Improving outcomes in robot-assisted urologic oncology surgery using a perioperative electronic health program

Introduction

Robotic surgery proved to facilitate recovery and early discharge, particularly in onco-urologic surgery (1,2). Rehabilitation and optimization of the perioperative pathways, including enhanced recovery after surgery (ERAS) protocols, were shown to provide additional benefits to minimally invasive approaches in onco-urological surgery (1-3).

However, the implementation of perioperative pathways can be challenging, especially when trying to convey information to patients, and could face significant organizational and financial constraints (4-6). A growing body of evidence suggests that digital health may help disseminate educational programs and enhance patient adherence with a positive impact on perioperative outcomes and outpatient organization (7-11), but very few studies have focused solely on major surgeries, as robot-assisted urological oncology surgery.

Herein, we evaluate in a multicenter study the impact of an optimized digital pathway, through a single mobile app that addressed prehabilitation and rehabilitation, patient education, preoperative checklists, and electronic patient-reported outcomes (ePROs), on post-operative complications, readmission and patient-experience after robotic onco-urological surgery. The purpose of this study is to evaluate the impact of the BETTY COACHING program on the 90-day complication rate following robot-assisted oncologic urologic surgery. We present this article in accordance with the TREND reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-74/rc).

Methods

Study design and participants

The BETTY-MIS study was a prospective, multicenter trial, conducted in accordance with Good Clinical Practice and the Declaration of Helsinki and its subsequent amendments, and was approved by an Institutional Review Board (“Comité d’Orientation Scientifique Ramsay Santé”, IRB registration number: IRB00010835/202311004). All patients gave their written consent.

Eligible participants were those aged 18 years or older who underwent robotic onco-urologic surgery. Consecutive patients were included in the study. Patients were excluded if they were not able to use a smartphone (n=3) or were unable to understand French (n=1). All patients gave informed consent before inclusion in the study protocol. Patients were prospectively followed for 90 days after surgery. The recruitment took place in five public and private hospitals in France. The participating centers are: La Croix du Sud Hospital, Quint Fonsegrives, France; Saint-Augustin Hospital, Bordeaux, France; APHM, Marseille, France; Sud Manche Hospital, Avranches, France; Sainte Marguerite Hospital, Auxerre, France; IUCT-O, Toulouse, France. The IRB approval is valid for all participating centers.

Procedures

All underwent elective urologic surgery performed by experienced surgeons with at least 10 years of post-fellowship experience and beyond their learning curve for any included intervention, in both academic and non-academic hospitals. All patients were divided into two groups: one benefiting from the BETTY COACHING digital program and the other receiving standard care without digital support. No changes in perioperative protocols were allowed during the study period, except for the implementation of the digital program in the intervention group. All patients were managed according to a standardized, institutionally approved ERAS program, which was uniformly applied across all participating centers.

The digital intervention consisted in the download on the patient’s smartphone and use of Betty.care, a smartphone app that includes pre- and rehabilitation programs, and ePROs (“BETTY Coaching” program; AIMED2 company, Toulouse, France, https://betty.care). This app was validated in a single-center cohort of radical prostatectomy patients undergoing same-day discharge surgery (9). It included checklists in preparation of key events (anesthesiologist visit, admission, discharge, post-operative visits), alerts for starting or stopping activities (medications, physical activity, compression stockings, diet, work), and educational materials (podcasts, videos on physical activities, publications) with the objective to enhance patient’s information and health status.

The patient app communicated with a professional app operated on by the surgeon (Betty Pro). Thereby, the surgeon could check the patients’ characteristics (medical history, medications, and allergies) and compliance with use of mandatory app items at any time through the app. Complications are managed through app by filling in daily data in the patient’s pre-operative journal. This information is automatically transmitted to the surgeon, who can review it and detect any anomalies early on. If any issues arise, the surgeon is promptly alerted, allowing for quick intervention. The main functionalities of both patient and surgeon apps are listed in Table S1. Patients in both groups were followed for at least 3 months after surgery.

Outcomes

The primary endpoint was to assess the overall post-operative complication rate within 90 days after surgery. Post-operative complications were classified according to the Clavien-Dindo classification and defined as minor (grade I–II) and major (grade III–V) complications. Secondary endpoints were major post-operative complication rate, length of hospital stay, readmission (at emergency units and/or surgery ward) rates, the number of days alive and out of hospital within the 90 days after surgery, need for prolonged care (additional medications or nurse care) at discharge, unplanned visits, and patient satisfaction. Readmission was defined by any hospitalization at the emergency and/or surgery department. All endpoints were collected within the 3 months after surgery. Patient satisfaction was evaluated at the end of the period by a visual analog scale (range from 0 to 10). Data from each center were collected in an anonymized, prospectively maintained, centralized database. Perioperative data included the demographic characteristics of patients [age, American Society of Anesthesiologists (ASA) score, body mass index (BMI)], surgery data (type of surgery, operative time, estimated blood loss), and post-operative outcomes.

Statistical analysis

Descriptive statistics were carried out to describe general population characteristics, categorical variables were reported as frequencies and percentages (%), and continuous variables as medians and interquartile ranges (IQR). Then we compared categorical variables by Chi-squared or Fisher test. Continuous variables were compared by Mann-Whitney U test.

Then, a multivariate logistic regression model was used to evaluate the association between the implementation of the digital program and the risk of overall post-operative complications. The model was adjusted for variables deemed clinically relevant, including age, ASA score, BMI, blood loss, type of surgery and operative time. Adjusted odds ratios (OR) and corresponding 95% confidence intervals (CI) were calculated. All statistical analyses were performed using SPSS 22.0 software (SPSS, Inc., Chicago, IL, USA). All tests were two-sided with a significance level set at P<0.05.

Results

A total of 196 consecutive participants who underwent robotic onco-urological surgery were included in the analysis (n=98 in each group). Patients’ characteristics and intraoperative outcomes are presented in Table 1. Surgery type (kidney, prostate, or bladder cancer surgery) repartition was not significantly different in both groups (P=0.25).

The median operative time in the intervention group was 80 min (70–95 min) in both groups (P=0.47). The estimated blood loss was 100 mL (100–200 mL) in the control group and 150 mL (100–250 mL) in the digital app program group (P=0.06). Main results are listed in Table 2.

Overall post-operative complications were lower after the implementation of the digital app program (9.2% vs. 26.2%; P=0.002) as well as major complications (1.0% vs. 5.1%; P=0.21). A higher proportion of patients benefited from same-day discharge after the implementation of the digital app program (48.0% vs. 27.6%; P=0.003). Hospital stay was significantly shorter in the BETTY coaching group (0.8 versus 2.0 days, P=0.01). After discharge, the rate of unplanned visits and readmission dropped from 11.2% to 1.0% (P=0.003) and from 12.2% to 3.1% (P=0.02) in the intervention cohort. Consequently, the number of days alive and out of the hospital after surgery was increased in BETTY coaching patients (89.1 versus 87.5 days, P=0.002). Prolonged care outside the planned protocol after discharge was reduced in the BETTY coaching group (7.1% vs. 26.5%; P=0.004). Finally, the patient satisfaction score was improved after digital program implementation (91% versus 77%, P=0.02). On multivariable logistic regression analysis taking into account age, ASA score, BMI, blood loss, type of surgery and operative time, the implementation of the digital app program was significantly associated with a reduced risk of overall post-operative complications (OR 0.30, 95% CI: 0.13 to 0.72; P=0.007).

Discussion

Digital health has emerged as a promising tool for improving patient monitoring and adherence to educational programs (8,12,13). In this multicenter study, we assessed that in association with robotic surgery, it leads to significant advantages regarding patient recovery after surgery over classical pathways, and could contribute to a wider dissemination of ERAS protocols, aiming at reducing hospital stay, increasing same-day discharge and quick recovery (14,15). Patients following the digital program experienced less overall and major post-operative complications, and this benefit was confirmed in a multivariable analysis taking into account major confounders such as patient and surgery characteristics.

The different results between the two groups could be explained by a better patient preparation for surgery: checklists and alerts to suspend or to start medications (e.g., anticoagulants, antibiotics, supplements), educational material about aerobic training, home-based moderate-intensity exercise regimens, diet, oral nutrition, and cardiorespiratory fitness.

As documented by Merhe et al., major complications do not manifest immediately post-operatively, but rather after a few days of recovery (16). Therefore, this provides a rationale to why a same-day discharge can be just as effective as a one- or two-night hospital stay. Since complications typically arise later in the recovery process, patients discharged on the same day can still be monitored closely for any signs of issues once they are home, without compromising their overall outcome.

Various studies have already demonstrated that prehabilitation programs, in- or out-hospital, led to significant improvements in the postoperative period and complication reduction (4,5,17). Indeed, digital platforms improve patient and surgeon adherence to outpatient surgery, facilitate fast-track procedure allowing reductions in costs at the hospital- and healthcare levels (10,14,18). Noteworthy, the increased rate of same-day discharge was not correlated with an increase in unplanned visits or readmission rates. Conversely, the use of the digital program secured the post-operative period after discharge by improving the awareness of the postoperative phases and the way to manage the path of domiciliary care (8). A recent randomized controlled trial demonstrated that an online multifaceted rehabilitation program could significantly accelerate the recovery time to normal activities following major surgery (11). Importantly, the objective benefits measured by healthcare providers were confirmed at the patient experience level, with an improved satisfaction with perioperative pathway (9).

One advantage of the digital over an on-site program is to overcome organizational and financial constraints, with the aim of offering an optimized pathway to all patients (6,7). In fact, the implementation of this digital pathway that led to benefits in terms of hospital stay, readmission, and prolonged care after discharge, can also reduce the health-related costs at a population level. Given the increased costs for hospitals and healthcare systems generated by the robotic devices and their maintenance, and more globally the overall economic burden of surgery costs, this consideration may have an important impact and promote wide acceptance of optimized digital pathways. By reducing hospitalization time, as well as the number of unplanned visits, a better rationalization of economic and human resources can also be achieved. Further investigations are underway to confirm this hypothesis on costs.

Some limitations must be acknowledged. The lack of randomization was a clear limitation. However, we identified ethical issues as previous assessments suggested the significant benefit of the digital pathway in the context of prostate cancer surgery (6,9). Therefore, the pre- and post-interventional design with consecutive recruitment of patient groups from the same surgeons before and after the intervention, as well as the relatively short study period to guarantee homogenous management, can be considered as acceptable to draw strong conclusions based on these results. Another limitation is the inclusion of a small number of kidney and bladder cases, which may introduce potential confounding bias in the results. However, these additional cases were included to demonstrate the application’s adaptability and its ability to manage a broader range of oncological interventions beyond prostatectomy, enriching the overall analysis. Finally, another limitation of our study is that we cannot fully account for whether minor complications were self-managed by patients in the coaching group and therefore not formally recorded. This could explain the lower number of minor complications observed in this group. Interestingly, the opposite result might have been expected, as patients often require reassurance when dealing with minor issues, which could typically lead to more reported complications.

Conclusions

In this multicenter study, we report that the addition of digital optimized perioperative program including pre- and rehabilitation programs, checklists, and ePRO collection, improves 90-day outcomes after robot-assisted procedures in onco-urologic surgery, in terms of post-operative complications, readmission, prolonged care, and patient satisfaction. Further studies are needed to determine its impact in other surgery settings.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the TREND reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-74/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-74/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-74/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-74/coif). J.B.B. and G.P. have ownership in AIMED2 company. G.F., A.M., B.M. and G.P. have ownership in OLTRE Medical Consulting company. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the ethics committee of Comité d’Orientation Scientifique Ramsay Santé (IRB registration number: IRB00010835/202311004), and was conducted in line with the principles of the Declaration of Helsinki and its subsequent amendments. The IRB approval is valid for all participating centers. All patients gave their written consent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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