June 25, 2001 ANN ARBOR, Mich. - No one likes to be in the hospital longer than needed. Now, a new approach to prostate cancer surgery using a combination of existing techniques may help men get home within 24 hours of having their prostates removed - without making them less satisfied with their care or putting them at extra risk of complications.
That finding, from a study comparing a "fast track" prostate surgery pathway with a standard approach that keeps patients in the hospital for up to three days, was presented this week at the American Urological Association's annual meeting in Anaheim, CA by researchers from the University of Michigan Comprehensive Cancer Center. It's the first study of its kind.
The U-M's 24-hour approach stood up to the prospective comparison well, yielding high patient satisfaction rates and low complication rates almost exactly like those seen with standard care, says senior author Martin Sanda, M.D., an associate professor of urology at the U-M Medical School and associate director of the U-M Health System's prostate cancer program.
Sanda and his colleagues devised the pathway, which uses epidural anesthesia, non-narcotic pain relief and tailored patient education materials to help early-stage prostate cancer patients get home sooner, just as safely, and with less expense. They then compared it prospectively with standard care in 153 patients operated on in the year 2000 by two U-M surgeons.
"Our findings suggest a possible new standard of care that would lead to a 24-hour stay for most patients, if their surgery is performed at centers specializing in prostate cancer care," Sanda says. "Since prostatectomy is the most common treatment for early-stage prostate cancer, and indeed is one of the most common cancer operations overall, a more streamlined approach could have a major impact on both patient experience and cost of care."
The U-M pathway doesn't rely on any brand-new advance - just coordinated use of a lower-body epidural anesthesia approach that avoids the "hangover" effect of general anesthesia, non-narcotic pain drugs such as ketorolac and ibuprofen that let the patient be more alert and active soon after surgery, and specially developed education materials to help the patient and his loved ones know what to expect regarding post-operative care and at-home self care.
Just by combining these elements and making a determined effort to offer the patient the option to go home after 24 hours, the U-M team was able to send 77 percent of patients home after one day's stay, while maintaining a satisfaction rate of 94 percent and a post-operative complication rate of about 5 percent. These two rates almost exactly matched the rates for patients receiving standard care. Long-term outcomes have also been favorable.
Other advantages to the new pathway included the decreased use of narcotic pain relievers, which in most cases were discontinued on the same day as surgery, and increased involvement of the patient and his spouse or family member in the post-operative period. The two go hand in hand, as patients who are off narcotic medication can take a more active role in caring for themselves.
The new pathway is becoming the standard for many early-stage prostate cancer patients at the U-M Cancer Center. Sande hopes it will help other centers determine whether they can streamline care for their patients.
"No one has looked at how perioperative and postoperative care can be optimized, to reduce the length of hospital stay while maintaining patient-reported satisfaction," Sanda explains. "This study indicates we can keep the patient happy and comfortable, and give him the option of going home earlier, with a proactive, coordinated approach."
But, he adds, no patient was shoved out the door just to cut the length of their hospital stay. "Fast track" patients who elect to stay longer are always allowed to do so.
"None of our patients reported feeling rushed, and no one was forced out; the option to leave at 24 hours is just that, an option, and not a requirement or expectation." Sanda emphasizes. "Nevertheless, most patients given this option did indeed choose to go home early and were medically well enough to do so."
The study's other authors are urology resident Stephanie Kielb, M.D., who presented the results in a poster at the AUA meeting; research associate Jennifer Resh; and James Montie, M.D., Valassis Professor of Urologic Oncology and head of the section of urology in the U-M Medical School's Department of Surgery.
This research was funded in part by a National Cancer Institute Prostate Cancer SPORE (Specialized Program of Reseach Excellence) grant to the University of Michigan.
For information on prostate cancer care at the U-M Comprehensive Cancer Center, please call the Cancer Answer Line at 800-865-1125.
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