# Fast Track Open Partial Nephrectomy: Reduced  Postoperative Length of Stay with a Goal-Directed  Pathway

Authors: Bilal Chughtai; Christa Abraham; Daniel Finn; Stuart Rosenberg; Bharat Yarlagadda; Michael Perrotti
Journal: Advances in Urology
 (2008)

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## Abstract

Introduction. The aim of this study is to examine the feasibility of reducing postoperative hospital stay following open partial nephrectomy through the implementation of a goal directed clinical management pathway. Materials and Methods. A fast track clinical pathway for open partial nephrectomy was introduced in July 2006 at our institution.  The pathway has daily goals and targets discharge for all patients on the 3rd postoperative day (POD).  Defined goals are (1) ambulation and liquid diet on the evening of the operative day; (2) out of bed (OOB) at least 4 times on POD 1; (3) removal of Foley catheter on the morning of POD 2; (4) removal of Jackson Pratt drain on the afternoon of POD 2; (4) discharge to home on POD 3.  Patients and family are instructed in the fast track protocol preoperatively.  Demographic data, tumor size, length of stay, and complications were captured in a prospective database, and compared to a control group managed consecutively immediately preceding the institution of the fast track clinical pathway. Results. Data on 33 consecutive patients managed on the fast track clinical pathway was compared to that of 25 control patients.  Twenty two (61%) out of 36 fast track patients and 4 (16%) out of 25 control patients achieved discharge on POD 3. Overall, fast track patients had a shorter hospital stay than controls (median, 3 versus 4 days; P = .012).  Age (median, 55 versus 57 years), tumor size (median, 2.5 versus 2.5 cm), readmission within 30 days (5.5% versus 5.1%), and complications (10.2% versus 13.8%) were similar in the fast track patients and control, respectively. Conclusions. In the present series, a fast track clinical pathway after open partial nephrectomy reduced the postoperative length of hospital stay and did not appear to increase the postoperative complication rate.


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## Body

## 1. Introduction

Radical nephrectomy has considered the optimal surgical
approach to the management of renal cancer [1]. Additional options include
observation, cryosurgery, and radiofrequency ablation [2, 3]. Management of the small renal mass requires multiple perspective
decision making on the part of the physician [4]. Recently, partial nephrectomy has been
shown to have efficacy in the management of select patients with small renal
masses (4 cm or less) [5, 6]. Several investigators have reported
an expanded use of this approach with success in patients with larger renal
neoplasms (7 cm or less). Hospital stay
after partial nephrectomy is usually 5–8 days [7]. Factors limiting early discharge are
usually pain, stress-induced major organ dysfunction (i.e., ileus, atelectasis),
tradition, fatigue, pain, nausea, and morbidity [8, 9]. In other abdominal procedures, including
colon resection, lung transplant, and laparoscopic nephrectomy, the
introduction of a program comprised of optimized pain relief using nonsteroidal
anti-inflammatories for analgesia enforced oral nutrition and mobilization, and
revision of traditional care principles has reduced hospital stay from 5–8 days to 220 133
days in some studies [10, 11]. The concept of fast-track (FT) surgery
has recently attracted more interest, but has not yet been applied in patients
undergoing partial nephrectomy. The purpose of this study was to investigate
the postoperative course before and after the introduction of a fast track program
in patients undergoing open partial nephrectomies. We sought to determine
whether the use of this fast track program might decrease length of hospital
stay without sacrificing outcomes.


## 2. Materials and Methods

A fast
track clinical pathway for open partial nephrectomy was introduced at our
institution in July 2006. The pathway
has an established management protocol (Table1). All patients undergoing open
partial nephrectomy from July 2006 thus far at our institution were managed by
the fast track protocol, and comprise the study cohort. Patients undergoing laparoscopic partial
nephrectomy and robotic partial nephrectomy were not included. In the event that the decision was made
intraoperatively to perform complete nephrectomy, patients were included on an
intention-to-treat basis. Demographic
data, tumor size, blood loss, transfusion, final pathology, margin status, length
of hospital stay, and complications were captured in a prospective database,
and compared to a control group managed consecutively immediately preceding the
institution of the fast track clinical pathway.
All operations were performed for a renal tumor less than 7 cm in
greatest diameter by the same surgical team.Table 1
Fast track pathway.
DayGoalPreoperativePatient and family counselingMedication reviewPreparation instructionsPostoperative day 0 (evening of surgery)OOB at least onceClear liquidsPostoperative day 1OOB four timesLiquid dietOral pain medicationsPostoperative day 2OOB ad libRegular dietRemove Foley catheter at 7 amFlank drain fluid for Cr at 2 pmRemove drain if fluid Cr = serum CrPostoperative day 3Discharge to home


### 2.1. Preoperative Preparation

Patients
were admitted to the hospital on the day of surgery and performed all
preparation on an outpatient basis. All
patients were counseled preoperatively regarding the target goals outlined in
Table1. Aspirin and nonsteroidal
anti-inflammatory drugs (NSAIDs) were stopped 10–14 days prior to
surgery. Coumadin was stopped 5 days
preoperatively and stat protime/partial thromboplastin time obtained on the morning of surgery
to confirm acceptable value. All patients received 3 bisacodyl
tablets and 1 bottle of magnesium citrate at noon on the day prior to surgery. All patients
received erythromycin and neomycin antibiotic per oral (PO),
500 mg (milligram) tab, at 3 pm, 6 pm, and 9 pm on the day prior to surgery. All patients were instructed to eat lightly
and orally hydrate on the day prior to surgery.


### 2.2. Intraoperative

This
report is restricted to patients undergoing open partial nephrectomy on an
intention to treat basis. General anesthesia, oral gastric tube (removed at
case conclusion), and Foley catheter were used in all cases. Compression pneumatic stockings were placed
as soon as the patient moved from the stretcher onto the operating table. The retroperitoneal flank approach was
used. All patients were positioned with
the bean bag, with legs straight, hyper-extended with the kidney rest raised
maximally. Before draping, the surgeon
marked the posterior axillary line (PAL),
the anterior axillary line (AAL), the lateral border of the rectus muscle, and
the course of the 10th, 11th, and 12th ribs. Incision was made from the PAL to the AAL in the course of the 11th rib using the cautery on pure cut (setting of 30). The distal tip of the 11th rib was removed in the standard manner.
An extra-pleural/extra-peritoneal approach to the kidney was used. The
kidney was explored, and vessel loop passed to tag the ureter, renal artery,
and renal vein. A double loop was passed around the vein for subsequent
occlusion. Patients received mannitol
12.5 gm (gram) IV (intravenous) bolus prior to manipulation of the renal vessels
followed by 5 gm/hour continuous infusion for the remainder of the operation.
Renal artery was clamped in all cases and the kidney cooled. The renal vein was
selectively occluded as required to provide a bloodless operative field. The
collecting system was closed with 3–0 monocryl on SH
needle in all cases. Renal arteries and venules were oversewn in
figure of eight fashions
with 3–0 monocryl on SH
needle. Prior to the removal of the renal artery clamp, the kidney was reconstructed essentially
obliterating the resection defect utilizing 0-Chromic suture on CT needle in
horizontal mattress
fashion. This resulted in a reniform shape approximation in nearly all cases. The rib bed
and skin were infiltrated with 0.25% marcaine (30 ml (milliliters)). The skin
wound was closed in a subcuticular (3–0 monocryl). A #7 Jackson-Pratt drain was placed in all
cases. In no case was a ureteral stent
placed.


### 2.3. Postoperative

On POD 0 (postoperative day), on the evening of surgery,
patients received celecoxib 200 mg per oral
in the postanesthesia care unit (PACU) with sip when awake, and daily thereafter (Table1). Morphine sulfate was administered IV at 2 hour
intervals as needed. Metoclopramide was
administered IV 10 mg every 6 hours. Famotidine was administered 20 mg IV every 12 hours. On the day of surgery, patients ambulated and
were encouraged to take liquids by mouth.
On POD 1, diet was advanced to tray of clears, and oral pain medication
administered (hydrocodone/acetominophen 5–10 mg/500 mg every 4 hours as
needed). On day 2, the Foley catheter
was removed at 7 am and regular diet initiated.
Patients received milk of magnesia 30 cc PO at 8 am and a repeat dose in 4 hours.
Jackson-Pratt drain fluid was sent to the laboratory for creatinine
measurement and if equal to serum creatinine level, the Jackson-Pratt drain was
removed. The patient was assessed and
discharged to home on POD 3 if appropriate.


## 2.1. Preoperative Preparation

Patients
were admitted to the hospital on the day of surgery and performed all
preparation on an outpatient basis. All
patients were counseled preoperatively regarding the target goals outlined in
Table1. Aspirin and nonsteroidal
anti-inflammatory drugs (NSAIDs) were stopped 10–14 days prior to
surgery. Coumadin was stopped 5 days
preoperatively and stat protime/partial thromboplastin time obtained on the morning of surgery
to confirm acceptable value. All patients received 3 bisacodyl
tablets and 1 bottle of magnesium citrate at noon on the day prior to surgery. All patients
received erythromycin and neomycin antibiotic per oral (PO),
500 mg (milligram) tab, at 3 pm, 6 pm, and 9 pm on the day prior to surgery. All patients were instructed to eat lightly
and orally hydrate on the day prior to surgery.


## 2.2. Intraoperative

This
report is restricted to patients undergoing open partial nephrectomy on an
intention to treat basis. General anesthesia, oral gastric tube (removed at
case conclusion), and Foley catheter were used in all cases. Compression pneumatic stockings were placed
as soon as the patient moved from the stretcher onto the operating table. The retroperitoneal flank approach was
used. All patients were positioned with
the bean bag, with legs straight, hyper-extended with the kidney rest raised
maximally. Before draping, the surgeon
marked the posterior axillary line (PAL),
the anterior axillary line (AAL), the lateral border of the rectus muscle, and
the course of the 10th, 11th, and 12th ribs. Incision was made from the PAL to the AAL in the course of the 11th rib using the cautery on pure cut (setting of 30). The distal tip of the 11th rib was removed in the standard manner.
An extra-pleural/extra-peritoneal approach to the kidney was used. The
kidney was explored, and vessel loop passed to tag the ureter, renal artery,
and renal vein. A double loop was passed around the vein for subsequent
occlusion. Patients received mannitol
12.5 gm (gram) IV (intravenous) bolus prior to manipulation of the renal vessels
followed by 5 gm/hour continuous infusion for the remainder of the operation.
Renal artery was clamped in all cases and the kidney cooled. The renal vein was
selectively occluded as required to provide a bloodless operative field. The
collecting system was closed with 3–0 monocryl on SH
needle in all cases. Renal arteries and venules were oversewn in
figure of eight fashions
with 3–0 monocryl on SH
needle. Prior to the removal of the renal artery clamp, the kidney was reconstructed essentially
obliterating the resection defect utilizing 0-Chromic suture on CT needle in
horizontal mattress
fashion. This resulted in a reniform shape approximation in nearly all cases. The rib bed
and skin were infiltrated with 0.25% marcaine (30 ml (milliliters)). The skin
wound was closed in a subcuticular (3–0 monocryl). A #7 Jackson-Pratt drain was placed in all
cases. In no case was a ureteral stent
placed.


## 2.3. Postoperative

On POD 0 (postoperative day), on the evening of surgery,
patients received celecoxib 200 mg per oral
in the postanesthesia care unit (PACU) with sip when awake, and daily thereafter (Table1). Morphine sulfate was administered IV at 2 hour
intervals as needed. Metoclopramide was
administered IV 10 mg every 6 hours. Famotidine was administered 20 mg IV every 12 hours. On the day of surgery, patients ambulated and
were encouraged to take liquids by mouth.
On POD 1, diet was advanced to tray of clears, and oral pain medication
administered (hydrocodone/acetominophen 5–10 mg/500 mg every 4 hours as
needed). On day 2, the Foley catheter
was removed at 7 am and regular diet initiated.
Patients received milk of magnesia 30 cc PO at 8 am and a repeat dose in 4 hours.
Jackson-Pratt drain fluid was sent to the laboratory for creatinine
measurement and if equal to serum creatinine level, the Jackson-Pratt drain was
removed. The patient was assessed and
discharged to home on POD 3 if appropriate.


## 3. Results

A total of 33 patients were managed
by fast track and compared to 25 control patients (Table2). The estimated
blood loss, transfusion rate, tumor size, pathology, and complication rate were
similar between groups. There was, however, a significant difference in the
length of hospital stay observed between groups. Of 25 control patients, 4 (16%) achieved
discharge to home in <3 days compared to 22 (67%) of the 33 patients
managed in the fast track program.
Overall, fast track patients had a shorter hospital stay compared to
controls (median, 3 days versus 4 days; P=.012). Of the 11 patients in
the fast track cohort who were discharged after the third postoperative day,
this was due to poor ambulation/inadequate pain control (n=5), abdominal
bloating (n=3), multiple co-morbidities (n=2), and respiratory distress
postoperatively requiring ICU care (n=1).Table 2
Outcomes of fast
track open partial nephrectomy.
Conservative groupFast track group(N)2533Discharge in<3 days422Age range32–7439–73Male/female18/822/11Length of stayRange3–10 days2–6 daysMedian4 days3 daysAverage4.4 days3.3 daysEstimated blood lossRange50–500 cc50–600 ccMedian200 cc200 ccAverage228 cc263 ccTransfusions32Complications44Respiratory distress11Conversion to nephrectomy21Post operative bleed01Urine leak01Tumor sizeRange1.1–6.8 cm1.2–6.2 cmMedian2.5 cm2.5 cmAverage2.8 cm2.9 cmPathologyClear Cell RCC17 (68%)25 (76%)Papillary
RCC2 (8%)3 (9%)Chromophobe
RCC—3 (9%)Oncocytoma3 (12%)—AML1 (4%)2 (6%)Other2 (8%)—Complications are worth noting to
determine whether the fast track approach was harmful in any way to the study
cohort. In the control cohort, there was
1 patient with respiratory distress requiring ICU admission, 3 patients
received blood transfusion, there were 2 conversions to complete nephrectomy,
and 1 positive surgical margin. In the
fast track cohort there was 1 patient with respiratory distress requiring ICU
admission, 2 patients required blood transfusion, there was one conversion to
total nephrectomy, 1 postoperative bleed (gross hematuria) requiring selective
arterial embolization, and 1 urine leak requiring percutaneous drainage and
ureteral stent placement.The percentage of patients with
malignancy increased in the fast track cohort compared to control (85% versus
76%). This may represent improved
preoperative assessment.


## 4. Discussion

Since 1950 in the United States, there has been a
126% increase in the incidence of renal cancer [7, 8]. Although there has been an increase
in all stages of renal cancer including advanced cases (i.e., regional
extension, distant metastases), there has been the greatest increase in those
discovered incidentally [8, 12]. In the early 1970s, approximately
10% of tumors were detected incidentally compared with 61% in 1988 [8].Previous studies of other types of major surgery have shown
that a combined effort comprising intensive preoperative information, effective
postoperative pain relief and enforced mobilization, and early enteral
nutrition can accelerate postoperative recovery and decrease hospital stay [11, 13].Investigators have recently illustrated that in elderly
high-risk patients undergoing colonic resection, mean hospital stay could be
reduced to 2-3 days [11]. In another group of high risk
patients undergoing open aortic surgery, mean hospital length of stay was
reduced from a mean of 9 days to 5 days [14–16]. In a study by Harinath et al., a
decrease in length of stay was observed from 5 to 4 days for ileal pouch-anal
anastomosis [11].  The concept of fast track has also
been applied to infants and children [17]. In the urologic literature, after
radical prostatectomy, median hospital stay in 252 consecutive patients was
reduced to 1 day [13]. Specifically with kidney surgery,
postoperative hospital stay after open nephrectomy was reduced to 4 days [18]. With laparoscopy, hospital stay has
been reduced to 2 days with an FT rehabilitation program [19].In this study, with the introduction of a fast-track program,
open partial nephrectomy hospital stay was decreased to 3 days, compared to 4
days before implementation of the program. Sixty six per cent of patients
achieved a target discharge on day 3 or less.
Notably, both groups did have similar characteristics as demonstrated in
Table 2. The estimated blood loss, transfusion rate, tumor size, pathology, and
complication rate were similar between groups. We suspect that based upon our
data the main contributing factors responsible for the decrease in hospital
stay was a clear protocol of expectations at each stage of the recovery
period. This was accomplished in the
present series without an apparent increase in complication rate. Most notably, fast track did not lead to an
increase in readmissions.It is
impossible to discern exactly which components of our protocol are “more
essential” than others, and this would require selective application in future
investigations. In addition, we have no proof from the present
investigation that the fast track protocol is advantageous to the
patient. The purpose of the present study was to assess the feasibility
of such an approach and we conclude that such an approach is feasible.
Ultimately, the patients in this study decided their discharge date.
Most patients were eager to receive discharge to home as soon as they are
medically safe. One patient in the fast track protocol was discharged to
home at her request on POD 2. She expressed regret at doing so at
her first postoperative visit.Our readmissions
to the hospital were as follows. One (3.0%) patient had returned to hospital for postoperative
hemorrhage resulting in gross hematuria. This patient was managed successfully
with embolization. One (3.0%) patient had returned to hospital
forurinoma. This was managed successfully with indwelling ureteral
stent for 6 weeks and transient percutaneous drainage of urinoma. Both patients had
complex resections, and it is unlikely that fast track management resulted
in return to hospital.


## 5. Conclusions

In the
present investigation, a fast track clinical pathway after open partial
nephrectomy reduced the postoperative length of hospital stay and did not
appear to increase the postoperative complication rate.



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