Healthcare utilization in men with poorer sexual and urinary function recovery following robot-assisted radical prostatectomy.

PURPOSE: Robotic radical prostatectomy focuses on oncologic cure, urinary continence and sexual function recovery. However, little is known about the effect of declines in urinary continence and sexual function on healthcare utilization. We aim to identify these factors. MATERIALS AND METHODS: From March 2011 to September 2013, all men undergoing robotic prostatectomy within our healthcare system were enrolled. Men completed the expanded prostate cancer index composite-26 survey at the time of diagnosis and 90 days post-operatively. Patients were stratified according to change in scores in the sexual function and urinary incontinence domains. Patient, treatment and post-op utilization patterns were examined for association with the extent of decline in sexual function and urinary continence. Multivariate linear regression was used to identify factors independently associated with decline in continence and sexual function. RESULTS: A total of 411 men who completed the baseline survey and at 90 days postoperatively were included. On multivariate linear regression, younger age (p < 0.01), higher preoperative sexual function (< 0.01), single marital status (p = 0.04) and more post-surgery email contacts (p = 0.04) were associated with higher declines in sexual function. For continence, no family history of prostate cancer (p = 0.01), higher baseline continence (p < 0.01) and more post-surgery physical therapy visits (p < 0.01) were associated with higher declines. CONCLUSIONS: Patients with the poorest quality of life outcomes at 90 days post-operatively were more likely to seek care via email and physical therapy encounters related to sexual function and urinary incontinence, respectively. This suggests that maximizing post-treatment quality of life can potentially reduce healthcare utilization.

Cryopreserved placental tissue allograft accelerates time to continence following robot-assisted radical prostatectomy.

Intra-operatively placed cryopreserved placental tissue allograft (CPTA) has shown promise in expediting the recovery urinary continence (UC) following robot-assisted radical prostatectomy (RARP). In this retrospective review of a prospectively maintained single-surgeon, single-institution RARP database, we compare three groups of patients: historical controls (C; N = 183 men) that received no allograft versus two different CPTA products (total CPTA N = 162 [A1 N = 81; A2 N = 81]). The CPTA product was intra-operatively placed as an onlay over the area of the neurovascular bundles during RARP. CPTA cases had significantly faster median time to UC (A1 = 1.4 months; A2 = 1.45 months) versus controls (1.64 months), p = 0.01. On multivariable analysis, use of A1 (HR 1.55, 95% CI [1.14-2.09], p = 0.005) and use of A2 (HR 1.53, CI [1.11-2.11], p = 0.01) were significantly associated with quicker return of UC. Older age (HR 0.97, CI [0.96-0.99], p = 0.001) and non-organ-confined clinical stage (HR 0.51, CI [0.26-1.0] p = 0.05), were significantly associated with slower return of UC. In a propensity score-matched analysis of 77 CPTA patients with sufficient follow-up versus controls, there was significantly less biochemical recurrence (BCR; p = 0.01). Our study indicates that CPTA use appears to accelerate time to UC in age- and performance status-matched men undergoing RARP without increased risk of BCR.

Neoadjuvant Leuprolide Therapy with Radical Prostatectomy: Long-term Effects on Health-related Quality of Life.

BACKGROUND: Neoadjuvant androgen ablation (neoadjuvant androgen deprivation therapy [NADT]) is used prior to radical prostatectomy, contrary to guidelines, but its long-term effects on quality of life is unknown. OBJECTIVE: To determine the effect of NADT on patient's long-term recovery following surgery. DESIGN, SETTING, AND PARTICIPANTS: From March 2011 to August 2013, 5808 men with newly diagnosed prostate were followed up to 24 mo. A cohort of men who received NADT prior to robotic-assisted laparoscopic prostatectomy (RALP; n=51) was compared 1:3 with a matched group that underwent RALP only (n=153). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patients were matched on Charlson comorbidities, biopsy Gleason score, and node status on final pathology. The Kruskall-Wallis test was used to compare the groups on their bowel, urinary, sexual, and hormonal domains of the 26-item Expanded Prostate Cancer Index Composite at baseline and at 1, 3, 6, 12, 18, and 24 mo postoperatively. RESULTS AND LIMITATIONS: The urinary irritative, urinary incontinence, and bowel domains were similar in the two groups during the 24 mo (p=0.832, 0.901, and 0.732, respectively). In the hormonal domain, the NADT group did worse (p<0.001). The sexual domain was also worse for the NADT group. However, when accounting for nerve sparing, there was no significant difference in sexual outcomes between the two groups (p=0.069). CONCLUSIONS: Patients who received NADT prior to RALP do not have worse sexual function, but have worse hormonal scores for up to 2yr after surgery. PATIENT SUMMARY: Neoadjuvant androgen deprivation therapy (NADT) is administered prior to robotic-assisted laparoscopic prostatectomy (RALP), contrary to clinical guidelines. NADT may not have worse sexual function outcomes up to 2yr after RALP.

Nephrometry score matched robotic vs. laparoscopic vs. open partial nephrectomy.

To compare perioperative outcomes in the three most common partial nephrectomy modalities: robotic (RPN), laparoscopic (LPN), and open (OPN), matched for nephrometry scores. Patients aged 16-85 who underwent RPN, LPN, or OPN from 2007 to 2014 for localized renal carcinoma within our healthcare system were enrolled. Age, sex, body mass index, and Charlson Comorbidity Index (CCI) as well as perioperative outcomes of estimated blood loss (EBL), length of hospital stay (LOS), ischemia time (IT), change in eGFR, positive margin rate, operative time (OT), and emergency room visit rates were compared between RPN, LPN, and OPN using the R.E.N.A.L nephrometry score. A total of 862 patients underwent partial nephrectomy (523 LPN, 176 OPN, and 163 RPN). Patients who underwent OPN were significantly older, and had higher nephrometry scores and CCI. When matched for nephrometry scores, minimally invasive (LPN and RPN) compared to OPN had lower EBL (< 0.0001), shorter LOS (< 0.0001), shorter IT (< 0.001), and less change in eGFR (< 0.001), particularly in nephrometry scores higher than 8 (0.0099). Comparing RPN with LPN, RPN had significantly shorter OT in all nephrometry scores (< 0.001); shorter IT and LOS in nephrometry scores higher than 7. Our study suggests that minimally invasive partial nephrectomy may have superior outcomes to OPN when matched by nephrometry scores, particularly at higher scores and for RPN. This finding may contribute to a surgeon's decision in the approach to partial nephrectomy.

Does the Level of Assistant Experience Impact Operative Outcomes for Robot-Assisted Partial Nephrectomy?

PURPOSE: A skilled assistant surgeon is presumed necessary during robot-assisted partial nephrectomy (RAPN) to minimize warm ischemia time (WIT) and to facilitate complex renorrhaphy. Studies observing impact of resident participation have focused on robotic prostatectomies, showing no impact on core surgical outcomes. Herein, we evaluated the level of experience of the bedside assistant and its impact on perioperative outcomes in RAPN. MATERIALS AND METHODS: All RAPN cases in our healthcare system from January 2011 to December 2013 were retrospectively reviewed. The cases were divided into teaching and nonteaching hospitals. There were 18 fellowship-trained attending surgeons. At teaching hospitals, surgeries were performed by an attending physician and postgraduate year (PGY)-2 or PGY-3 resident at bedside; at nonteaching hospitals, surgeries were performed by two attending surgeons. We compared age, gender, body mass index, Charlson comorbidity index, operative difficulty by R.E.N.A.L. nephrometry score, and operative outcomes (WIT, estimated blood loss, operative time (OT), positive margin rate, length of stay (LOS), postoperative glomerular filtration rate, and readmission rate). RESULTS: Of the 170 patients captured, 162 had R.E.N.A.L. nephrometry score and WIT: 112 from teaching hospitals and 50 from nonteaching hospitals. Patient characteristics were equivalent between both cohorts with the exception of the R.E.N.A.L. score, which was higher (6.3 vs 5.7, p = 0.046) in the teaching hospitals cohort. Regarding operative outcomes, we noted an overall increase in LOS by 1 day (p = 0.001) and OT by 16 minutes (p = 0.011) in the teaching hospitals. CONCLUSION: We observed that increased LOS was the only clinically relevant measure negatively impacted by resident physician involvement during RAPN.

Out-of-Pocket Costs for Men Undergoing Infertility Care and Associated Financial Strain.

INTRODUCTION: We determined the out-of-pocket expenses, measures taken to finance these expenses and associated financial strain for men seeking fertility care. METHODS: In this retrospective cohort the patients completed questionnaires recording the total amount of money spent on infertility care and on what aspect of care the money was spent. Participants also recorded measures taken to finance these costs, the amount of financial strain experienced, and how this strain impacted decisions to seek and continue care. Multivariable logistic regression was performed to assess the relationships of fertility characteristics to financial costs and financial strain. RESULTS: A total of 111 participants completed the full survey. During the course of care 16% of patients spent more than $50,000 dollars. 16% spent between $30,000 and $49,999, 32% spent between $15,000 and $29,999, and 37% spent less than $15,000. Procedures comprised the largest component of costs. Of the subjects 47% reported financial strain. On multivariate analysis patients who used savings and went into debt were significantly more likely to experience financial strain (p = 0.03 and <0.001, respectively). CONCLUSIONS: This study elucidates the previously uncharacterized economic hardships of male infertility care. Overall 64% of men who pursued fertility treatment had out-of-pocket expenses exceeding $15,000 dollars. Almost half reported financial strain and limitation of treatment options due to these expenses. These data give men and their partners a realistic expectation of the cost of pursuing fertility treatment, the extreme measures that many patients take to finance care and the financial strain associated with such options.

Robotic versus laparoscopic resection for sigmoid diverticulitis with fistula.

Robotic abdominal surgery is growing despite a paucity of clinical reports to evaluate its impact on patient outcomes. In this retrospective case series, we aim to analyze our early experience with robotic resection in 11 consecutive patients with chronic colonic diverticulitis complicated by fistula to bladder, vagina, or skin and to compare the results of the robotic approach to 20 patients undergoing laparoscopic resection for the same indication. Our main outcome measures include operative time, blood loss, conversion rate, transfusion rate, hospital length of stay, complications, readmission, and fistula healing rate. In our study, we found robotic resection for colonic diverticulitis with fistula was technically feasible and yielded 100% fistula healing rate. The operative time, complication and readmission rates were similar to laparoscopy. A higher conversion rate, diverting stoma need, and longer hospital length of stay were noted in the robotic group; however, these findings could have been attributed to a higher number of cases involving rectal excision in the robotic group. Larger studies are needed to further examine the impact of robotic surgery on the outcome of patients with complicated chronic sigmoid diverticulitis.