One-year healthcare costs after robotic-assisted and laparoscopic partial and radical nephrectomy: a cohort study.

OBJECTIVE: Despite the wide-spread adoption of robotic-assisted surgery (RAS), the cost-benefit implications for partial (PN) and radical nephrectomy (RN) versus laparoscopic surgery (Lap) is not well established. We sought to examine the trend of adoption and 1-year healthcare expenditure of PN and RN, and compare 1-year expenditures of RAS versus Lap for PN and RN. PATIENTS AND METHODS: This cohort study used the MerativeTM MarketScan® Databases between 2013 and 2020. A total of 5,353 patients with kidney cancer undergoing PN (2,980, 55.7%) or RN (2,373, 44.3%). We compared open-conversion, length of stay (LOS), index expenditure, 1-year healthcare expenditure and utilization, and missed work-days between RAS and Lap for PN and RN. RESULTS: Adoption of PN increased overtime (47.0% to 55.8%), mainly driven by robotic PN increase. Among PN, RAS had lower open-conversion, shorter LOS and lower index expenditure than Lap. Among RN, RAS had shorter LOS, and similar open-conversion and index expenditures. During 1-year post-discharge, RAS had lower hospital outpatient visits (IRR = 0.92, 95% CI = 0.85, 0.99, p = 0.029) and office-based visits (IRR = 0.91, 95% CI = 0.86, 0.96, p = 0.002) for PN, translating to a 1-day less (95% CI = 0.25, 1.75, p = 0.008) missed from work for RAS. Following RN, RAS had lower 1-year readmission than Lap (O.R = 0.72, 95% CI = 0.55, 0.94, p = 0.018). RAS and Lap had comparable 1-year post-discharge expenditures for both PN (mean difference, MD = -$475, 95% CI = -$4362, $3412, p = 0.810) and RN (MD = -$4,204, 95% CI = -$13,837, $5430, p = 0.404). CONCLUSION: At index surgery, RAS was associated with shorter LOS for both PN and RN, and lower open-conversion and expenditures for PN. RAS and Lap had comparable 1-year total expenditures, despite lower healthcare visits for RAS.

Comparison of 1-Year Health Care Expenditures and Utilization Following Minimally Invasive vs Open Nephrectomy.

Importance: Given the widespread adoption and clinical benefits of minimally invasive surgery approaches (MIS) in partial nephrectomy (PN) and radical nephrectomy (RN), assessment of long-term cost implications is relevant. Objective: To compare health care utilization and expenditures within 1 year after MIS and open surgery (OS). Design, Setting, and Participants: This cohort study was conducted using a US commercial claims database between 2013 and 2018. A total of 5104 patients aged 18 to 64 years who underwent PN or RN for kidney cancer and were continuously insured for 180 days before and 365 days after surgery were identified. An inverse probability of treatment weighting analysis was performed to examine differences in costs and use of health care services. Exposures: Surgical approach (MIS or OS). Main Outcomes and Measures: Outcomes assessed included 1-year total health care expenditure, health care utilizations, and estimated days missed from work. Results: Of the 5104 patients, 2639 had PN (2008 MIS vs 631 OS) and 2465 had RN (1816 MIS vs 649 OS) and most were male (PN: 1657 [62.8%]; RN: 399 [63.1%]) and between 55 and 64 years of age (PN: 1034 [51.3%]; RN: 320 [55.7%]). Patients who underwent MIS had lower index hospital length of stay compared with OS (mean [95% CI] for PN: 2.45 [2.37-2.53] vs 3.78 [3.60-3.97] days; P < .001; for RN: 2.82 [2.73-2.91] vs 4.62 [4.41-4.83] days; P < .001), and lower index expenditure for RN ($28 999 [$28 243-$29 796] vs $31 977 [$30 729-$33 329]; P < .001). For PN, index expenditure was lower for OS than MIS (mean [95% CI], $27 480 [$26 263-$28 753] vs $30 380 [$29614-$31 167]; P < .001). Patients with MIS had lower 1-year postdischarge readmission rate (PN: 15.1% vs 21.5%; odds ratio [OR], 0.65; 95% CI, 0.52-0.82; P < .001; RN: 15.6% vs 18.9%; OR, 0.79; 95% CI, 0.63-1.00; P = .05), and fewer hospital outpatient visits (mean [95% CI] for PN: 4.69 [4.48-4.90] vs 5.25 [4.84-5.66]; P = .01; RN: 5.50 [5.21-5.80] vs 6.71 [6.12-7.30]; P < .001) than those with OS. For RN, MIS was associated with 1.47 fewer missed workdays (95% CI, 0.57-2.38 days; P = .001). The reduction in health care use in MIS was associated with lower or similar total cumulative expenditures compared with OS (mean difference [95% CI] for PN: $331 [-$3250 to $3912]; P = .85; for RN: -$11 265 [-$17 065 to -$5465]; P < .001). Conclusions and Relevance: In this cohort study, MIS was associated with lower or similar total cumulative expenditure than OS in the period 1 year after discharge from the index surgery. These findings suggest that downstream expenditures and resource utilization should be considered when evaluating surgical approach for nephrectomy.

Comparison of 1-Year Health Care Costs and Use Associated With Open vs Robotic-Assisted Radical Prostatectomy.

Importance: With the current patterns of adoption and use of robotic surgery and improvement in the overall survival of patients with prostate cancer, it is important to evaluate the immediate and long-term cost implications of treatments for patients with prostate cancer. Objective: To compare health care costs and use 1 year after open radical prostatectomy (ORP) vs robotic-assisted radical prostatectomy (RARP). Design, Setting, and Participants: This retrospective cohort study used a US commercial claims database from January 1, 2013, to December 31, 2018. A total of 11 457 men aged 18 to 64 years who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after inpatient prostatectomy were identified. An inverse probability of treatment weighting analysis was performed to examine the differences in costs and use of health care services by surgical modality. Data analysis was conducted from September 2019 to July 2020. Exposures: Type of surgical procedure: ORP vs RARP. Main Outcomes and Measures: Three outcomes within 1 year after the inpatient prostatectomy were investigated: (1) total health care costs, including reimbursement paid by insurers and out of pocket by patients; (2) health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and (3) estimated days missed from work due to health care use. Results: Of the 11 457 patients who underwent inpatient prostatectomy, 1604 (14.0%) had ORP and 9853 (86.0%) had RARP and most patients (8467 [73.9%]) were aged 55 to 64 years. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (mean difference, $2367; 95% CI, $1821-$2914; P < .001), but similar total cumulative costs were observed within 180 days (mean difference, $397; 95% CI, -$582 to $1375; P = .43) and 1 year after discharge (-$383; 95% CI, -$1802 to $1037; P = .60). One-year postdischarge health care use was significantly lower in the RARP compared with ORP group for mean numbers of emergency department visits (-0.09 visits; 95% CI, -0.11 to -0.07 visits; P < .001) and hospital outpatient visits (-1.5 visits; -1.63 to -1.36 visits; P < .001). The reduction in use of health care services among patients who underwent RARP translated into additional savings of $2929 (95% CI, $1600-$4257; P < .001) and approximately 1.69 fewer days (95% CI, 1.49-1.89 days; P < .001) missed from work for health care visits. Conclusions and Relevance: Total cumulative cost in this study was similar between ORP and RARP 1 year post discharge; this finding suggests that lower postdischarge health care use after RARP may offset the higher costs during the index hospitalization.

Urine Exosomes for Non-Invasive Assessment of Gene Expression and Mutations of Prostate Cancer.

PURPOSE: The analysis of exosome/microvesicle (extracellular vesicles (EVs)) and the RNA packaged within them (exoRNA) has the potential to provide a non-invasive platform to detect and monitor disease related gene expression potentially in lieu of more invasive procedures such as biopsy. However, few studies have tested the diagnostic potential of EV analysis in humans. EXPERIMENTAL DESIGN: The ability of EV analysis to accurately reflect prostate tissue mRNA expression was examined by comparing urinary EV TMPRSS2:ERG exoRNA from pre-radical prostatectomy (RP) patients versus corresponding RP tissue in 21 patients. To examine the differential expression of TMPRSS2:ERG across patient groups a random urine sample was taken without prostate massage from a cohort of 207 men including prostate biopsy negative (Bx Neg, n = 39), prostate biopsy positive (Bx Pos, n = 47), post-radical prostatectomy (post-RP, n = 37), un-biopsied healthy age-matched men (No Bx, n = 44), and young male controls (Cont, n = 40). The use of EVs was also examined as a potential platform to non-invasively differentiate Bx Pos versus Bx Neg patients via the detection of known prostate cancer genes TMPRSS2:ERG, BIRC5, ERG, PCA3 and TMPRSS2. RESULTS: In this technical pilot study urinary EVs had a sensitivity: 81% (13/16), specificity: 80% (4/5) and an overall accuracy: 81% (17/21) for non-invasive detection of TMPRSS2:ERG versus RP tissue. The rate of TMPRSS2:ERG exoRNA detection was found to increase with age and the expression level correlated with Bx Pos status. Receiver operator characteristic analyses demonstrated that various cancer-related genes could differentiate Bx Pos from Bx Neg patients using exoRNA isolated from urinary EVs: BIRC5 (AUC 0.674 (CI:0.560-0.788), ERG (AUC 0.785 (CI:0.680-0.890), PCA3 (AUC 0.681 (CI:0.567-0.795), TMPRSS2:ERG (AUC 0.744 (CI:0.600-0.888), and TMPRSS2 (AUC 0.637 (CI:0.519-0.754). CONCLUSION: This pilot study suggests that urinary EVs have the potential to be used as a platform to non-invasively differentiate patients with prostate cancer with very good accuracy. Larger studies are needed to confirm the potential for clinical utility.

Is there a difference in laterality during robot-assisted radical prostatectomy? Assessment of lymph node yield and neurovascular bundle dissection.

BACKGROUND AND PURPOSE: The da Vinci Surgical System (dVSS) has been reported to eliminate innate hand dominance of the surgeon. There are no studies to date, however, that specifically address whether the dVSS has its own inherent "handedness" resulting from the fixed left-right preference of specific instrument docking and assistant positioning. We identified the pelvic lymph node (LN) and neurovascular bundle (NVB) dissections as well as positive surgical margin rates as procedure points during robot-assisted radical prostatectomy (RARP) that could be influenced by laterality and sought to illustrate left-right consistency. PATIENTS AND METHODS: Patients who underwent RARP by a single right-handed surgeon (KKB) between 2008 and 2010 were identified. Surgeon instrument preference and port placement were consistent across all cases. Pathologic LN yield was stratified by the intended limits of dissection (limited or extended) and laterality. In addition, fascial widths (FW) were prospectively measured for 93 consecutive patients, a narrower FW indicating a more precise intended NVB dissection. The pathologists were blinded to intended dissections. RESULTS: A total of 340 limited, 11 bilateral extended, 11 right extended, and 5 left extended LN dissections were performed. For patients undergoing limited LN dissection, the mean LN yield was greater on the right compared with the left (3.26 vs 2.76, P=0.010). This difference was not seen in the extended LN dissection (P=0.96). Average FW was narrower on the right surgical margin compared with the left (1.99 vs 2.64 mm, P<0.001). CONCLUSIONS: Our findings suggest that a greater number of LNs and a closer NVB dissection are achieved on the right compared with the left using the dVSS during RARP. This can be attributed to surgeon handedness, robotic instrument laterality, or assistant instrument laterality. Surgeon awareness of these potential differences is important for the preoperative planning before RARP.

Assessment of lymph node yield after pelvic lymph node dissection in men with prostate cancer: a comparison between robot-assisted radical prostatectomy and open radical prostatectomy in the modern era.

BACKGROUND AND PURPOSE: Studies of radical prostatectomy (RP) suggest that higher lymph node yield (LNY) improves tumor staging. Robot-assisted radical prostatectomy (RARP) is becoming increasingly popular, yet LNY data are not well reported. We compare LNY from contemporary open RP (ORP) with RARP at an academic center. PATIENTS AND METHODS: A retrospective study was conducted of an Urologic Oncology Database. Between January 2005 and November 2009, 217 men underwent ORP with pelvic lymph node dissection (PLND); 99 underwent RARP with PLND by a single surgeon during the same period. Men were stratified according to the D'Amico risk criteria. For intermediate and high-risk disease, an extended PLND was performed. Patient demographic, operative, and pathologic variables were measured, and LNY was compared across groups. RESULTS: No significant differences were seen between groups for race, body mass index, preoperative prostate-specific antigen level or biopsy Gleason score. Patients were younger for RARP vs ORP (P = 0.003) and had higher clinical tumor stage (P = 0.02). Operative time was longer (P = 0.03) and estimated blood loss was greater (P < 0.001) in the ORP group. Overall, only a borderline significant difference was seen in LNY between ORP and RARP (7.49 vs 6.35 nodes, respectively, P = 0.06). No difference was seen for intermediate and high-risk patients, with 7.7 vs 6.8 nodes for ORP and RARP, respectively (P = 0.27). The lymph node metastasis rate was 6.3%, with more positive nodes detected during ORP vs RARP: 19/217 (8.8%) vs 1/99 (1.0%), P = 0.009. CONCLUSIONS: No significant differences were seen in LNY during RARP and ORP for intermediate and high-risk men. For experienced surgeons, RARP can achieve equivalent LNY as ORP. A future study with a larger sample size is necessary to make a definitive statement of equivalence.

Penile rehabilitation protocol after robot-assisted radical prostatectomy: assessment of compliance with phosphodiesterase type 5 inhibitor therapy and effect on early potency.

STUDY TYPE: Therapy (case series). LEVEL OF EVIDENCE: 4. OBJECTIVE: To evaluate factors that affect compliance in men who enroll in a phosphodiesterase type 5 inhibitor (PDE5I) protocol after nerve-sparing robot-assisted prostatectomy (RAP), and report on short-term outcomes, as PDE5Is may help restore erectile function after RAP and patient adherence to the regimen is a factor that potentially can affect outcome. PATIENT AND METHODS: We prospectively followed 77 men who had nerve-sparing RAP and enrolled in a postoperative penile rehabilitation protocol. The men received either sildenafil citrate or tadalafil three times weekly. The minimum follow-up was 8 weeks. Potency was defined as erection adequate for penetration and complete intercourse. Compliance was defined as men adhering to the regimen for > or =2 months. RESULTS: The mean age of the cohort was 57.8 years and the median follow-up was 8 months. In all, 32% of the men discontinued the therapy <2 months after RAP and were deemed noncompliant with an additional 39% discontinuing therapy by 6 months, with the high cost of medication being the primary reason (65%). Long-term compliance and preoperative erectile dysfunction were independent predictors of potency return after adjusting for age and nerve sparing. CONCLUSIONS: The high cost of medication remains a significant barrier to maintaining therapy. Noncompliance to PDE5I therapy in a tertiary care centre was much higher than reported in clinical trial settings. With longer-term follow-up, we need to further define the factors that improve overall recovery of sexual function after RAP.

Evolution of robotic radical prostatectomy: assessment after 2766 procedures.

BACKGROUND: Robotic-assisted radical prostatectomy (RAP) is the dominant minimally invasive surgical treatment for patients with localized prostate cancer. Only a few large series have been published to date, with few long-term data available. The current study presents what to the authors' knowledge is the largest series of patients undergoing RAP with the longest follow-up to data available to date. Using a continuous quality improvement initiative, several technical refinements were adopted, evaluating the impact of this on patient outcome. METHODS: Over a 6-year period, 2766 consecutive men underwent RAP at the study institution. Data were collected prospectively including demographic, surgical, oncologic, and functional outcomes with up to 5-year follow-up. The first 200 and most recent 200 patients were compared to determine the impact of experience and quality improvement for patients. RESULTS: The mean age of the patients was 60.2 years and the mean prostate-specific antigen (PSA) level at time of diagnosis was 6.43 ng/mL; 42.4% and 64.2% of patients, respectively, had a biopsy and pathologic Gleason sum of >/=7. The mean surgical and console time was 154 minutes and 116 minutes, respectively. Estimated blood loss was 100 mL; 96.7% of patients were discharged within 24 hours of surgery. At a median follow-up of 22 months, 7.3% of men had a PSA recurrence. The 5-year actuarial biochemical free survival rate was 84%. CONCLUSIONS: To the authors' knowledge, the current study is the first report of 5-year outcomes in men undergoing RAP. These data demonstrate that RAP can be performed with favorable outcomes while minimizing complications. As experience increases, further improvements in clinicopathologic and functional parameters are achieved.