We aimed to evaluate outcomes of patients undergoing urogynecologic procedures with post-operative care in an overnight-stay unit at a tertiary care centre. There is no previously described overnight-stay unit within the urology, gynecologic or urogynecologic literature, and it has been used for almost all major vaginal reconstructive surgeries at our hospital for over ten years. We sought to determine rates of successful next-day discharge and to identify factors associated with failure of this approach. Knowledge of such factors could help refine appropriate patient selection for overnight-stay unit and inform efforts to improve outpatient follow-up protocols.

A retrospective cohort study of female patients undergoing urogynecologic procedures performed by seven fellowship-trained pelvic reconstructive surgeons at a tertiary care centre between January 1, 2014, and June 30, 2018 was performed. Patients were eligible for inclusion if they were female, were 18 years of age or older at the time of their urogynecologic procedure, and had been booked for admission to the overnight-stay unit at the time of admission prior to surgery. A multivariable logistic regression model was fit to identify risk factors for failed next-day discharge. Patients were deemed to have failed next-day discharge if they had a hospital length of stay beyond 10 a.m. on the day after surgery, were seen in the emergency room for assessment within 7 days of surgery, were readmitted to hospital within 30 days of surgery, or had reoperation within 30 days of surgery. A manual medical record review was completed for all patients with failed next-day discharge. Continuous variables are reported as mean ± standard deviation (SD) and were compared using t-tests. Categorical variables are reported as number (%) and were compared via Chi square tests. A prespecified multivariable logistic regression model was fit using patients with complete data to identify potential risk factors for failed next-day discharge, including variables previously suggested to influence hospital length of stay or need for reoperation such as procedure type, age, body mass index, diabetes, pulmonary disease, use of neuraxial anesthesia, operating room duration, and both hemorrhagic non-hemorrhagic surgical complications. All analyses were performed using Stata 15.1. A two-tailed α level of 0.05 was used to define statistical significance.

A total of 4821 women underwent elective surgery by one of the 7 urogynecologists during the study period with 3022 (62.7%) being booked for day surgery, 155 (3.2%) for same day admission and 1644 (34.1%) for overnight unit stay during the study period. 1578 patients (96%) booked for overnight-unit stay were discharged within 24 hours of surgery. Mean patient age was 53.7 ± 15.1 years, with 21.2% aged ≥70 years. Surgical approaches included laparotomy (8.9%), major vaginal surgery (70.9%), and open retropubic procedure (2.1%). Hysterectomy was performed in 1120 patients (68.1%). 101 patients (6.1%) were assessed in the emergency department within 7 days of surgery and 57 (3.5%) were readmitted to hospital within 30 days of their procedure. 

Of the 1644 patients booked for overnight unit stay, 1469 patients (89.4%) were discharged within 24 hours of surgery, did not present to an emergency room for assessment within 7 days, and were without re-operation/readmission within 30 days of surgery. Reasons for failure of next-day discharge were the need for emergency room reassessment within 7 days of surgery (6.1%), admission directly from the overnight-stay unit (4.0%), hospital readmission within 30 days of surgery (3.5%), and return to the operating room within 30 days of surgery (1.3%) Multivariable regression identified the following as risk factors for failed next-day discharge: pulmonary disease (OR 3.26; 95% CI 1.32 - 8.06, P=0.010), longer operating time (OR 1.40; 95% CI 1.10 - 1.79, P=0.006 per 60 minutes), and intra-operative hemorrhagic complications (OR 22.64; 95% CI 5.83 - 88.00, P<0.001). Success rate of overnight unit stay was no different among older women (greater than or equal to age 70) compared to women under age 70 (90.0% vs 89.2% p 0.18). Of the 101 patients assessed in the emergency room within 7 days of discharge, the most common indications for assessment included pain (42.6%), urinary symptoms (19.8%), fever (10.9%), bleeding (8.9%), wound complications (9.9%), nausea/vomiting (9.9%) and constipation (7.9%).

The overnight-stay unit is a valuable addition to post-operative urogynecologic care as allows for improved patient flow through the hospital and operating rooms. These data suggest that women with pre-existing pulmonary disease and those with hemorrhagic surgical complications may not be good candidates for an overnight-stay. As the demand for prolapse and incontinence surgery increases with the aging population, identifying and critically evaluating strategies to effectively and safely optimize patient flow and surgical outcomes are warranted.

Admission to an overnight-stay unit with next-day discharge is feasible for most patients undergoing urogynecologic surgery including patients undergoing major vaginal surgery and laparotomy. Factors associated with requiring a longer hospital stay, presentation to an emergency department within seven days, or readmission/re-operation within 30 days of surgery include pulmonary disease, longer operating times, and intra-operative hemorrhagic complications.