bladder stone
7
PKVP vaporization
34
ASA
%
GA
157
1
15%
Spinal
14
2
53%
3
32%
4
<1%
Intent for early discharge (147 /171)
83 discharged same day usually after 2 hours irrigation
within 6 hour surgery
49% discharged same
day
49 discharged early next day - intent 23 hour stay
8 discharged after 48 hours - catheter free (some prolonged
bleeding)
77% discharged within
23hrs
5 discharged after 3 days catheter free
2 discharged by 5 days catheter free
Ideal plan - home with a catheter and early removal
TWOC day
160/171
day 0
4
day 1
27
day 2
122
day 3
5 (bleeding)
day 5
2 (bleeding)
90% had successful
TWOC within 2 days
All patients delighted with outcome although as expected some took
time for urinary symptoms to settle
1 admission due to administration of morphine
1 re-admitted having failed a home TWOC
7 delayed discharge longer than 23 hours due to bleeding
7 readmissions with secondary bleeding (also 1 patient bled for 1 month but was not admitted)
4 re-admissions with infection, GP treated 2 at home
1 haematemesis 3 days post-op – admitted
3 re-operation TURP (2 cancer underwent channel TURP , 1 BPH patient at 3 yrs after PKVP)
4 later diagnosed with cancer, 2 underwent radical prostatectomy
BPH
127
histology
assumed
BPH
37
vaporized
Cancer
2 known; 5
new
+ 4 later
diagnosis
Reasons to do day case TURP
• Reduced pressure on beds
• Increasing pool of patients (e.g. 33% - ASA 3; AUR)
• Reduced risk of hospital acquired infection and complications
• Patient choice
• Cheaper – electrodes cost £100 more; but savings on fluid + reduced
hospital stay
• Day case tariff incentive £300 (day case fee £1863; inpatient fee £1563)
£51,300 bonus plus reduced cost of 6-7 days inpatient stay
Suggested sequence of pathways
• Initially do a day-case through an inpatient ward
• Plan 23 hour stay for all
• True day-case with early discharge with recourse to inpatient bed or 23 hour
bed
• Plan day-case for suitable elective cases (4-6hr stay)
• Consider a urinary retention pathway - hospital discharge and readmit as a
day-case
• Direct booking from other units or primary care assessment