Urethroplasties have experienced a significant increase in the ratio of outpatient to inpatient procedures, with a marginal increase in the rate of postoperative complications. The rate of urethroplasty procedures being performed as outpatient procedures has been increased in a national report.[1] Advocating outpatient approach provides multiple advantages including conservation of resources, reduced healthcare costs, and increased patient convenience.[2] We sought to compare short-term (30-day) postoperative morbidity between patients who were discharged early (same-day) versus late (>1 day) following urethroplasty and to determine factors associated with postoperative complications in each group.

Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005-2016, patients who underwent urethroplasty procedure were identified. Study cohort included adult (≥ 18 years) male patients who received primary anterior urethroplasty (current procedural terminology (CPT) codes: 53400, 53405, 53410) and posterior urethroplasty (CPT codes: 53415, 53431, 53425, 53420). Secondary CPT codes (14040, 14041, 15240, 15740, 20926, 40818, 41870) were used to identify whether patients received any tissue transfer (i.e. flaps or grafts) during urethroplasty procedure. We categorized the study cohort into two groups based on their length of stay (LOS, days): “early discharge” (LOS = 1) and “late discharge” (LOS > 1). Extracted data included patient characteristics, preexisting chronic medical conditions, the American Society of Anesthesiologists (ASA) patient classification, preoperative labs and short-term (30-day) postoperative complications and mortality. Multivariable logistic regressions were performed to determine factors associated with increased risk of postoperative complications in each group. Adjusted odds ratios and 95% CIs were reported.

Overall n=1,435 male urethroplasty patients were identified, of which 396 (27.6%) were discharged early and 1,039 (72.4%) were discharged late. Approximately, 43% of the patients in the study cohort were aged 18–44 years and 58.8% were of white race. The majority of patients had ASA class I/II (72.3%), normal WBC count (61.7%), low hematocrit (48.5%) before receiving urethroplasty and received urethroplasty in 2011 onward (88.5%). Regards etiology of urethral stricture, about 89% of all patients had idiopathic stricture, with small proportion who had a post-traumatic (9.7%) and post-infective (1.4%) urethral stricture. About 69% of the patients received an anterior urethroplasty, and only 27.9% received tissue transfer during their surgery. Among those who had tissue transfer whether flaps and grafts, 70.5% received anterior urethroplasty and 29.5% received posterior urethroplasty. The average operating time (minutes) in patients who were discharged early was shorter compared to those who were discharged late (124.2 ± 74.9 vs. 179.9 ± 89.9, p<0.001). The average LOS of patients in late-discharge group was 2.9±2.8 days. The proportion of patients with postoperative complications was relatively lower among early-discharge group compared to those in the late discharge (5.6% vs. 7.4%, p=0.215). Rates of early mortality (0.2% vs. 0%, p=0.275, respectively) and reoperation (0.8% vs. 1.2%, p=0.578, respectively) were similar between early- and late-discharge groups. After adjusting for confounders, patients discharged early had a lower likelihood of being readmitted (OR [95%CI]: 0.35 [0.14, 0.88]) compared to those discharged late. The multivariable analysis suggested that patient’s age of 45-54 years (vs. 18-44) was associated with increased risk of postoperative complications in early-discharge group (OR [95%CI]: 3.60 [1.05, 12.35]). In late-discharge group, white race (OR [95%CI]: 0.53 [0.28, 0.99]) was associated with decreased risk of postoperative complications, while every 10-minute increment in operating time (OR [95%CI]: 1.04 [1.02, 1.07]) increased the odds of early postoperative complications.

Our results showed that there was no significant difference in the rates of early postoperative complications, readmissions and reoperations between early- and late-discharge groups following urethroplasy. This would encourage reconstructive urologists to adopt the outpatient approach of urethroplasty procedure for selected patients. Older age (45-54 years) among early-discharge group and longer operating time among late-discharge group were associated with higher risk of early postoperative complications. These factors would help urologists selecting the best approach in terms of LOS when dealing with urethral stricture patients.

Rates of 30-day morbidity, mortality and reoperation were similar between early- and late-discharge groups following urethroplasty. Predictors of early complications following urethroplasty was age group of 45-54 (vs. 18-44) in early-discharge group and longer operating time (10-minute increment) in late-discharge.

MacDonald S, Haddad D, Choi A, Colaco M, Terlecki R (2017) Anterior urethroplasty has transitioned to an outpatient procedure without serious rise in complications: data from the national surgical quality improvement program. Urology 102:225–228. https ://doi.org/10.1016/j.urolo gy.2016.09.043
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