Same-Day Discharge after HoLEP: A Safety and Feasibility Study to Address Hospital Capacity Stressors in the COVID 19 Era
Adam Wiggins, MD, Jessica Mandeville, MD.
Lahey Hospital and Medical Center, Burlington, MA, USA.
BACKGROUND: Holmium Laser Enucleation of the Prostate (HoLEP) is an increasingly popular contemporary surgical procedure to address lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). The typical post-operative pathway involves catheterization and weaning of continuous bladder irrigation overnight for a void-trial and hospital discharge on post-operative day (POD) one. Inpatient capacity constraints on hospitals due to COVID-19 surges have forced the delay or cancellation of many in-patient elective operations, thus resulting in the delay of care and frustration for patients with bothersome LUTS or retention. There has been an increased desire in the urologic community to investigate means to continue surgical care under these intermittent constraints. As such, this study seeks to investigate the safety and feasibility of same-day discharges after HoLEP, in hopes of addressing patient demand for the operation, while not contributing to further inpatient hospital burden.
METHODS: Patients at a single tertiary care center who were awaiting a delayed HoLEP procedure were selected as meeting pre-defined study criteria and were offered a HoLEP with planned same-day discharge. Inclusion criteria were prostate size less than 150 grams, American Society of Anesthesiologists (ASA) Physical Status Score less than or equal to 3, no peri-operative anticoagulation/anti-platelet medication other than aspirin, no major medical comorbidity, and first-start surgical scheduling. These patients underwent attempted out-patient HoLEP, and patient demographics, medical history, procedure details and outcomes were analyzed. Patients not meeting the above criteria were delayed or underwent HoLEP with POD-1 discharge when hospital capacity allowed.
RESULTS: From 11/08/2022 - 2/16/22, 13 patients met criteria to undergo a scheduled out-patient HoLEP. All surgeries were performed by a single surgeon (JAM) with resident assistance. The median patient age was 71.6 years and median prostate size was 96 grams. Of these 13 patients, 12 (92%) were safely and successfully discharged the afternoon of their operation, while 9 (75%) were offered and successfully completed a void trial prior to POD-0 discharge. The median resection time was 62 minutes and median resection weight was 72 grams. The median post-void residual change (PVR) change was -197cc, and median post-operative PVR was 5cc. Zero patients experienced intra-operative or peri-operative complications.
CONCLUSIONS: In the current COVID-19 era of volatility in hospital capacity constraints, it is necessary to minimize the capacity burden of elective urologic procedures. While the standard HoLEP post-operative pathway includes an overnight hospital admission, these data suggest that carefully selected patients can safely and feasibly undergo a void trial and discharge on the day of surgery, thus allowing for the timely care and treatment of this select group of patients, while not impacting in-patient hospital capacity. 
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