Learning curve assessment of robot-assisted radical prostatectomy compared with open-surgery controls from the premier perspective database.

INTRODUCTION: The primary aims of this study were to assess the learning curve effect of robot-assisted radical prostatectomy (RARP) in a large administrative database consisting of multiple U.S. hospitals and surgeons, and to compare the results of RARP with open radical prostatectomy (ORP) from the same settings. MATERIALS AND METHODS: The patient population of study was from the Premier Perspective Database (Premier, Inc., Charlotte, NC) and consisted of 71,312 radical prostatectomies performed at more than 300 U.S. hospitals by up to 3739 surgeons by open or robotic techniques from 2004 to 2010. The key endpoints were surgery time, inpatient length of stay, and overall complications. We compared open versus robotic, results by year of procedures, results by case volume of specific surgeons, and results of open surgery in hospitals with and without a robotic system. RESULTS: The mean surgery time was longer for RARP (4.4 hours, standard deviation [SD] 1.7) compared with ORP (3.4 hours, SD 1.5) in the same hospitals (p<0.0001). Inpatient stay was shorter for RARP (2.2 days, SD 1.9) compared with ORP (3.2 days, SD 2.7) in the same hospitals (p<0.0001). The overall complications were less for RARP (10.6%) compared with ORP (15.8%) in the same hospitals, as were transfusion rates. ORP results in hospitals without a robot were not better than ORP with a robot, and pretreatment co-morbidity profiles were similar in all cohorts. Trending of results by year of procedure showed no differences in the three cohorts, but trending of RARP results by surgeon experience showed improvements in surgery time, hospital stay, conversion rates, and complication rates. CONCLUSIONS: During the initial 7 years of RARP development, outcomes showed decreased hospital stay, complications, and transfusion rates. Learning curve trends for RARP were evident for these endpoints when grouped by surgeon experience, but not by year of surgery.

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.

2003 American Urological Association Gallup survey: physician practice patterns, cryosurgery/brachytherapy, male infertility, female urology and insurance/professional liability.

PURPOSE: The Health Policy Survey and Research Committee of the American Urological Association and the Gallup Organization have performed 10 surveys of American urologists since 1992 for the purpose of assessing demographics and practice patterns. The results of the 2003 survey are presented. MATERIALS AND METHODS: A random sample of 510 urologists who have completed urological residencies was interviewed by telephone in February 2003. Major content areas were physician practice patterns, cryosurgery/brachytherapy, male infertility, female urology and insurance/ professional liability. RESULTS: Urologists are older, staying in practice longer and planning to retire later than ever before. Urologists are also seeing more patients in the office every year. Most urologists treat male infertility and female voiding dysfunction. CONCLUSIONS: American urologists are older, working harder and planning on continuing to do so for longer than in any year sampled in the last decade.

Computerized tomography tailored for the assessment of microscopic hematuria.

PURPOSE: We report the results of a multicenter study of arterial, corticomedullary, nephrographic and excretory phase helical computerized tomography (CT) for detecting and characterizing abnormalities causing asymptomatic microscopic hematuria. MATERIALS AND METHODS: We evaluated 350 consecutive patients, including 216 men and 134 women 23 to 88 years old, with asymptomatic microscopic hematuria of undetermined cause at 4 medical centers. Patients with known urological pathology were excluded from study. We performed 4 helical CT sequences, including pre-enhancement phase imaging from kidney to symphysis pubis, arterial phase imaging of the kidney and lower pelvis, corticomedullary nephrographic phase imaging of the kidney and lower pelvis, and excretory phase imaging from kidney to symphysis pubis with 2 to 5 mm. collimation and 1 to 1.5 pitch. RESULTS: Of 171 proved lesions 158 were correctly diagnosed. There were 10 false-positive and 13 false-negative diagnoses, indicating 0.9239 sensitivity, 0.9441 specificity, 0.9404 positive and 0.9285 negative predictive values, (p <0.001). All cases of congenital renal lesions, calculous disease, ureteral lesion and neoplastic lesion of the bladder were correctly diagnosed, as were 40 of 41 inflammatory renal, 21 of 23 renal masses and 13 of 16 inflammatory bladder lesions. In 27 patients with renal calculi the study was limited to pre-enhancement spiral CT. CONCLUSIONS: A positive diagnosis rate of 45.1% (158 of 350 cases) for the causes of heretofore refractory cases of hematuria with high sensitivity and specificity attest to the effectiveness of our hematuria CT protocol and support its use.