Perspectives on technology: Single-use catheters - evidence and environmental impact.

OBJECTIVE: To explore the data comparing single- vs multi-use catheters for clean intermittent catheterisation (CIC), consider if the widespread use of single-use catheters is warranted given the cost and environmental impact, and put forth ideas for future consideration. METHODS: A primary literature review was performed in PubMed over the past 50 years. Studies that performed comparative analysis of single- and multi-use catheters were included in our review. All studies that reported on primary data were narratively summarised. RESULTS: A total of 11 studies were identified that reported on primary data comparing single- and multi-use catheters. There was no appreciable evidence suggesting reusable multi-use catheters were inferior to single-use catheters from an infection or usability standpoint. In addition, the environmental and monetary burden of single-use catheters is significant. CONCLUSIONS: The intermittent catheter landscape in the USA has a complex past: defined by policy, shaped by industry, yet characterised by a paucity of data demonstrating superiority of single-use over multi-use catheters. We believe that the aversion to reusable catheters by many patients and healthcare professionals is unwarranted, especially given the cost and environmental impact. Moving forward, better comparative data and more sustainable practices are needed.

To stage or not to stage?-A cost minimization analysis of sacral neuromodulation placement strategies.

AIMS: Sacral neuromodulation (SNM) is a standard therapy for refractory overactive bladder (OAB). Traditionally, SNM placement involves placement of an S3 lead with 1-3 weeks of testing before considering a permanent implant. Given the potential risk of bacterial contamination during testing and high success rates published by some experts, we compared the costs of traditional 2-stage against single-stage SNM placement for OAB. METHODS: We performed a cost minimization analysis using published data on 2-stage SNM success rates, SNM infection rates, and direct reimbursements from Medicare for 2017. We compared the costs associated with a 2-stage vs single-stage approach. We performed sensitivity analyses of the primary variables listed above to assess where threshold values occurred and used separate models for freestanding ambulatory surgery centers (ASC) and outpatient hospital departments (OHD). RESULTS: Based on published literature, our base case assumed a 69% SNM success rate, a 5% 2-stage approach infection rate, a 1.7% single-stage approach infection rate, and removal of 50% of non-working single-stage SNMs. In both ASC ($17 613 vs $18 194) and OHD ($19 832 vs $21 181) settings, single-stage SNM placement was less costly than 2-stage placement. The minimum SNM success rates to achieve savings with a single-stage approach occur at 65.4% and 61.3% for ASC and OHD, respectively. CONCLUSIONS: Using Medicare reimbursement, single-stage SNM placement is likely to be less costly than 2-stage placement for most practitioners. The savings are tied to SNM success rates and reimbursement rates, with reduced costs up to $5014 per case in centers of excellence (≥ 90% success).

First-in-human implantation of a mid-field powered neurostimulator at the sacral nerve: Results from an acute study.

INTRODUCTION: Commercially approved implantable systems for sacral neuromodulation require the implantation of a multipolar lead subcutaneously connected to an implantable pulse generator (IPG). Eliminating the need for an IPG would eliminate the need for tunneling of the lead, reduce procedure time, infection risk, and the need for IPG replacement. The objective was to demonstrate the feasibility of implanting the AHLeveeS System in the S3 Foramen to stimulate the S3 sacral nerve. MATERIALS AND METHODS: A first-in-human, prospective, single center, nonrandomized, acute feasibility clinical investigation at the Maastricht University Medical Center+. Patients with refractory overactive bladder underwent acute implantation of the AHLeveeS neurostimulator before the InterStim procedure. Outcome measurements included motor responses, procedural time and a scoring of the difficulty of the implant and explant procedure. Retrospectively, qualitative responses to the stimulation protocol were assessed by video motion analyses. Only descriptive statistics were used. RESULTS: During the stimulation a motor response to stimulation was seen in four of the five subjects. In all implantations the AHLeveeS was correctly placed. The median time for complete procedure was 24 minutes. The implant and explant procedures were successfully performed and no device or procedure related adverse events occurred. CONCLUSIONS: The results from this acute first-in-human study demonstrate the feasibility of implantation and acute stimulation of the sacral nerve with this mid-field powered system. Future clinical studies will focus on safety and efficacy of a chronically implanted device.

Outcomes of Sacral Nerve Stimulation for Treatment of Refractory Overactive Bladder Among Octogenarians.

OBJECTIVE: Sacral nerve stimulation (SNS) is an effective treatment for refractory overactive bladder (OAB). However, advanced age is often cited as a reason to avoid SNS in the elderly. This study evaluates the safety and efficacy of SNS for refractory OAB among our octogenarian population. METHODS: A retrospective review from a single institution was performed on all SNS lead placements from December 1998 to June 2017 for refractory OAB. Octogenarians were characterized as 80 years of age or older at the time of Stage I. Efficacy and safety were determined by the rate of progression to Stage II, subsequent need for multimodal therapy, and rate of surgical revision and explantation. All patients were followed for a minimum of 12 months. RESULTS: Of 374 patients in this study, 37 (9.9%) were octogenarians. There was no difference in gender, race, smoking history, or prior OAB treatment regimens between cohorts. The rate of progression to Stage II was 56.8% for octogenarians compared to 60.5% for nonoctogenarians (p = 0.66). The rate of surgical revision, explantation, and need for multimodal therapy did not differ between groups. Subgroup analysis of octogenarians did not reveal any significant differences between successful and nonsuccessful Stage I patients. CONCLUSIONS: The safety and efficacy of SNS was similar between cohorts. This result suggests that SNS is a safe and effective therapy that should be considered among the treatment options for refractory OAB in octogenarian patients. Further studies are needed to determine predictive factors of Stage I success in elderly patients.

Volitional Voiding of the Bladder after Spinal Cord Injury: Validation of Bilateral Lower Extremity Motor Function as a Key Predictor.

PURPOSE: In many individuals with spinal cord injury a return of volitional bladder voiding is considered more important than regaining motor function. Recently a predictive model using only composite bilateral lower extremity motor scores for levels L2-S1 (range 0 to 50) was proposed by the EMSCI (European Multicenter Study about Spinal Cord Injury) group. The model showed exceptional predictive power with an AUC of 0.912. We sought to further validate the EMSCI model in a national spinal cord injury cohort. MATERIALS AND METHODS: We created models of volitional voiding using the United States NSCID (National Spinal Cord Injury Database) for 2007 to 2016. In addition to testing lower extremity motor scores, we evaluated other patient variables that we hypothesized might affect volitional voiding. RESULTS: Volitional voiding was present in 1,333 of the cohort of 4,327 individuals (30.8%) at 1-year followup. While younger age, female gender, increased sacral sparing, improved AIS (American Spinal Injury Association Impairment Scale) classification and a more caudal sensory level predicted volitional voiding, lower extremity motor scores were most predictive (AUC 0.919). Adding the other patient characteristics did little to improve model performance (full model AUC 0.932). Further analysis of the predictive power of lower extremity motor scores suggested that while the AUC appeared to decrease in persons who were most likely to void volitionally, the performance of the predictive model remained outstanding with a combined AIS C and D AUC of 0.792. CONCLUSIONS: Our study verifies the validity of the EMSCI predictive model of volitional voiding after spinal cord injury. The differing performance of lower extremity motor scores in various AIS classifications should be noted.

The cost of a catheter: An environmental perspective on single use clean intermittent catheterization.

METHODS: We estimated the prevalence of CIC use in the United States using a neurogenic population, consisting of persons with multiple sclerosis, spina bifida, and spinal cord injury. We measured catheter samples to obtain the amount of waste per catheter. RESULTS: At least 300 800 persons in the United States perform CIC for neurogenic bladder management. Assuming five catheterization events per day, the amount of waste generated by single-use CIC is between 26 500 to 235 400 pounds or 22 600 to 564 000 liters per day, depending on catheter model. CONCLUSIONS: Single-use CIC may generate up to 85 million pounds or 206 million liters of waste annually, equivalent to more than 26 000 cars or 80 Olympic-sized swimming pools. Laid end-to-end, there is enough catheter length circumscribe the world more than 5.5 times. The most common materials used in catheter construction have little to no degradation once in a landfill. Given the unproven clinical benefit of single-use catheterization, the environmental impact and alternatives should be considered.

A Systematic Approach to the Evaluation and Management of the Failed Artificial Urinary Sphincter.

In men with post-prostatectomy incontinence, persistent or recurrent urinary leakage following artificial urinary sphincter placement is a frustrating complaint. Surgical failure can be classified as occurring early in the post-operative period vs. late-following a period of established continence-and should be managed according to the time course and severity of urinary leakage. We present a systematic approach for the evaluation and treatment of the failed artificial urinary sphincter. After considering the patient's individualized treatment goals and impact on quality of life, the clinician can more appropriately advise patients on a management strategy for their recurrent or persistent urinary incontinence following artificial urinary sphincter placement.

Urodynamics of men with urinary retention.

OBJECTIVES: To describe the urodynamic characteristics of men with urinary retention, and to show the diverse treatment plans based on urodynamic findings. METHODS: We carried out a 3-year retrospective review of men with urinary retention who were referred to our clinic for urodynamic evaluation. Men with a history of neurogenic voiding dysfunction or major pelvic surgery were excluded. Multichannel videourodynamic studies were carried out, and the subsequent treatment modality offered was recorded. RESULTS: A total of 67 men with urinary retention and a median age of 68 years underwent urodynamic evaluation. The median maximum flow rate was 3 mL/s, and the median detrusor pressure at maximum flow was 54 cm H2 O. Bladder outlet obstruction was diagnosed in 60%. Detrusor underactivity was present in 73% according to the bladder contractility index; however, just 29% were classified as having detrusor underactivity according to isometric detrusor pressure, an alternative measure of contractility. A total of 76% of patients had low detrusor reserve (<20 cm H2 O). Based on urodynamic findings, just 57% of patients were offered de-obstructive surgery. CONCLUSIONS: In the present cohort, just 60% of men with urinary retention showed urodynamic evidence of bladder outlet obstruction. Depending on how contractility is measured (bladder contractility index vs isometric detrusor pressure), the rate of detrusor underactivity varies. The majority of men with retention had a low detrusor reserve. Given the wide spectrum of urodynamic findings in men with retention, surgical intervention might not be necessary for all. Furthermore, a careful consideration of urodynamics can assist in the selection of optimal treatment.

Chronic sacral nerve stimulation as a novel treatment for stress urinary incontinence-A rat model.

AIMS: We propose an animal model to evaluate the effect of chronic sacral nerve stimulation (SNS) on surgically induced intrinsic sphincter deficiency (ISD) secondary to transabdominal urethrolysis (U-Lys). METHODS: Twenty-five 6-week old virgin female Sprague-Dawley rats were divided into four groups: control (CTRL), U-Lys only, SNS only, and both (U-Lys/SNS). Groups CTRL (N = 5) and U-Lys only (N = 5) were maintained in the animal research facility in standard fashion for 2 weeks. Groups SNS only (N = 5) and U-Lys/SNS (N = 10) underwent chronic SNS for 6 continuous hours daily for 2 weeks. Retrograde leak point pressure (RLPP) was measured at baseline and at 2 weeks following observation or treatment. Five consecutive RLPP measurements were averaged per measurement cycle. SAS 9.3 was used to evaluate means and standard deviation. RESULTS: Baseline mean RLPP was 65 mmHg. The U-Lys only group mean RLPP at initial urethrolysis (58 mmHg) decreased (31 mmHg, P < 0.0001) after 2 weeks of observation. In the SNS only group, mean RLPP significantly increased from baseline (73 mmHg) after 2 weeks of chronic SNS stimulation (80 mmHg, P < 0.01). In rats that underwent both U-Lys and SNS stimulation mean RLPP was initially low (46 mmHg) after U-Lys and then significantly increased after 2 weeks of SNS (65 mmHg, P < 0.0001). CONCLUSION: Chronic SNS mediates an improvement in urethral sphincteric function at stimulation parameters similar to those used in humans for treating voiding dysfunction. SNS increased urethral resistance in rats with and without surgically induced ISD.

The effect of angiotensin inhibition on urinary incontinence: data from the National Health and Nutrition Examination Survey (2001-2008).

INTRODUCTION: Local renin-angiotensin systems exist within the genitourinary tract, specifically in the bladder and urethra. Experimental data suggest that angiotensin receptor blockade with either angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) decreases both detrusor overactivity and urethral sphincter tone leading to decreased urge incontinence (UUI) and increased stress urinary incontinence (SUI). This has not been examined in a human population. METHODS: Data from the National Health and Nutrition Examination Survey (NHANES) was accessed for the years 2001-2008. Multivariate logistic regression was used for modeling. RESULTS: We studied 8,754 females and 8,886 males who met inclusion criteria. Use of ACE inhibitors or ARBs was not associated with a change in SUI in either men or women. In men, use of an ACE inhibitor or ARB was associated with a statistically significant 25-30% decrease in UUI (monthly or any urge incontinence). A similar, albeit non-significant trend was also seen for daily and weekly UUI. Other antihypertensive medications (diuretics, beta-blockers, calcium-channel blockers) were not associated with a decrease in UUI. In subanalysis, duration of ACE inhibitor or ARB use did not alter the strength of the effect on UUI nor did an elevated prostate specific antigen (PSA) level (used as a surrogate for bladder outlet obstruction due to benign prostatic hypertrophy). ACE inhibitor and ARB use did not affect UUI rates in women, though did show a trend for improvement in nulliparous women without SUI. CONCLUSION: Angiotensin receptor blockade may be a viable treatment approach for the treatment of UUI, especially in men.

To sling or not to sling at time of abdominal sacrocolpopexy: a cost-effectiveness analysis.

PURPOSE: We compare the cost-effectiveness of 3 strategies for the use of a mid urethral sling to prevent occult stress urinary incontinence in patients undergoing abdominal sacrocolpopexy. MATERIALS AND METHODS: Using decision analysis modeling we compared cost-effectiveness during a 1-year postoperative period of 3 treatment approaches including 1) abdominal sacrocolpopexy alone with deferred option for mid urethral sling, 2) abdominal sacrocolpopexy with universal concomitant mid urethral sling and 3) preoperative urodynamic study for selective mid urethral sling. Using published data we modeled probabilities of stress urinary incontinence after abdominal sacrocolpopexy with or without mid urethral sling, the predictive value of urodynamic study to detect occult stress urinary incontinence and the likelihood of complications after mid urethral sling. Costs were derived from Medicare 2010 reimbursement rates. The main outcome modeled was incremental cost-effectiveness ratio per quality adjusted life-years gained. In addition to base case analysis, 1-way sensitivity analyses were performed. RESULTS: In our model, universally performing mid urethral sling at abdominal sacrocolpopexy was the most cost-effective approach with an incremental cost per quality adjusted life-year gained of $2,867 compared to abdominal sacrocolpopexy alone. Preoperative urodynamic study was more costly and less effective than universally performing intraoperative mid urethral sling. The cost-effectiveness of abdominal sacrocolpopexy plus mid urethral sling was robust to sensitivity analysis with a cost-effectiveness ratio consistently below $20,000 per quality adjusted life-year. CONCLUSIONS: Universal concomitant mid urethral sling is the most cost-effective prophylaxis strategy for occult stress urinary incontinence in women undergoing abdominal sacrocolpopexy. The use of preoperative urodynamic study to guide mid urethral sling placement at abdominal sacrocolpopexy is not cost-effective.

The predictive value of a cystocele for concomitant vaginal apical prolapse.

PURPOSE: Recent studies showing a correlation between descent of the anterior and apical vaginal compartments suggest that cystoceles may recur if associated apical prolapse is not corrected. However, to date the anatomical relationship of apical prolapse with respect to cystocele has been incompletely reported. We present the predictive value of a cystocele for clinically significant vaginal apical prolapse. MATERIALS AND METHODS: We retrospectively reviewed the records of all new patient visits to a urogynecology clinic in a 30-month period. Women with a point Ba value of -1 or greater (stage 2 cystocele and above) were included in analysis. Predictive values of clinically significant apical prolapse, defined as point C -3 or greater, were calculated and stratified by cystocele stage. RESULTS: A total of 385 women were included in study. Point Ba was the leading edge of prolapse in 83.9% of cases. The position of Ba strongly correlated with that of the vaginal apex (Spearman ρ = 0.769, p <0.001). Overall 59.7% of patients had a point C of -3 or greater. The finding of clinically significant apical prolapse increased significantly with increasing Ba values. Of patients with stage 2, 3 and 4 cystocele point C was -3 or greater in 42%, 85% and 100%, respectively. CONCLUSIONS: The finding of stage 2 or greater cystocele is highly suggestive of clinically significant apical vaginal descent to -3 or greater. Furthermore, as cystocele stage increases, the predictive value of apical prolapse also increases. Surgeons contemplating cystocele repair should have high suspicion for vaginal apical prolapse and consider concomitant repair.

Improving the accuracy of prolapse and incontinence procedure epidemiology by utilizing both inpatient and outpatient data.

INTRODUCTION AND HYPOTHESIS: The epidemiologic description of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) procedures is documented in several large studies using national database cohorts. These studies, however, may underestimate the number of procedures performed because they only capture procedures performed in either the inpatient or outpatient settings alone. We present a complete annual description of all inpatient and outpatient surgeries for POP and SUI in California. METHODS: We reviewed a record of all inpatient and outpatient POP and SUI surgeries performed in California in 2008 using data from the Office of Statewide Health Planning (OSHPD). RESULTS: In 2008, 20,004 and 20,330 women in California underwent POP and SUI procedures, respectively. Of these, 3,134 (15.6%) and 9,016 (44.3%) were performed in an outpatient setting. The age-adjusted rates of POP and SUI were 1.20 and 1.20 per 1,000 US females, respectively. This correlates to 186,000 POP and 186,000 SUI procedures per year nationally. Vaginal apical suspensions were more common in those undergoing surgery as an inpatient (45.1 vs 19.4%). The use of mesh to augment prolapse repairs was similar (22.3% inpatient vs 19.3% outpatient). SUI procedures performed in the outpatient setting were more likely to be performed as stand-alone procedures (82.9 vs 18.8%, respectively). CONCLUSIONS: In California, 16% of POP and 44% of SUI procedures were performed in an outpatient surgical setting in 2008. Epidemiologic studies of POP and SUI should account for the fact that a substantial number of repairs are performed in the outpatient setting in order to achieve accuracy.

Urodynamic and urethral pressure profilometry findings in women with voiding phase dysfunction treated with surgical urethrolysis.

INTRODUCTION: Long-term urodynamic (UDS) and urethral pressure profilometry (UPP) parameters in women with voiding phase dysfunction following an anti-incontinence (AI) procedure have been poorly characterized. We report our 10-year UDS findings in women with voiding phase dysfunction after AI procedure, who underwent urethrolysis. METHODS: We identified sequential records containing urethrolysis current procedural terminology codes over a 10-year period. Records of women with preoperative UDS were reviewed for demographics, UDS tracing, and outcomes following urethrolysis. RESULTS: Twenty-five women (mean age 60 years) had voiding phase dysfunction and underwent urethrolysis at a mean of 47 months (interquartile range [IQR] 12-61) after AI procedure. Preoperatively, six (24%) women required intermittent catheterization. Free uroflowmetry revealed a mean maximum peak flow (Qmax) of 9.6 ml/s (IQR 7.0-11.0), voided volume of 137 ml (IQR 81-169), and postvoid residual of 167 ml (IQR 43-288). UDS revealed a mean UPP length of 24 mm (IQR 20-27), UPP closure pressure of 78 cmH2O (IQR 59-103), detrusor pressure at maximum flow (Pdet@Qmax) of 31 cmH2O (IQR 19-43), Qmax of 7.9 ml/s (IQR 5.0-12.0), bladder outlet obstruction index of 15 (IQR 0-34), and bladder contractility index of 71 (IQR 60-81). UPP length was significantly associated (Pearson correlation, p<0.05) with bladder outlet obstruction index (r=0.80), Pdet@Qmax (r=0.75), and time since AI procedure (r=-0.70). UPP closure pressure was significantly associated with age (r=-0.64), volume of first (r=-0.64) and strong (r=-0.78) desire, and capacity (r=-0.71). Following urethrolysis, spontaneous voiding was achieved in 23 (92%) women at followup (mean 308 days). CONCLUSIONS: UPP may help characterize outlet parameters in women with voiding phase dysfunction following an AI procedure, who ultimately undergo urethrolysis.

Outcomes of Aquablation in Men With Acute and Chronic Urinary Retention.

OBJECTIVE: To compare outcomes of Aquablation in men with acute and chronic urinary retention. METHODS: We conducted a retrospective review of all men undergoing Aquablation resection of the prostate between May 2021 and August 2022. Men were classified as having acute urinary retention if they required either intermittent or indwelling catheter and chronic urinary retention if they had a postvoid residual >300 mL prior to surgery. We compared success rates and time to passage of trial without catheter as well as complication rates to those with no retention. RESULTS: A total of 113 men underwent Aquablation including 28 with acute retention and 16 with chronic retention. Failure of initial void trial was significantly higher in patients with preoperative urinary retention (40%) and chronic retention with postvoid residual >300 mL (12.5%) compared to those with no retention (7.2%, P < .001). Among men with acute and chronic retention 98% were voiding spontaneously at a mean 5months follow-up. There was no difference in utilization of postoperative prostate medications, complications, International Prostate Symptom Score or uroflowmetry among men with acute, chronic, or no retention. CONCLUSION: Aquablation is an effective method for treatment of men with urinary retention, with 98% achieving spontaneous voiding regardless of preoperative urodynamic findings. Men in acute retention prior to surgery were more likely to fail their initial void trial, which may support the recommendation for a delayed trial without catheter.

A new quadratic sling for male stress incontinence: retrograde leak point pressure as a measure of urethral resistance.

PURPOSE: Objective methods are essential for evaluating post-prostatectomy incontinence. While symptom score and pad weight may be the most useful methods to evaluate preoperative vs postoperative continence, neither is useful for guiding intraoperative sling tension. The Virtue quadratic sling (Coloplast, Humlebaek, Denmark) is a new device for treating post-prostatectomy incontinence that combines a transobturator and prepubic surgical approach. We examined urethral resistance by measuring retrograde leak point pressure during key portions of the surgery. MATERIALS AND METHODS: A total of 22 consecutive men who elected to undergo Virtue sling surgery were evaluated with retrograde leak point pressure before and during the surgery. Retrograde leak point pressure was measured via perfusion sphincterometry at baseline, after transobturator tensioning, after prepubic tensioning, and after transobturator and prepubic arms were secured in place. RESULTS: Mean patient age was 70 years. Mean baseline retrograde leak point pressure was 33.4 ± 8.8 cm water. After transobturator tensioning, mean retrograde leak point pressure increased to 43.3 ± 6.8 cm water. After prepubic tensioning mean retrograde leak point pressure was 55.8 ± 8.7, and final retrograde leak point pressure after transobturator and prepubic fixation increased to 68.8 ± 6.0 cm water. Each mean retrograde leak point pressure value was significantly higher than the preceding value. CONCLUSIONS: The Virtue sling provides ventral urethral elevation using a transobturator approach, and a long segment of urethral compression against the genitourinary diaphragm via a straightforward prepubic technique without the risks of bone screws or retropubic needle passage. Transobturator and prepubic components of the quadratic fixation contributed to increasing urethral resistance as measured by intraoperative retrograde leak point pressure. This quadratic technique has a potentially greater ability to provide urethral compression than does a purely perineal or transobturator sling.

Robot-assisted versus open sacrocolpopexy: a cost-minimization analysis.

PURPOSE: Abdominal sacrocolpopexy is considered a standard of care operation for apical vaginal vault prolapse repair. Using outcomes at our center we evaluated whether the robotic approach to sacrocolpopexy is as cost-effective as the open approach. MATERIALS AND METHODS: After obtaining institutional review board approval we performed cost-minimization analysis in a retrospective cohort of patients who underwent sacrocolpopexy at our institution between 2006 and 2010. Threshold values, that is model variable values at which the most cost effective approach crosses over to an alternative approach, were determined by testing model variables over realistic ranges using sensitivity analysis. Hospital billing data were also evaluated to confirm our findings. RESULTS: Operative time was similar for robotic and open surgery (226 vs 221 minutes) but postoperative length of stay differed significantly (1.0 vs 3.3 days, p <0.001). Base case analysis revealed an overall 10% cost savings for robot-assisted vs open sacrocolpopexy ($10,178 vs $11,307). Tornado analysis suggested that the number of institutional robotic cases done annually, length of stay and cost per hospitalization day in the postoperative period were the largest drivers of cost. Analysis of our hospital billing data showed a similar trend with robotic surgery costing 4.2% less than open surgery. CONCLUSIONS: A robot-assisted approach to sacrocolpopexy can be equally or less costly than an open approach. This depends on a sufficient institutional robotic case volume and a shorter postoperative stay for patients who undergo the robot-assisted procedure.