Comparing ambulatory to inpatient percutaneous nephrolithotomy: systematic review and meta-analysis.
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OBJECTIVES: To investigate the differences in perioperative characteristics and postoperative outcomes between inpatient and ambulatory percutaneous nephrolithotomy (PCNL) with a subgroup analysis of same-day discharge (SDD) patients, summarise published ambulatory pathways and compare cost and satisfaction data. PATIENTS AND METHODS: This study was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered a priori with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023438692). Ambulatory PCNL was defined as patients who were discharged after an overnight stay (≤23 h) and SDD was considered a subgroup discharged on postoperative Day 0. RESULTS: A total of 25 studies were included in the systematic review, of which 12 comparative studies were utilised for meta-analysis. We had a pooled population of 2463 patients, of which 1956 (79%) ambulatory (747 [30%] SDD) and 507 (21%) inpatients. The ambulatory PCNL cohort had fewer overall complications (risk ratio [RR] 0.65, 95% confidence interval [CI] 0.47-0.90; P = 0.010); however, there were no differences in major complications (i.e., Clavien-Dindo Grade ≥III; RR 0.46; 95% CI 0.17-1.21; P = 0.12), emergency department visits (RR 1.09, 95% CI 0.69-1.74; P = 0.71), 30-day readmission (RR 1.09, 95% CI 0.54-2.21; P = 0.81) or readmission at any point (RR 1.00, 95% CI 0.53-1.88; P = 0.99). The ambulatory PCNL cohort was more likely to be stone-free defined by imaging (RR 1.35, 95% CI 1.09-1.66; P = 0.005); however, when stone-free was inclusive of any definition there was no difference in stone-free rates (RR 1.10, 95% CI 0.98-1.23; P = 0.10). Subgroup analysis of SDD did not result in any significant differences. Cost savings ranged from $932.37 to a mean (standard deviation) $5327 (442) United States Dollars per case. No studies reported patient satisfaction data. CONCLUSIONS: Ambulatory PCNL seems to be a safe and efficacious model for select patients. Selection bias likely influenced ambulatory outcomes; however, this supports overall safety of current ambulatory inclusion criteria.
