Patterns-of-care and health economic analysis of robot-assisted radical prostatectomy in the Australian public health system.

OBJECTIVES: To compare patterns of care and peri-operative outcomes of robot-assisted radical prostatectomy (RARP) with other surgical approaches, and to create an economic model to assess the viability of RARP in the public case-mix funding system. PATIENTS AND METHODS: We retrospectively reviewed all radical prostatectomies (RPs) performed for localized prostate cancer in Victoria, Australia, from the Victorian Admitted Episode Dataset, a large administrative database that records all hospital inpatient episodes in Victoria. The first database, covering the period from July 2010 to April 2013 (n = 5 130), was used to compare length of hospital stay (LOS) and blood transfusion rates between surgical approaches. This was subsequently integrated into an economic model. A second database (n = 5 581) was extracted to cover the period between July 2010 and June 2013, three full financial years, to depict patterns of care and make future predictions for the 2014-2015 financial year, and to perform a hospital volume analysis. We then created an economic model to evaluate the incremental cost of RARP vs open RP (ORP) and laparoscopic RP (LRP), incorporating the cost-offset from differences in LOS and blood transfusion rate. The economic model constructs estimates of the diagnosis-related group (DRG) costs of ORP and LRP, adds the gross cost of the surgical robot (capital, consumables, maintenance and repairs), and manipulates these DRG costs to obtain a DRG cost per day, which can be used to estimate the cost-offset associated with RARP in comparison with ORP and LRP. Economic modelling was performed around a base-case scenario, assuming a 7-year robot lifespan and 124 RARPs performed per financial year. One- and two-way sensitivity analyses were performed for the four-arm da Vinci SHD, Si and Si dual surgical systems (Intuitive Surgical Ltd, Sunnyvale, CA, USA). RESULTS: We identified 5 581 patients who underwent RP in 20 hospitals in Victoria with an open, laparoscopic or robot-assisted surgical approach in the public and private sector. The majority of RPs (4 233, 75.8%), in Victoria were performed in the private sector, with an overall 11.5% decrease in the total number of RPs performed over the 3-year study period. In the most recent financial year, 820 (47%), 765 (44%) and 173 patients (10%) underwent RARP, ORP and LRP, respectively. In the same timeframe, RARP accounted for 26 and 53% of all RPs in the public and private sector, respectively. Public hospitals in Victoria perform a median number of 14 RPs per year and 40% of hospitals perform <10 RPs per year. In the public system, RARP was associated with a mean (±sd) LOS of 1.4 (±1.3) days compared with 3.6 (±2.7) days for LRP and 4.8 (±3.5) days for ORP (P < 0.001). The mean blood transfusion rates were 0, 6 and 15% for RARP, LRP and ORP, respectively (P < 0.001). The incremental cost per RARP case compared with ORP and LRP was A$442 and A$2 092, respectively, for the da Vinci S model, A$1 933 and A$3 583, respectively, for the da Vinci Si model and A$3 548 and A$5 198, respectively for the da Vinci Si dual. RARP can become cost-equivalent with ORP where ~140 cases per year are performed in the base-case scenario. CONCLUSIONS: Over the period studied, RARP has become the dominant approach to RP, with significantly shorter LOS and lower blood transfusion rate. This translates to a significant cost-offset, which is further enhanced by increasing the case volume, extending the lifespan of the robot and reductions in the cost of consumables and capital.

The social media revolution is changing the conference experience: analytics and trends from eight international meetings.

OBJECTIVE: To analyse the use of Twitter at urology conferences to enhance the social media conference experience. MATERIALS AND METHODS: We prospectively registered the hashtags of eight international urology conferences taking place in 2013, using the social media metrics website, Symplur.com. In addition, we prospectively registered the hashtag for the European Association of Urology (EAU) Annual Congress for 3 consecutive years (2012-2014) to analyse the trend in the use of Twitter at a particular meeting. Metrics including number of 'tweets', number of participants, tweet traffic per day, and overall digital impressions, which were captured for 5 days before each conference, the conference itself, and the following 2 days. We also measured corresponding social media activity at a very large non-urology meeting (the American Society of Clinical Oncology) for comparative purposes. RESULTS: Twitter activity was noted at all eight conferences in 2013. In all, 12,363 tweets were sent generating over 14 million impressions. The number of participants tweeting at each meeting varied from 80 (Congress of the Société Internationale d'Urologie, #SIU2013) to 573 (the American Urological Association, #AUA13). Overall, the AUA meeting (#AUA13) generated the most Twitter activity with >8.6 million impressions and a total of 4663 tweets over the peri-conference period. It also had the most impressions and tweets per day over this period, at 717,000 and 389, respectively. The EAU Annual Congress 2013 (#EAU13) generated 1.74 million impressions from a total of 1762 tweets from 236 participants. For trends in Twitter use, there was a very sharp rise in Twitter activity at the EAU Annual Congress between 2012 and 2014. Over this 3-year period, the number of participants increased almost 10-fold, leading to an increase in the number of tweets from 347 to almost 6000. At #EAU14, digital impressions reached 7.35 million with 5903 tweets sent by 797 participants. CONCLUSIONS: Urological conferences, to a varying extent, have adopted social media as a means of amplifying the conference experience to a wider audience, generating international engagement and global reach. Twitter is a very powerful tool that amplifies the content of scientific meetings, and conference organisers should put in place strategies to capitalise on this.

Patients with medical risk factors for chronic kidney disease are at increased risk of renal impairment despite the use of nephron-sparing surgery.

OBJECTIVE: To determine whether patients with normal preoperative renal function, but who possess medical risk factors for chronic kidney disease (CKD), experience poorer renal function after partial nephrectomy (PN) for renal cell carcinoma (RCC) compared with those without risk factors. PATIENTS AND METHODS: The effects of age, hypertension (HTN) and diabetes mellitus (DM) on estimated glomerular filtration rate (eGFR) were investigated in 488 consecutive operations for RCC performed during 2005-2012 at six Australian tertiary referral centres; 156 patients underwent PN and 332 patients underwent radical nephrectomy (RN). We used chi-squared test and binary logistic regression to analyse new-onset CKD, and multiple linear regression to investigate determinants of postoperative eGFR. RESULTS: The development of new-onset eGFR of <60 mL/min was related to undergoing RN rather than PN (risk ratio [RR] 2.7, P < 0.001), older age (RR 1.6, P < 0.001) and the presence of HTN (RR 1.6, P = 0.001) and DM (RR 1.5, P = 0.003). Patients undergoing PN were still at risk of new-onset CKD if medical risk factors were present. Whereas 7% of patients undergoing PN without CKD risk factors developed new-onset eGFR <60 mL/min, this figure increased to 24%, 30% and 42% for older age, HTN and DM, respectively. Patients with eGFR of 45-59 mL/min were more likely to progress to more severe forms of CKD and end-stage renal failure than those with eGFR of ≥60 mL/min. On multivariate analysis, RN, rather than PN, age and the presence of DM (but not HTN), predicted both the development of new-onset eGFR of <60 mL/min (R(2) = 0.37) and new-onset eGFR <45 mL/min (R(2) = 0.42). CONCLUSION: Patients with medical risk factors for CKD are at increased risk of progressive renal impairment despite the use of PN. Where feasible, nephron-sparing surgery should be considered for these patients.

Early urinary continence recovery after robot-assisted radical prostatectomy in older Australian men.

OBJECTIVE: To compare the recovery of urinary continence (UC) after robot-assisted radical prostatectomy (RARP) in men aged ≥70 and <70 years at 1-year follow-up and to assess for preoperative predictors of UC recovery, as older, healthy men with localised prostate cancer are often denied curative surgical treatment on the grounds of worse UC recovery. PATIENTS AND METHODS: In all, 262 patients with prostate cancer having undergone RARP between May 2008 and September 2012, under the care of two consultant urological surgeons at three Melbourne hospitals, were identified. Patients were categorised based on their age ≥70 and <70 years and compared with regards to two endpoints; percentage fully continent and mean pads/day at 4-6 weeks, and 3, 6, 9 and 12 months after RARP. RESULTS: Of the 262 men, 9% (24) were aged ≥70 years. Older men had higher PSA levels (P = 0.007) and clinical stages (P < 0.001) compared with the younger cohort. There were more non-nerve sparing procedures in the older group (P = 0.009) and a shorter mean operative time (P = 0.004). At 4-6 weeks after RARP, the number of pads used per day was greater in older men (P = 0.03) and there was a trend towards fewer older men being fully continent (P = 0.08) than their younger counterparts; however, by 3 months and all time-points thereafter there was no difference. The 12-month UC rates were 89% and 92% for men aged <70 and ≥70 years, respectively. Neither age, body mass index, D'Amico risk group, nerve sparing nor use of Rocco suture were predictors of time to UC recovery. CONCLUSION: UC recovery after RARP in men aged ≥70 years appears comparable to younger men and therefore not a reason to deny older men with a reasonable life-expectancy curative surgical treatment of localised prostate cancer.

ChatGPT can help guide and empower patients after prostate cancer diagnosis.

BACKGROUND/OBJECTIVES: Patients often face uncertainty about what they should know after prostate cancer diagnosis. Web-based information is common but is at risk of being of poor quality or readability. SUBJECTS/METHODS: We used ChatGPT, a freely available Artificial intelligence (AI) platform, to generate enquiries about prostate cancer that a newly diagnosed patient might ask and compared to Google search trends. Then, we evaluated ChatGPT responses to these questions for clinical appropriateness and quality using standardised tools. RESULTS: ChatGPT generates broad and representative questions, and provides understandable, clinically sound advice. CONCLUSIONS: AI can guide and empower patients after prostate cancer diagnosis through education. However, the limitations of the ChatGPT language-model must not be ignored and require further evaluation and optimisation in the healthcare field.

Anatrophic nephrolithotomy and pyelolithotomy for dual staghorn calculi in bifid collecting system.

A bifid ureter is an atypical anatomical variation that occurs with an incidence of 1-10%. This anomaly is in a continuum of duplex collecting systems and most commonly involves a common distal ureter. This is usually asymptomatic and is predominantly an incidental diagnosis, nevertheless, is a potential risk factor for urolithiasis formation. Current surgical management of larger staghorn calculi favours percutaneous nephrolithotomy (PCNL) over traditional open surgery, however for multiple calculi and complex anatomy PCNL would require multiple punctures, with increased risk of bleeding, pleural injury, sepsis and ultimately failed stone clearance. We describe the case of a 71-year-old female with multiple calculi in bifid anatomy. A single open approach, aided with cold-ischaemia was successfully utilized in this context.

Nephron-sparing surgery for the management of upper tract urothelial carcinoma: an outline of surgical technique and review of outcomes.

Upper tract urothelial carcinoma (UTUC) often occurs in elderly patients with multiple co-morbidities including renal impairment. As such, nephron sparing surgery (NSS) often needs to be considered. This article reviews the available NSS techniques for UTUC, including ureteroscopy, percutaneous approaches and segmental ureterectomy. PubMed and OvidMEDLINE reviews of available case series from the last 10 years demonstrated that recurrence was highly variable between studies and occurred in 19-90.5% of ureteroscopic cases, 29-98% of percutaneous resections and in 10.2-31.4% of patients who underwent segmental ureterectomy. The small number of included studies and variable follow up periods made comparison between techniques difficult. NSS is a necessary alternative for patients with significant comorbidities or renal impairment who cannot undergo radical nephro-ureterectomy. However, there is significant variation in oncological outcomes, with an increased risk of progression or death from cancer-salvage by radical surgery may sometimes be required.

Laparoscopic versus robotic-assisted radical prostatectomy: an Australian single-surgeon series.

BACKGROUND: In Australia, robotic-assisted radical prostatectomy (RARP) has steadily replaced open and laparoscopic surgery in the management of localized prostate cancer. Given the increased cost of this technology, we aimed to compare the perioperative, pathological, oncological and functional outcomes as well as short-term complications of laparoscopic and RARP. METHODS: We performed a retrospective review of prospectively collected data on 200 consecutive patients during the transition of a single surgeon (DM) from pure laparoscopic (n = 100) to RARP (n = 100) between September 2007 and March 2011. RESULTS: Median operative time and estimated blood loss were the same for both surgical approaches, 195 min (P = 0.29) and 300 mL (P = 0.88) respectively. Median length of hospital stay was shorter for RARP (P = 0.003). Complication rates were not statistically different between groups. There was no significant difference in positive surgical margin rates in pT2 (P = 0.36) or pT3 disease (0.99) or biochemical recurrence rate between groups (P = 0.14). The 12 months continence rate was improved with RARP compared with laparoscopic radical prostatectomy (93% versus 82%; P = 0.025). The potency rate was 56% and 74% at 12 months after laparoscopic radical prostatectomy and RARP respectively (P = 0.12) for a bilateral nerve sparing procedure. CONCLUSION: We conclude from our single-surgeon comparative series that the robotic approach results in a significantly shorter length of hospital stay and improved 12 months continence rates and demonstrated a trend towards better potency rates. Complications, positive surgical margin rates and the requirement for adjuvant therapy are all improved with the robotic approach but did not show statistically significant differences.

Early experience and operative technique of robotic-assisted partial nephrectomy.

BACKGROUND: The adoption of robotic-assisted partial nephrectomy (RAPN) is increasing in Australia; however, to date no Australian RAPN series has been reported. This paper describes a single-surgeon initial experience with RAPN and evaluates perioperative, pathological and oncological outcomes. METHODS: Data on the first 50 consecutive patients to undergo RAPN by a single surgeon were reviewed. Demographic, perioperative, tumour characteristics and Clavien complications were collected in addition to oncological follow-up and renal function monitoring. RESULTS: Mean age was 58.2 ± 10.4 years, body mass index was 28.8 ± 4.5 kg/m(2) and Charlson Co-morbidity Index was 4.6 ± 1.2. Tumour diameter was 31 ± 13 mm and RENAL score was 6.8 ± 1.5. Average total operative time was 151 ± 32.7 min, estimated blood loss was 171.1 ± 185.8 mL, warm ischaemia time was 17.8 ± 6.7 min and length of hospital stay was 3 ± 0.9 days. There were seven Clavien complications and no deaths. Estimated glomerular filtration rate did not decrease significantly post-operatively (P = 0.8); and there was 14.6% upstaging of chronic kidney disease scoring although no patient required dialysis. There were no positive malignant surgical margins, and to date no patient has evidence of disease recurrence. Of 50 patients, 54% had a minimum follow-up of 6 months and 28% had a minimum follow-up of 1 year. CONCLUSION: We report the largest RAPN study in Australia or New Zealand to date. Initial results suggest that RAPN can be safely introduced into the Australian public and private health systems, and has been effective in oncologic control and renal function preservation.