The impact of cannabis use disorder on urologic oncologic surgery morbidity, length of stay, and inpatient cost: analysis of the National Inpatient Sample from 2003 to 2014.

PURPOSE: This study examined the impact of cannabis use disorder (CUD) on inpatient morbidity, length of stay (LOS), and inpatient cost (IC) of patients undergoing urologic oncologic surgery. METHODS: The National Inpatient Sample (NIS) from 2003 to 2014 was analyzed for patients undergoing prostatectomy, nephrectomy, or cystectomy (n = 1,612,743). CUD was identified using ICD-9 codes. Complex-survey procedures were used to compare patients with and without CUD. Inpatient major complications, high LOS (4th quartile), and high IC (4th quartile) were examined as endpoints. Univariable and multivariable analysis (MVA) were performed to compare groups. RESULTS: The incidence of CUD increased from 51 per 100,000 admissions in 2003 to 383 per 100,000 in 2014 (p < 0.001). Overall, 3,503 admissions had CUD. Patients with CUD were more frequently younger (50 vs. 61), male (86% vs. 78.4%), Black (21.7% vs. 9.2%), and had 1st quartile income (36.1% vs. 20.6%); all p < 0.001. CUD had no impact on any complication rates (all p > 0.05). However, CUD patients had higher LOS (3 vs. 2 days; p < 0.001) and IC ($15,609 vs. $12,415; p < 0.001). On MVA, CUD was not an independent predictor of major complications (p = 0.6). Conversely, CUD was associated with high LOS (odds ratio (OR) 1.31; 95% CI 1.08-1.59) and high IC (OR 1.33; 95% CI 1.12-1.59), both p < 0.01. CONCLUSION: The incidence of CUD at the time of urologic oncologic surgery is increasing. Future research should look into the cause of our observed phenomena and how to decrease LOS and IC in CUD patients.

The Association between Income Status and Treatment Selection for Prostate Cancer in a Universal Health Care System: A Population-Based Analysis.

PURPOSE: Treatment selection for localized prostate cancer is guided by risk stratification and patient preferences. While socioeconomic status (SES) disparities exist for access to care, less is known about the effect of SES on treatment decision-making. We sought to evaluate whether income status was associated with the treatment selected (radical prostatectomy [RP] vs radiation therapy [RT]) for nonmetastatic prostate cancer in a universal health care system. MATERIALS AND METHODS: All men from Manitoba, Canada who were diagnosed with nonmetastatic prostate cancer between 2005 and 2016 and subsequently treated with RP or RT were identified using a provincial cancer database. SES was defined as neighborhood income by postal code and divided into income quintiles (Q1-Q5, with Q1 the lowest quintile and Q5 the highest). Multivariable logistic regression nested models were used to compare whether SES was associated with treatment type received. RESULTS: We identified 3,966 individuals who were diagnosed with nonmetastatic prostate cancer and were treated with RP (2,354) or RT (1,612). After adjusting for demographic and clinicopathological characteristics, as income quintile increased, men were incrementally more likely to undergo RP than RT (range Q2 vs Q1: adjusted OR 1.40, 95% CI 1.01-1.93; Q5 vs Q1: adjusted OR 2.30, 95% CI 1.70-3.12). CONCLUSIONS: As income levels increased there was a stepwise incremental increase in the odds of receiving RP over RT for localized prostate cancer. These results may inform initiatives to better understand the values, priorities and barriers that patients experience when making treatment decisions in a universal health care system.

Active Surveillance for Men with Intermediate Risk Prostate Cancer.

PURPOSE: Optimal treatment of intermediate risk prostate cancer remains unclear. National Comprehensive Cancer Network® guidelines recommend active surveillance, prostatectomy or radiotherapy. Recent trials demonstrated no difference in prostate cancer specific mortality for men undergoing active surveillance for low risk prostate cancer compared to prostatectomy or radiotherapy. The use of active surveillance for intermediate risk prostate cancer is less clear. In this study we characterize U.S. national trends for demographic, clinical and socioeconomic factors associated with active surveillance for men with intermediate risk prostate cancer. MATERIALS AND METHODS: This retrospective cohort study examined 176,122 men diagnosed with intermediate risk prostate cancer from 2010 to 2016 in the National Cancer Database. Temporal trends in demographic, clinical and socioeconomic factors among men with intermediate risk prostate cancer and association with the use of active surveillance were characterized. The analysis was performed in April 2020. RESULTS: In total, 176,122 men were identified with intermediate risk prostate cancer from 2010 to 2016. Of these men 57.3% underwent prostatectomy, 36.4% underwent radiotherapy and 3.2% underwent active surveillance. Active surveillance nearly tripled from 1.6% in 2010 to 4.6% in 2016 (p <0.001). On multivariate analysis use of active surveillance was associated with older age, diagnosis in recent years, lower Gleason score and tumor stage, type of insurance, treatment at an academic center and proximity to facility, and attaining higher education (p <0.05). Race and comorbidities were not associated with active surveillance. CONCLUSIONS: Our findings highlight increasing active surveillance use for men with intermediate risk prostate cancer demonstrating clinical and socioeconomic disparities. Prospective data and improved risk stratification are needed to guide optimal treatment for men with intermediate risk prostate cancer.

Perioperative outcomes and cost of robotic vs open simple prostatectomy in the modern robotic era: results from the National Inpatient Sample.

OBJECTIVES: To perform a comparative analysis of perioperative outcomes and hospitalisation cost between open (OSP) and robot-assisted simple prostatectomy (RASP) for treatment of benign prostatic hyperplasia (BPH) using the National Inpatient Sample (NIS) in the contemporary robotic era. MATERIALS AND METHODS: The NIS was queried for cases of OSP and RASP for the treatment of BPH between 2013 and 2016. Perioperative complications, unadjusted hospital cost and length of stay (LOS) were compared between RASP and OSP. Smoothed linear regression curves comparing hospitalisation cost by increasing LOS was stratified by surgical approach to identify point of cost equivalency between RASP and OSP. Multivariable linear regression analysis was used to construct a hospitalisation cost model to examine the contribution of the robotic approach and LOS to hospitalisation cost. RESULTS: The total analytical cohort included 2551 OSP and 704 RASP procedures. Patients undergoing RASP were younger, at a median (interquartile range [IQR]) age of 68 (63-73) vs 71 (65-77) years, and with less comorbidity (76.8% vs 86.5%, P < 0.01). RASP was associated with fewer total complications (11.1% vs 29.2%, P < 0.01) and a greater likelihood of routine discharge to home rather than another facility (88.9% vs 76.7%, P < 0.01). While LOS was shorter with RASP (median [IQR], 2 [1-3] vs 4 [3-6] days, P < 0.01), total unadjusted hospitalisation cost (in United States dollars) was greater (median [IQR], $10 855 [$7965-$15 675] vs $13 467 [$10 572-$17 722], P < 0.01). Presence of any complication increased both LOS and hospitalisation cost (P < 0.01). Linear regression modelling determined the point of cost equivalence between RASP staying a median of 2 days was an OSP case staying between 5 and 6 days. On multivariable regression analysis, the robotic approach contributed an additional $6175 (P < 0.01) to the cost model, whereas each additional day of hospitalisation contributed $1687 (P < 0.01), suggesting LOS would need to be 3-4 days shorter with RASP to offset surgical costs of the robot. CONCLUSIONS: While RASP appears to have significantly better perioperative complication rates with shorter LOS and likely discharge to home, total hospitalisation cost remained greater, likely related to upfront operative costs. While this retrospective study is limited by selection bias for patients undergoing RASP, the benefits of improved convalescence, discharge to home, and lower rate of perioperative complications appear to justify performance of RASP in an experienced pelvic robotic centre despite relatively greater hospitalisation cost if referral to an experienced holmium laser enucleation of the prostate centre is not feasible.

[Cost analysis of GreenLight photoselective vaporization of the prostate versus standard transurethral resection of the prostate: Benefit of ambulatory care]. / Analyse des coûts de la photovaporisation prostatique au laser Greenlight versus résection transurétrale de la prostate : intérêt de la prise en charge ambulatoire.

PURPOSE: To compare the costs associated with GreenLight XPS 180W photoselective vaporization of the prostate (PVP) for an outpatient versus standard transurethral resection of the prostate (TURP) with a three nights hospitalization in a French private hospital. MATERIAL AND METHODS: A retrospective cost minimization analysis was performed between 2017 and 2019 in a French private hospital for the hospital stays associated with TURP and PVP procedures for benign prostatic hyperplasia (BPH). The peri-operative cost-benefit assessment of the two procedures was analyzed from the establishment's point of view according to the micro-costing method. RESULTS: 871 surgical treatment for BPH had been performed during the period of the study, including 743 photoselective laser vaporization (85%). The average length of stay of patients undergoing TURP was 3,7 days versus 0,9 days for PVP including 64,7% ambulatory. The cost-benefit was more of 500€ per patient in favor of ambulatory PVP compared with TURP in conventional three nights hospitalization for level 1 hospital stays. CONCLUSION: In this private hospital center, ambulatory PVP seemed more cost-effective than TURP with a three nights hospitalization for a severity level 1 patient. The financial profit for the establishment was mostly due to reduction of the main length of stay and ambulatory care. LEVEL OF EVIDENCE: 3.

Modelling the lifetime cost-effectiveness of radical prostatectomy, radiotherapy and active monitoring for men with clinically localised prostate cancer from median 10-year outcomes in the ProtecT randomised trial.

BACKGROUND: Optimal management strategies for clinically localised prostate cancer are debated. Using median 10-year data from the largest randomised controlled trial to date (ProtecT), the lifetime cost-effectiveness of three major treatments (radical radiotherapy, radical prostatectomy and active monitoring) was explored according to age and risk subgroups. METHODS: A decision-analytic (Markov) model was developed and informed by clinical input. The economic evaluation adopted a UK NHS perspective and the outcome was cost per Quality-Adjusted Life Year (QALY) gained (reported in UK£), estimated using EQ-5D-3L. RESULTS: Costs and QALYs extrapolated over the lifetime were mostly similar between the three randomised strategies and their subgroups, but with some important differences. Across all analyses, active monitoring was associated with higher costs, probably associated with higher rates of metastatic disease and changes to radical treatments. When comparing the value of the strategies (QALY gains and costs) in monetary terms, for both low-risk prostate cancer subgroups, radiotherapy generated the greatest net monetary benefit (£293,446 [95% CI £282,811 to £299,451] by D'Amico and £292,736 [95% CI £284,074 to £297,719] by Grade group 1). However, the sensitivity analysis highlighted uncertainty in the finding when stratified by Grade group, as radiotherapy had 53% probability of cost-effectiveness and prostatectomy had 43%. In intermediate/high risk groups, using D'Amico and Grade group > = 2, prostatectomy generated the greatest net monetary benefit (£275,977 [95% CI £258,630 to £285,474] by D'Amico and £271,933 [95% CI £237,864 to £287,784] by Grade group). This finding was supported by the sensitivity analysis. Prostatectomy had the greatest net benefit (£290,487 [95% CI £280,781 to £296,281]) for men younger than 65 and radical radiotherapy (£201,311 [95% CI £195,161 to £205,049]) for men older than 65, but sensitivity analysis showed considerable uncertainty in both findings. CONCLUSION: Over the lifetime, extrapolating from the ProtecT trial, radical radiotherapy and prostatectomy appeared to be cost-effective for low risk prostate cancer, and radical prostatectomy for intermediate/high risk prostate cancer, but there was uncertainty in some estimates. Longer ProtecT trial follow-up is required to reduce uncertainty in the model. TRIAL REGISTRATION: Current Controlled Trials number, ISRCTN20141297: http://isrctn.org (14/10/2002); ClinicalTrials.gov number, NCT02044172: http://www.clinicaltrials.gov (23/01/2014).

Outcomes for urologic oncology procedures: are there differences between academic and community hospitals?

OBJECTIVE: To compare the rate of hospital-based outcomes including costs, 30-day readmission, mortality, and length of stay in patients who underwent major urologic oncologic procedures in academic and community hospitals. METHODS: We retrospectively reviewed the Vizient Database (Irving, Texas) from September 2014 to December 2017. Vizient includes ~ 97% of academic hospitals (AH) and more than 60 community hospitals (CH). Patients aged ≥ 18 with urologic malignancies who underwent surgical treatment were included. Chi square and Student t tests were used to compare categorical and continuous variables, respectively. RESULTS: We identified a total of 37,628 cases. There were 33,290 (88%) procedures performed in AH and 4330 (12%) in CH. These included prostatectomy (18,540), radical nephrectomy (rNx) 8059, partial nephrectomy (pNx) (5287), radical cystectomy (4421), radical nephroureterectomy (rNu) (1006), and partial cystectomy (321). There were no significant differences in 30-day readmission rates or mortality for any procedure between academic and community hospitals (Table 1), p > 0.05 for all. Length of stay was significantly lower for radical cystectomy and prostatectomy in AH (p < 0.01 for both) and lower for rNx in CH (p = 0.03). The mean direct cost for index admission was significantly higher in AH for rNx, pNx, rNu, and prostatectomy. Case mix index was similar between the community and academic hospitals. CONCLUSION: Despite academic and community hospitals having similar case complexity, direct costs were lower in community hospitals without an associated increase in readmission rates or deaths. Length of stay was shorter for cystectomy in academic centers.

Economic burden of illness associated with localized prostate cancer in the United States.

Aim: Prior studies have established the economic burden of prostate cancer on society. However, changes to screening, novel therapies and increased use of active surveillance (AS) create a need for an updated analysis. Methods: A deterministic, decision-analytic model was developed to estimate medical costs associated with localized prostate cancer over 10 years. Results: 10-year costs averaged $45,957, $99,445 and $188,928 for low-, intermediate- and high-risk patients, respectively. For low-risk patients, AS 10-year costs averaged $33,912/patient, whereas definitive treatment averaged $49,667/patient. Despite higher failure rates in intermediate-risk patients, AS remained less costly than definitive treatment, with 10-year costs averaging $90,614/patient and $99,394/patient, respectively. Conclusion: Broader incorporation of AS, guided by additional prognostic tools, may mitigate this growing economic burden.

Health economic impact of a biopsy-based cell cycle gene expression assay in localized prostate cancer.

Background: Prior studies have established that broader incorporation of active surveillance, guided by additional prognostic tools, may mitigate the growing economic burden of localized prostate cancer in the USA. This study sought to further explore the potential of a particular gene expression-based prognostic tool to address this unmet need. Materials & methods: A deterministic, decision-analytic model was developed to estimate the economic impact of the Prolaris® test on a US commercial health plan. Results & conclusion: When adopted in patients classified by the American Urological Association as low or intermediate risk, the assay was projected to reduce costs by $1894 and $2129 per patient over 3 and 10 years, respectively, largely through the increased use of active surveillance.

Cost-Effectiveness of Active Surveillance, Radical Prostatectomy and External Beam Radiotherapy for Localized Prostate Cancer: An Analysis of the ProtecT Trial.

PURPOSE: Despite increasing emphasis on value based care, to our knowledge the cost-effectiveness of prostate cancer management options has not been compared using prospective clinical trial data. The ProtecT (Prostate Testing for Cancer and Treatment) trial demonstrated no difference in survival in patients randomized to active surveillance, external beam radiotherapy or radical prostatectomy. We compared cost-effectiveness among the arms of ProtecT. MATERIALS AND METHODS: Using a Markov model we compared the cost-effectiveness of active surveillance, radical prostatectomy and external beam radiotherapy based on ProtecT outcomes, specifically 6-year quality of life data and 10-year oncologic data. Costs were based on 2017 Medicare reimbursement while utility values were assigned using the literature. Univariable and multivariable sensitivity analyses were performed. RESULTS: Six years after randomization the mean costs per patient were $12,143 for active surveillance, $17,781 for radical prostatectomy and $29,238 for external beam radiotherapy. The incremental cost-effectiveness ratio relative to active surveillance was $127,752/QALY for radical prostatectomy and $381,894/QALY for external beam radiotherapy. Ten years after randomization radical prostatectomy ($5,627/QALY) and external beam radiotherapy ($78,291/QALY) were more cost-effective than active surveillance. The model was sensitive to the metastasis rate on active surveillance with a threshold of 2.4% at 10 years, below which active surveillance was more cost-effective than radical prostatectomy. On multivariable sensitivity analysis at 10 years using a willingness to pay threshold of $100,000/QALY the most cost-effective strategy was radical prostatectomy in 45% of model microsimulations, external beam radiotherapy in 30% and active surveillance in 25%. CONCLUSIONS: Although active surveillance represents a cost-effective strategy to manage localized prostate cancer during the initial several years after diagnosis, the relative cost-effectiveness of treatment emerges with extended followup.

Financial Margins for Prostate Cancer Surgery: Quantifying the Impact of Modifiable Cost Inputs in an Episode Based Reimbursement Model.

PURPOSE: The United States health care system is rapidly moving away from fee for service reimbursement in an effort to improve quality and contain costs. Episode based reimbursement is an increasingly relevant value based payment model of surgical care. We sought to quantify the impact of modifiable cost inputs on institutional financial margins in an episode based payment model for prostate cancer surgery. MATERIALS AND METHODS: A total of 157 consecutive patients underwent robotic radical prostatectomy in 2016 at a tertiary academic medical center. We compiled comprehensive episode costs and reimbursements from the most recent urology consultation for prostate cancer through 90 days postoperatively and benchmarked the episode price as a fixed reimbursement to the median reimbursement of the cohort. We identified 2 sources of modifiable costs with undefined empirical value, including preoperative prostate magnetic resonance imaging and perioperative functional recovery counseling visits, and then calculated the impact on financial margins (reimbursement minus cost) under an episode based payment. RESULTS: Although they comprised a small proportion of the total episode costs, varying the use of preoperative magnetic resonance imaging (33% vs 100% of cases) and functional recovery counseling visits (1 visit in 66% and 2 in 100%) reduced average expected episode financial margins up to 22.6% relative to the margin maximizing scenario in which no patient received these services. CONCLUSIONS: Modifiable cost inputs have a substantial impact on potential operating margins for prostate cancer surgery under an episode based payment model. High cost health systems must develop the capability to analyze individual cost inputs and quantify the contribution to quality to inform value improvement efforts for multiple service lines.

Same Day Discharge after Robotic Radical Prostatectomy.

PURPOSE: The typical mean length of stay following robot-assisted laparoscopic prostatectomy is 24 to 48 hours. We began routinely offering same day discharge from the hospital after robot-assisted laparoscopic prostatectomy. We evaluated the success rate, safety and cost implications in what is to our knowledge the only large series of same day discharge to date. MATERIALS AND METHODS: Beginning in September 2016 all patients were given the option of same day discharge without it being mandated. After allowing 3 months to solidify the protocol we evaluated our prospective database for the next 500 patients. RESULTS: Of the 500 consecutive men who underwent robot-assisted laparoscopic prostatectomy performed by 1 surgeon in 18 months 246 (49.2%) were discharged home the day of surgery and all of the remaining 254 were discharged the next day for a mean 0.51-day length of stay. Mean patient age was 62 years (range 42 to 81) and mean body mass index was 29.7 kg/m2 (range 20 to 53). Of the patients 34 (6.8%) had a Clavien-Dindo grade I-III complication within 90 days but there were no grade IV-V complications. Only 5 patients (1%) required an emergency department visit and only 8 (1.6%) required readmission. Only 1 of the patients who elected same day discharge was rehospitalized and only 1 presented to the emergency department. The estimated charge for an overnight stay at our institution is $2,109. The approximate reduction in charges was $518,814 during 18 months ($345,876 per year) with no increased cost due to emergency department visits or hospital readmissions compared with that of overnight patients. In the most recent 100 patients the rate of same day discharge improved to 65%. CONCLUSIONS: Same day discharge following robot-assisted laparoscopic prostatectomy can be safely routinely offered with no increase in readmissions or emergency visits. It may lead to significant savings in health care costs.

Regional differences in total hospital charges between open and robotically assisted radical prostatectomy in the United States.

BACKGROUND: Robotically assisted radical prostatectomy (RARP) has become the most frequently used surgical approach for patients treated with radical prostatectomy (RP) for localized prostate cancer (PCa). Previous studies reported higher total hospital charges (THCs) for RARP than open RP (ORP). We hypothesized that based on increasing RARP surgical expertise, differences in THCs between RARP and ORP should have decreased or even disappeared in the United States in most contemporary years. PATIENTS AND METHODS: Within the National Inpatient Sample database (2008-2015), we identified patients who underwent RARP or ORP. Multivariable linear regression models with adjustment for clustering were used to test for differences in THCs. Subgroup analyses focused on geographical regions, defined as West, Midwest, South and Northeast. RESULTS: Of 83,693 RP patients, 51,363 (61.4%) underwent RARP. RARP rates increased from 13.1 to 81.5% (p = 0.04). Overall, median THCs were $11,898 vs. $10,162 (p < 0.001) for RARP vs. ORP, respectively. After adjustment for complications, length of stay and clustering, RARP was associated with higher THCs ($3124 more for each RARP, p < 0.001). Additional charges for RARP did not change over time (p = 0.3). However, additional charges for RARP were highest in the West ($4610, p < 0.001), followed by the Midwest ($3278, p < 0.001), the South ($2906, p < 0.001) and the Northeast ($2216, p < 0.001). CONCLUSION: RARP rates have increased exponentially from 13.1 to over 80%. Similar rates were identified across all four geographical regions. RARP THCs exceeded those of ORP. Finally, important regional differences in RARP THCs were identified and persisted even after most detailed adjustment for population differences.

A comprehensive analysis of cost of an active surveillance cohort compared to radical prostatectomy as primary treatment for prostate cancer.

INTRODUCTION: Active surveillance (AS) seems to be a cost-effective strategy. However, most publications are based on simulation models of theoretical cohorts, and long-term implications are not usually considered. OBJECTIVE: To assess the real cost differences of two cohorts of men with low-risk prostate cancer (PCa) treated with AS or laparoscopic radical prostatectomy (LRP) in a public health system. MATERIALS AND METHODS: Patients diagnosed from 2005 to 2009 were included in an AS program (Group 1) or treated with LRP at diagnosis (Group 2), with a minimum follow-up of 5 years. Actual costs for each patient were calculated on an individual basis: Group 1: semiannual PSA measurements and repeat biopsies are scheduled every 1-3 years. Costs of outpatient clinic visits were calculated, as well as all tests required for monitoring or active treatment. Group 2: costs of the procedure, emergency visits, re-admissions and outpatient clinic visits were calculated, as well as costs of oncological salvage therapies or functional surgical procedures. RESULTS: Out of 151 men diagnosed with low-risk PC, 54 (35.8%) were included in an AS (Group 1) and 97 (64.2%) were submitted to LRP (Group 2). Mean follow-up for both groups was 6.5 years (SD 1.8) and 6.7 years (SD 1.4), respectively, p = 0.49. Group 1 had a total cost per patient of 2970.47€. Group 2 had a total cost per patient of 5694.06€. CONCLUSIONS: AS was associated with cost-saving over LRP. This cost reduction of AS in the management of low-risk PCa is based on the accounting of real costs of individual patients and confirms previously published estimation-based reports.

Comparison of retropubic, laparoscopic and robotic radical prostatectomy: who is the winner?

PURPOSE: This study is a systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes and the cost of open retropubic radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALP). METHODS: Summary data was abstracted from 104 original research articles representing 227,400 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE and the Cochrane Library were reviewed in December 2016. A total of 104 publications were selected for inclusion. The primary outcomes were positive surgical margin (PSM) and major complication rate according to Clavien classifications. Secondary outcomes were operative time, length of hospital stay, estimated blood loss, transfusions, conversions, rate of post-operative erectile dysfunction and incontinence and total cost of procedure. RESULTS: ORP had a significantly higher rate than RALP for PSM (OR: 1.18; 95% CI 1.05-1.32; p = 0.004), but the rate of PSM was not significantly different between ORP versus LRP (OR: 1.37; 95% CI 0.88-2.14; p = 0.17) and RALP versus LRP (OR: 0.83; 95% CI 0.40-1.72; p = 0.62). The major Clavien complication rate was significantly different between ORP and RALP (OR: 2.14; 95% CI 1.24-3.68; p = 0.006). Estimated blood loss, transfusions and length of hospital stay were low for RALP, moderate for LRP and high for ORP. The rate of erectile dysfunction (OR: 2.58; 95% CI 1.77-3.75; p < 0.001) and incontinence (OR: 3.57; 95% CI 2.28-5.58; p < 0.001) were significantly lower after RALP than LRP and equivalent for other comparisons. Total cost was highest for RALP, followed by LRP and ORP. CONCLUSIONS: For PSM and peri- and post-operative complications, RALP showed better results than ORP and LRP. In the context of the biases between the studies, one should interpret the results with caution.

Robotic assisted simple prostatectomy: recent advances.

PURPOSE OF REVIEW: Robotic assisted simple prostatectomy (RASP) represents a minimally invasive evolution of traditional open simple prostatectomy for the surgical treatment of severe lower urinary tract symptoms (LUTS) because of benign prostatic enlargement (BPE). Aim of the present review is to summarize the most recent evidence on this novel procedure, and to better define its current role in the surgical armamentarium for the treatment of BPE. RECENT FINDINGS: Several studies demonstrated that RASP can be safely and effectively performed in centers with sufficient expertise. The procedure can duplicate its open counterpart with the advantage of lower perioperative morbidity, and ultimately faster patient recovery. Overall, the status of RASP seems to be well beyond that of an 'investigational' procedure, and guidelines should be amended accordingly.Nevertheless, it remains to be determined what the place of the RASP procedure in the surgical armamentarium for the treatment of symptomatic BPE will be. Over the most recent years, few comparative studies have been reported, allowing in part to draw some conclusions. RASP seems to be attractive when compared with open simple prostatectomy as it can offer less blood loss, and shorter hospital stay. However, its advantages over transurethral enucleation techniques - such as HoLEP - remain unclear. There are some specific indications, such as the presence of concomitant bladder diverticula or stones, for example, where a robotic approach could represent an appealing solution. Ultimately, further research should look at a cost analysis to determine which technique can be more cost effective. Last, the issue of the learning curve for the different procedures for symptomatic BPE remain to be further scrutinized. SUMMARY: RASP offers potential advantages over other available techniques for the treatment of large prostate glands. In centers, wherever a solid robotic program is already in place, this procedure is likely to be increasingly implemented.

Redefining and Contextualizing the Hospital Volume-Outcome Relationship for Robot-Assisted Radical Prostatectomy: Implications for Centralization of Care.

PURPOSE: Robot-assisted radical prostatectomy has undergone rapid dissemination driven in part by market forces to become the most frequently used surgical approach in the management of prostate cancer. Accordingly, a critical analysis of its volume-outcome relationship has important health policy implications. Therefore, we evaluated the association of hospital robot-assisted radical prostatectomy volume with perioperative outcomes, and examined the distribution of hospital procedure volume to contextualize the volume-outcome relationship. MATERIALS AND METHODS: We identified 140,671 men who underwent robot-assisted radical prostatectomy from 2009 to 2011 in NIS (Nationwide Inpatient Sample). The associations of hospital volume with perioperative outcomes and total hospital costs were evaluated using multivariable logistic regression and generalized linear models. RESULTS: In 2011, 70% of hospitals averaged 1 robot-assisted radical prostatectomy per week or less, accounting for 28% of surgeries. Compared to patients treated at the lowest quartile hospitals, those treated at the highest quartile hospitals had significantly lower rates of intraoperative complications (0.6% vs 1.4%), postoperative complications (4.8% vs 13.9%), perioperative blood transfusion (1.5% vs 4.0%), prolonged hospitalization (4.3% vs 13.8%) and mean total hospital costs ($12,647 vs $15,394, all ptrend <0.001). When modeled as a nonlinear continuous variable, increasing hospital volume was independently associated with improved rates of each perioperative end point up to approximately 100 robot-assisted radical prostatectomies per year, beyond which there appeared to be marginal improvement. CONCLUSIONS: Increasing hospital robot-assisted radical prostatectomy volume was associated with improved perioperative outcomes up to approximately 100 surgeries per year, beyond which there appeared to be marginal improvement. A substantial proportion of these procedures is performed at low volume hospitals.

Minimally invasive surgery and its impact on 30-day postoperative complications, unplanned readmissions and mortality.

BACKGROUND: A critical appraisal of the benefits of minimally invasive surgery (MIS) is needed, but is lacking. This study examined the associations between MIS and 30-day postoperative outcomes including complications graded according to the Clavien-Dindo classification, unplanned readmissions, hospital stay and mortality for five common surgical procedures. METHODS: Patients undergoing appendicectomy, colectomy, inguinal hernia repair, hysterectomy and prostatectomy were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Non-parsimonious propensity score methods were used to construct procedure-specific matched-pair cohorts that reduced baseline differences between patients who underwent MIS and those who did not. Bonferroni correction for multiple comparisons was applied and P < 0·006 was considered significant. RESULTS: Of the 532 287 patients identified, 53·8 per cent underwent MIS. Propensity score matching yielded an overall sample of 327 736 patients (appendicectomy 46 688, colectomy 152 114, inguinal hernia repair 59 066, hysterectomy 59 066, prostatectomy 10 802). Within the procedure-specific matched pairs, MIS was associated with significantly lower odds of Clavien-Dindo grade I-II, III and IV complications (P ≤ 0·004), unplanned readmissions (P < 0·001) and reduced hospital stay (P < 0·001) in four of the five procedures studied, with the exception of inguinal hernia repair. The odds of death were lower in patients undergoing MIS colectomy (P < 0·001), hysterectomy (P = 0·002) and appendicectomy (P = 0·002). CONCLUSION: MIS was associated with significantly fewer 30-day postoperative complications, unplanned readmissions and deaths, as well as shorter hospital stay, in patients undergoing colectomy, prostatectomy, hysterectomy or appendicectomy. No benefits were noted for inguinal hernia repair.

Risk of hospitalisation after primary treatment for prostate cancer.

OBJECTIVE: To compare the risk of hospitalisation and associated costs in patients after treatment for prostate cancer. PATIENTS AND METHODS: We identified 29 571 patients aged 66-75 years without significant comorbidity from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database who were diagnosed with localised prostate cancer between 2004 and 2009. We compared the rates of all-cause and treatment-related hospitalisation that occurred within 365 days of the initiation of definitive therapy. We used multivariable logistic regression analysis to identify determinants associated with hospitalisation. RESULTS: Men who underwent radical prostatectomy (RP) rather than radiotherapy (RT) had lower odds of being hospitalised for any cause after therapy [odds ratio (OR) 0.80, 95% confidence interval (CI): 0.74-0.87]. Patients who underwent RP rather than RT had higher odds of being hospitalised for treatment-related complications (OR 1.15, 95% CI: 1.03-1.29). However, men who underwent external beam RT (EBRT)/intensity modulated RT (IMRT) (OR 0.84, 95% CI: 0.72-0.99) had a 16% lower odds of hospitalisation from treatment-related complications than patients undergoing RP. Using propensity score-weighted analyses there was no significant difference in the odds of hospitalisation from treatment-related complications for men who underwent RP vs RT (OR 1.06, 95% CI: 0.92-1.21). Patients hospitalised for treatment-related complications after RT were costlier than patients who underwent RP (Mean $18 381 vs $13 203, P < 0.001). CONCLUSIONS: With the exception of men who underwent EBRT/IMRT, there was no statistically significant difference in the odds of hospitalisation from treatment-related complications. Costs from hospitalisation after treatment were significantly higher for men undergoing RT than RP. Our findings are relevant in the context of penalties linked to hospital readmissions and bundled payment models.

Income and health-related quality of life among prostate cancer patients over a one-year period after radical prostatectomy: a linear mixed model analysis.

PURPOSE: To examine income-related disparities in health-related quality of life (HRQOL) over a one-year period after surgery (radical prostatectomy) and its contributory factors in a longitudinal perspective. Evidence of associations between income and HRQOL among patients with prostate cancer (PCa) is sparse and their explanations still remain unclear. METHODS: 246 males of two German hospitals filled out a questionnaire at the time of acute treatment, 6 and 12 months later. Age, partnership status, baseline disease and treatment factors, physical and psychological comorbidities, as well as treatment factors and adverse effects at follow-up were additionally included in the analyses to explain potential disparities. HRQOL was assessed with the EORTC (European Organisation for Research and Treatment of Cancer) QLQ-C30 core questionnaire and the prostate-specific QLQ-PR25. A linear mixed model for repeated measures was calculated. RESULTS: The fixed effects showed highly significant income-related inequalities regarding the majority of HRQOL scales. Less affluent PCa patients reported lower HRQOL in terms of global quality of life, all functional scales and urinary symptoms. After introducing relevant covariates, some associations became insignificant (physical, cognitive and sexual function), while others only showed reduced estimates (global quality of life, urinary symptoms, role, emotional and social function). In particular, mental disorders/psychological comorbidity played a relevant role in the explanation of income-related disparities. CONCLUSIONS: One year after surgery, income-related disparities in various dimensions of HRQOL persist. With respect to economically disadvantaged PCa patients, the findings emphasize the importance of continuous psychosocial screening and tailored interventions, of patients' empowerment and improved access to supportive care.