How the Beneficial Effects of Alvimopan Differ With Surgical Approach for Radical Cystectomy.

OBJECTIVE: To assess whether the beneficial perioperative effects of alvimopan differ with surgical approach for patients who undergo open radical cystectomy (ORC) vs robot-assisted radical cystectomy (RARC). METHODS: This retrospective study reviewed all patients who underwent cystectomy with urinary diversion at our institution between January 1, 2007, and January 1, 2018. Data were collected on demographic characteristics, comorbidities, surgical approach, alvimopan therapy, hospital length of stay (LOS), days until return of bowel function (ROBF), and complications. Outcomes and interactions were evaluated through regression analysis. RESULTS: Among 573 patients, 236 (41.2%) underwent RARC, 337 (58.8%) underwent ORC, and 205 (35.8%) received alvimopan. Comparison of 4 cohorts (ORC with alvimopan, ORC without alvimopan, RARC with alvimopan, and RARC without alvimopan) showed that patients who underwent ORC without alvimopan had the highest rate of postoperative ileus (25.6%, P = .02), longest median hospital LOS (7 days, P < .001), and longest time until ROBF (4 days, P < .001). On multivariable analysis, the interaction between surgical approach and alvimopan use was significant for the outcome of ROBF (estimate, 1.109; 95% confidence interval, 0.418-1.800; P = .002). In the RARC cohort, multivariable analysis showed no benefit of alvimopan with respect to ileus (P = .27), LOS (P = .09), or ROBF (P = .36). Regarding joint effects of robotic approach and alvimopan, RARC had no effect on gastrointestinal tract outcomes. CONCLUSION: We observed a diminished beneficial effect of alvimopan among patients undergoing RARC and a statistically significant benefit of alvimopan among patients undergoing ORC. The implications of these findings may permit more selective medication use for patients who would benefit the most from this drug.

Crowdsourcing Assessment of Surgeon Dissection of Renal Artery and Vein During Robotic Partial Nephrectomy: A Novel Approach for Quantitative Assessment of Surgical Performance.

INTRODUCTION: We sought to describe a methodology of crowdsourcing for obtaining quantitative performance ratings of surgeons performing renal artery and vein dissection of robotic partial nephrectomy (RPN). We sought to compare assessment of technical performance obtained from the crowdsourcers with that of surgical content experts (CE). Our hypothesis is that the crowd can score performances of renal hilar dissection comparably to surgical CE using the Global Evaluative Assessment of Robotic Skills (GEARS). METHODS: A group of resident and attending robotic surgeons submitted a total of 14 video clips of RPN during hilar dissection. These videos were rated by both crowd and CE for technical skills performance using GEARS. A minimum of 3 CE and 30 Amazon Mechanical Turk crowdworkers evaluated each video with the GEARS scale. RESULTS: Within 13 days, we received ratings of all videos from all CE, and within 11.5 hours, we received 548 GEARS ratings from crowdworkers. Even though CE were exposed to a training module, internal consistency across videos of CE GEARS ratings remained low (ICC = 0.38). Despite this, we found that crowdworker GEARS ratings of videos were highly correlated with CE ratings at both the video level (R = 0.82, p < 0.001) and surgeon level (R = 0.84, p < 0.001). Similarly, crowdworker ratings of the renal artery dissection were highly correlated with expert assessments (R = 0.83, p < 0.001) for the unique surgery-specific assessment question. CONCLUSIONS: We conclude that crowdsourced assessment of qualitative performance ratings may be an alternative and/or adjunct to surgical experts' ratings and would provide a rapid scalable solution to triage technical skills.

Racial disparities in survival for patients with clinically localized prostate cancer adjusted for treatment effects.

OBJECTIVE: To examine whether racial disparities in survival exist among black, Hispanic, and Asian patients compared with white patients with clinically localized prostate cancer (CLPC) after adjustment for the effects of treatment. PATIENTS AND METHODS: We performed a retrospective cohort study of patients with CLPC diagnosed from January 1, 1995, through December 31, 2003, as documented in the Surveillance, Epidemiology, and End Results registry. Treatment-stratified, risk-adjusted Cox proportional hazards models were constructed. RESULTS: During the study period, CLPC was diagnosed in 294,160 patients. Of these patients, 123,850 (42.1%) underwent surgery and 101,627 (34.5%) underwent radiotherapy, whereas 68,683 (23.3%) received no treatment. Overall 5-year and 10-year survival rates for Asians (85.6% and 67.6%, respectively), Hispanics (85.9% and 69.0%, respectively), and whites (83.9% and 65.7%, respectively) were higher than for blacks (81.5% and 61.7%, respectively) (P<.001). Prostate cancer-specific survival also varied significantly by race (P<.001). A risk-adjusted model stratified by primary treatment modality revealed that blacks had worse overall survival than whites (hazard ratio, 1.37; 95% CI, 1.33-1.41; P<.001), whereas Asians had better survival compared with whites (hazard ratio, 0.79; 95% CI, 0.76-0.83; P<.001). After the effects of treatment were accounted for, Hispanics had similar overall survival compared with whites (hazard ratio, 0.97; 95% CI, 0.94-1.01; P=.10). CONCLUSION: Blacks with CLPC have poorer survival than whites, whereas Asians have better survival, even after risk adjustment and stratification by treatment. These data may be relevant to US regions with large underserved populations that have limited access to health care.

Cost analysis of open radical cystectomy versus robot-assisted radical cystectomy.

Bladder cancer is the fourth and ninth most common malignancy in males and females, respectively, in the U.S. and one of the most costly cancers to manage. With the current economic condition, physicians will need to become more aware of cost-effective therapies for the treatment of various malignancies. Robot-assisted radical cystectomy (RARC) is the latest minimally invasive surgical option for muscle-invasive bladder cancer. Current reports have shown less blood loss, a shorter hospital stay, and a lower morbidity with RARC, as compared with the traditional open radical cystectomy (ORC), although long-term oncologic results of RARC are still maturing. There are few studies that have assessed the cost outcomes of RARC as compared with ORC. Currently, ORC appears to offer a direct cost advantage due to the high purchase and maintenance cost of the robotic platform, although when the indirect costs of complications and extended hospital stay with ORC are considered, RARC may be less expensive than the traditional open procedure. In order to accurately evaluate the cost effectiveness of RARC versus ORC, prospective randomized trials between the two surgical techniques with long-term oncologic efficacy are needed.

Rectal injury during robot-assisted radical prostatectomy: incidence and management.

PURPOSE: Rectal injury during robot-assisted radical prostatectomy is a rare but significant complication. Since the Clavien grading classification of complications does not include intraoperative injury without further sequelae, rectal injury may be underreported in the literature. We present what is to our knowledge the largest retrospective review to date of rectal injury and subsequent management. MATERIALS AND METHODS: We reviewed the records of 6,650 patients who underwent robot-assisted radical prostatectomy at a total of 6 institutions. Patient characteristics, perioperative parameters, pathological findings and rectal injury management were tabulated and analyzed for intraoperative predictors of outcome and subsequent management. RESULTS: A total of 11 rectal injury cases were identified of the 6,650 robot-assisted radical prostatectomies for a combined 0.17% incidence of rectal injury. Of rectal injuries 72.7% were identified intraoperatively and most did well with primary closure. Delayed recognition injury presented as rectourethral fistula without septic complications and required delayed fistula repair after primary diversion. We found no conclusive association of rectal injury with any patient parameter, intraoperative differences, pathological finding or surgeon experience. Posterior prostate plane dissection, including seminal vesicle dissection, is the crucial stage when rectal injury can occur and be identified. CONCLUSIONS: Our review of the records at 6 centers revealed a combined 0.17% incidence of rectal injury. This compares favorably to the incidence in modern open and laparoscopic radical prostatectomy series. No preoperative, intraoperative or pathological differences correlated with injury. Cases in which rectal injury was identified intraoperatively required fewer surgical repeat interventions but ultimately each group had acceptable long-term urinary and bowel function results.

Robot-assisted radical cystectomy versus open radical cystectomy: a complete cost analysis.

OBJECTIVES: To perform a complete cost analysis comparing robot assisted radical cystectomy (RARC) versus open radical cystectomy (ORC). MATERIAL AND METHODS: After institutional review board approval for data collection, we prospectively recorded perioperative outcomes and costs, such as hospital stay, transfusion rate, readmission rate, and medications for consecutive patients undergoing RARC or ORC. Using actual cost data, we developed a cost decision tree model to determine typical perioperative costs for both RARC and ORC. Multivariate sensitivity analysis was performed to elucidate which variables had the greatest impact on overall cost. Breakeven points with ORC were calculated using our model to better evaluate variable influence. In addition to the above modeled analysis, actual patient costs, including complications 30 days from surgery, were also compared for each procedure. RESULTS: Our model analysis showed that operative time and length of stay had the greatest impact on perioperative costs. Robotic cystectomy became more expensive than open cystectomy at the following break-even points: operating room (OR) time greater than 361 minutes, length of stay greater than 6.6 days, or robotic OR supply cost exceeding $5853. RARC was 16% more expensive when only comparing direct operative costs. Interestingly, actual total patient costs revealed a 38% cost advantage favoring RARC due to increased hospitalization costs for ORC in our cohort. CONCLUSIONS: RARC can provide a cost-effective alternative to ORC with operative time and length of stay being the most critical cost determinants. Higher complication rates with ORC make total actual costs much higher than RARC.

Cost analysis of radical retropubic, perineal, and robotic prostatectomy.

BACKGROUND AND PURPOSE: Radical prostatectomy can be performed via a retropubic, perineal, laparoscopic, or robot-assisted laparoscopic approach. Our goal was to evaluate the actual charges incurred at our institution with patients undergoing retropubic prostatectomy (RRP), perineal prostatectomy (RPP), and robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: We retrospectively reviewed all prostatectomy patients treated over a 22-month period (February 2002-December 2004). The case log included 78 RALPs, 16 RRPs, and 16 RPPs. Hospital charges were broken down into operative and nonoperative amounts. Operative times, blood loss, and length of hospital stay were all determined from the patient medical record. The robotic charges were divided further into the initial and final 20 cases. RESULTS: There were significantly higher overall charges for patients undergoing RALP. The operative charges encountered during the robotic "learning curve" were substantially higher than those during our most recent 20 cases. This reduction seemed to correlate directly with the decreasing operative time. The mean operative time for RALP was 262 minutes (range 150-679 minutes). The mean operative time decreased to 225 minutes for our last 20 cases. In contrast, the mean times for RRP and RPP were similar, 202 minutes (range 142-348 minutes) and 196 minutes (range 105-337 minutes), respectively. CONCLUSION: Robot-assisted prostatectomy is associated with substantially higher operative and total hospital charges in addition to the capital expense incurred by the hospital in acquiring and maintaining the robotic system. The operative charges did decrease substantially (27%) once the learning curve had been overcome. Perineal prostatectomy, in experienced hands, remains the most cost-effective procedure, with lower operative costs and shorter times. There was no significant difference in the nonoperative charges in the three treatment groups secondary to the short hospital stay.

Prospective evaluation of concomitant lymphadenectomy in robot-assisted radical prostatectomy: preliminary analysis of outcomes.

BACKGROUND AND PURPOSE: Lymph-node staging is important in many patients with prostate cancer, as it influences adjuvant treatment and prognosis. However, lymphadenectomy adds to the operating time, cost, and potential for complications. Herein, we compared the effects of concomitant lymphadenectomy in patients undergoing robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: Data were collected prospectively on 145 consecutive RARPs. Patients were evaluated in two groups. Group I was patients who underwent RARP and concomitant lymphadenectomy (LAD)(N = 40), and group II consisted of patients who underwent RARP only (N = 105). Operative time (OT), length of hospital stay (LOS), estimated blood loss (EBL), cost, and complications were compared in the two groups. RESULTS: The mean number of lymph nodes removed per patient in group I was 14.08 (range 9-24). Lymph-node metastases were detected in 2 (5%) of the patients. There were no statistically significant differences in LOS, EBL, OT, operative charges, or hospital charges in the two groups. However, the mean OT increased 9.3% when LAD was performed. At a mean follow-up of 14.8 months (range 3-32 months), 16 complications had been observed in the entire series of patients (11.03%). According to the Clavien system, there were eight grade I complications, seven grade II complications, and one grade III complication. Four complications occurred in group I (10%) and 12 in group II (11.4%). There were no lymphoceles or deep venous thromboses (DVTs) in group I. Cost analysis showed no statistically significant difference between the groups. CONCLUSION: There was no significant impact of concomitant lymphadenectomy on LOS, EBL, charges, or complications when RARP was performed. Although the difference was not statistically significant, the OT will be slightly longer, as an additional procedure is being performed.

The use of stab incisions for instrument access in laparoscopic urological procedures.

PURPOSE: Traditional laparoscopic procedures use expensive cannulas to facilitate the insertion and removal of laparoscopic instruments. We report our experience with limited access stab incisions for the insertion of instruments into the peritoneal cavity during laparoscopic urological procedures to minimize the use of disposable cannulas. MATERIALS AND METHODS: All patients undergoing laparoscopic urologic procedures using stab incisions, as performed by us, from November 1999 through March 2003 were included. Procedures included nephrectomy, partial nephrectomy, varicocelectomy, nephroureterectomy, orchiopexy and adrenal procedures. A single cannula was used for telescope access. In select cases additional cannulas were used for unique instruments or specimen manipulation/extraction. Abdominal wall stab incisions were used for the remaining instruments. Stab incisions were closed with a Steri-Strip (3M Healthcare, St. Paul, Minnesota) at the skin level only. RESULTS: A total of 53 procedures were performed during the study period. Pneumoperitoneum was maintained in all cases. There were no complications associated with the use of stab incisions. A total of 105 cannulas were saved using our technique. At a cost to the patient of dollars 140 per cannula the overall cost saving was dollars 14,700 with an average saving of dollars 277 per case. CONCLUSIONS: Laparoscopic urological procedures can be performed effectively and safely with stab incisions for instrument access. There are significant cost savings related to the elimination of cannulas. We believe that our technique of stab incisions for instrument access is equivalent to the traditional cannula approach and should be used when possible.