Patient-centred pathology reporting improves patient experience and understanding of disease in prostate cancer care.

Introduction and Objectives: Patient-centred (PC) and holistic care improves patient satisfaction and health outcomes. We sought to investigate the benefit of utilising a PC pathology report in patients undergoing radical prostatectomy (RP) for prostate cancer (PCa). Our study aimed to evaluate and compare patient understanding of their PCa diagnosis after RP, upon receiving either a standard histopathology report or a personalised and PC report (PCR). Moreover, we evaluated knowledge retention at 4 weeks after the initial consultation. Methods: We invited patients undergoing RP at three metropolitan Urology clinics to participate in our randomised controlled study. Patients were randomised to receive either a PCR or standard pathology report. Patient satisfaction questionnaires (Perceived Efficacy in Patient-Physician Interactions [PEPPI], Consultation and Relational Empathy [CARE] and Communication Assessment Tool [CAT]) and a knowledge test were conducted within 72 h of the initial appointment and again at 4 weeks. Accurate recollection of Gleason grade group (GGG) and extracapsular extension (ECE) were classified as 'correct'. Baseline demographic data included age, education, marital and employment status, pre-op prostate specific antigen (PSA) and clinical stage. Baseline data were tested for differences between groups using the Student's t test, chi-squared test or Fisher's exact test depending on whether data were continuous, categorical or sparse. Comparison of correctly answered 'knowledge' questions was analysed using chi-squared test. A significance level of p ≤ 0.05 was used. Results: Data from 62 patients were analysed (30 standard vs. 32 PCR). No significant differences in baseline demographics were found between groups. Both groups reported high levels of satisfaction with their healthcare experiences in all domains of patient-physician rapport, empathy and communication. There were no significant differences between groups in PEPPI (p = 0.68), CAT (p = 0.39) and CARE (p = 0.66) scores, at baseline and 4 weeks. Ninety-three per cent of patients who received the PCR understood the report while 90% felt the report added to their understanding of their PCa. Regarding patient knowledge, the PCR group had significantly more correct answers on GGG and ECE as compared with the standard report group at baseline and 4 weeks (p < 0.001 and 0.001, respectively). Conclusions: Our findings demonstrate that PC pathology reports improve patient knowledge and understanding of their PCa that is retained for at least 4 weeks after initial receipt of results.

Outcomes in robot-assisted partial nephrectomy for imperative vs elective indications.

OBJECTIVES: To assess and compare peri-operative outcomes of patients undergoing robot-assisted partial nephrectomy (RAPN) for imperative vs elective indications. PATIENT AND METHODS: We retrospectively reviewed a multinational database of 3802 adults who underwent RAPN for elective and imperative indications. Laparoscopic or open partial nephrectomy (PN) were excluded. Baseline data for age, gender, body mass index, American Society of Anaesthesiologists score and PADUA score were examined. Patients undergoing RAPN for an imperative indication were matched to those having surgery for an elective indication using propensity scores in a 1:3 ratio. Primary outcomes included organ ischaemic time, operating time, estimated blood loss (EBL), rate of blood transfusions, Clavien-Dindo complications, conversion to radical nephrectomy (RN) and positive surgical margin (PSM) status. RESULTS: After propensity-score matching for baseline variables, a total of 304 patients (76 imperative vs 228 elective indications) were included in the final analysis. No significant differences were found between groups for ischaemia time (19.9 vs 19.8 min; P = 0.94), operating time (186 vs 180 min; P = 0.55), EBL (217 vs 190 mL; P = 0.43), rate of blood transfusions (2.7% vs 3.7%; P = 0.51), or Clavien-Dindo complications (P = 0.31). A 38.6% (SD 47.9) decrease in Day-1 postoperative estimated glomerular filtration rate was observed in the imperative indication group and an 11.3% (SD 45.1) decrease was observed in the elective indication group (P < 0.005). There were no recorded cases of permanent or temporary dialysis. There were no conversions to RN in the imperative group, and seven conversions (5.6%) in the elective group (P = 0.69). PSMs were seen in 1.4% (1/76) of the imperative group and in 3.3% of the elective group (7/228; P = 0.69). CONCLUSION: We conclude that RAPN is feasible and safe for imperative indications and demonstrates similar outcomes to those achieved for elective indications.

Omission of Cortical Renorrhaphy During Robotic Partial Nephrectomy: A Vattikuti Collective Quality Initiative Database Analysis.

OBJECTIVES: To analyze the outcomes of patients in whom cortical (outer) renorrhaphy (CR) was omitted during robotic partial nephrectomy (RPN). METHODS: We analyzed 1453 patients undergoing RPN, from 2006 to 2018, within a large multi-institutional database. Patients having surgery for bilateral tumors (n = 73) were excluded. CR and no-CR groups were compared in terms of operative and ischemia time, estimated blood loss (EBL), complications, surgical margins, hospital stay, change in estimated glomerular filtration rate (eGFR), and need of angioembolization. Inverse probability of treatment weighting with Firth correction for center code was performed to account for selection bias. RESULTS: CR was omitted in 120 patients (8.7%); 1260 (91.3%) patients underwent both inner layer and CR. There was no difference in intraoperative complications (7.4% CR; 8.9% no-CR group; P = .6), postoperative major complications (1% and 2.8% in CR and no-CR groups, respectively; P = .2), or median drop in eGFR (7.3 vs 10.4 mL/min/m2). The no-CR group had a higher incidence of minor complications (26.7% vs 5.5% in CR group; P < .001). EBL was 100 mL (IQR 50-200) in both groups (P = .6). Angioembolization was needed in 0.7% patients in CR vs 1.4% in no-CR group (P = .4). Additionally, there was no difference in median operative time (168 vs 162 min; P = .2) or ischemia time (18 vs 17 min; P = .7). CONCLUSION: In selected patients with renal masses, single layer renorrhaphy does not significantly improve operative time, ischemia time, or eGFR after RPN. There is a higher incidence of minor complications, but not major perioperative complications after no-CR technique.

Predicting intra-operative and postoperative consequential events using machine-learning techniques in patients undergoing robot-assisted partial nephrectomy: a Vattikuti Collective Quality Initiative database study.

OBJECTIVE: To predict intra-operative (IOEs) and postoperative events (POEs) consequential to the derailment of the ideal clinical course of patient recovery. MATERIALS AND METHODS: The Vattikuti Collective Quality Initiative is a multi-institutional dataset of patients who underwent robot-assisted partial nephectomy for kidney tumours. Machine-learning (ML) models were constructed to predict IOEs and POEs using logistic regression, random forest and neural networks. The models to predict IOEs used patient demographics and preoperative data. In addition to these, intra-operative data were used to predict POEs. Performance on the test dataset was assessed using area under the receiver-operating characteristic curve (AUC-ROC) and area under the precision-recall curve (PR-AUC). RESULTS: The rates of IOEs and POEs were 5.62% and 20.98%, respectively. Models for predicting IOEs were constructed using data from 1690 patients and 38 variables; the best model had an AUC-ROC of 0.858 (95% confidence interval [CI] 0.762, 0.936) and a PR-AUC of 0.590 (95% CI 0.400, 0.759). Models for predicting POEs were trained using data from 1406 patients and 59 variables; the best model had an AUC-ROC of 0.875 (95% CI 0.834, 0.913) and a PR-AUC 0.706 (95% CI, 0.610, 0.790). CONCLUSIONS: The performance of the ML models in the present study was encouraging. Further validation in a multi-institutional clinical setting with larger datasets would be necessary to establish their clinical value. ML models can be used to predict significant events during and after surgery with good accuracy, paving the way for application in clinical practice to predict and intervene at an opportune time to avert complications and improve patient outcomes.

Adverse impact of malnutrition markers on major abdominopelvic cancer surgery.

BACKGROUND: Malnutrition has been associated with adverse postoperative outcomes in a range of procedures but none have evaluated the interaction between clinical indicators of malnutrition. We aimed to comparatively evaluate how combinations of nutritional parameters impact postoperative outcomes amongst patients undergoing major cancer operations. METHODS: Major abdominopelvic cancer surgery cases (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, nephrectomy, pancreatectomy, pneumonectomy and prostatectomy) were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2007-2016. Malnutrition was defined by the presence of the following parameters: body mass index <18.5 kg/m2 ; preoperative serum albumin <3.0 g/dL or more than 10% weight loss in the last 6 months. Malnourished cases were matched with cases with satisfactory nutritional status using propensity scores. The primary outcome was the incidence of Clavien III-IV complications. RESULTS: Of the 30 207 cases included, 8.5% had at least one marker of malnutrition. The incidence of Clavien III-IV complications across all cases was 5.8%. In the matched cohort, malnourished cases had a higher rate of complications than those with adequate nutritional status (11.3% versus 9.6%, P = 0.018). A correlation was observed between the number of malnutrition markers possessed and the incidence of Clavien III-V complications. Cases with all three makers had the highest likelihood of experiencing a complication (odds ratio 5.47, 95% confidence interval 1.85-16.17). CONCLUSION: Poor nutritional status confers an increased risk of major postoperative complications and being discharged to a facility in non-upper gastrointestinal cancer patients. There was a correlation between the number of malnutrition parameters and the risk of complications.

Retroperitoneal vs Transperitoneal Robot-assisted Partial Nephrectomy: Comparison in a Multi-institutional Setting.

OBJECTIVES: To evaluate retroperitoneal robot-assisted partial nephrectomy (RAPN) against transperitoneal approach in a multi-institutional prospective database, after accounting for potential selection bias that may affect this comparison. PATIENTS AND METHODS: Post-hoc analysis of the prospective arm of the Vattikuti Collective Quality Initiative database from 2014 to 2018. Six hundred and ninety consecutive patients underwent RAPN by 22 surgeons at 14 centers in 9 countries. Patients who had surgery at centers not performing retroperitoneal approach (n = 197) were excluded. Inverse probability of treatment weighting was done to account for potential selection bias by adjusting for age, gender, body mass index, comorbidities, side of surgery, location/size/complexity of tumor, renal function, American Society of Anesthesiologists score, and year of surgery. Operative and perioperative outcomes were compared between weighted transperitoneal and retroperitoneal cohorts. RESULTS: Ninety-nine patients underwent retroperitoneal RAPN; 394 underwent transperitoneal RAPN. Hospital stay in days-median 3.0 (Interquartile range [IQR] 2.0-4.0) transperitoneal vs 1.0 (1.0-3.0) retroperitoneal; P < .001, and blood loss in mL-125 (50-250) transperitoneal vs 100 (50-150) retroperitoneal; P = .007-were lower in the retroperitoneal group. There were no differences in operative time (P = .6), warm ischemia time (P = .6), intraoperative complications (P = .99), conversion to radical nephrectomy (P = .6), postoperative major complications (P = .6), positive surgical margins (P = .95), or drop in estimated glomerular filtration rate (P = .7). CONCLUSION: In a multi-institutional setting, both retroperitoneal and transperitoneal approach to RAPN have comparable operative and perioperative outcomes, except for shorter hospital stay with the retroperitoneal approach.

Changing face of robot-assisted radical prostatectomy in Melbourne over 12 years.

BACKGROUND: This study aims to characterize the trends in disease presentation for robot-assisted radical prostatectomy (RARP) over a 12-year period in Melbourne, Australia. METHODS: All patients undergoing an RARP between 2004 and October 2016 while under the care of six high-volume surgeons were included in this study. Data were collected prospectively regarding patient demographics and clinical details of their cancer. RESULTS: Over the 12-year time span of the study, 3075 men underwent an RARP with a median age of 63.01 years. Temporal analysis demonstrated that the median age of patients undergoing prostatectomy advanced with time with the median age in 2016 being 65.51 years compared with 61.0 years in 2004 (P < 0.001). There was also a significant trend to increased D'Amico risk groups over time with the percentage procedures for high-risk patients increasing from 12.6% to 28.10% from 2004 to 2016 (P < 0.001). Upgrade rates between biopsy and pathological Gleason grade scoring significantly trended down over the period of the study (P < 0.001). There was also a shift to increased pathological stage over the 12 years with 22.1% of men having T3 disease in 2004 compared with 49.8% in 2016. CONCLUSION: Our analysis demonstrates increasing treatment of older men with higher risk tumours, consistent with international trends. While this largely reflects a shift in case selection, further work is needed to assess whether the stage shift may relate partially to a decline in screening and increased presentation of higher risk disease.

Conversion of Robot-assisted Partial Nephrectomy to Radical Nephrectomy: A Prospective Multi-institutional Study.

OBJECTIVE: To assess the incidence and factors affecting conversion from robot-assisted partial nephrectomy (RAPN) to radical nephrectomy. METHODS: Between November 2014 and February 2017, 501 patients underwent attempted RAPN by 22 surgeons at 14 centers in 9 countries within the Vattikuti Collaborative Quality Initiative database. Patients were permanently logged for RAPN prior to surgery and were analyzed on an intention-to-treat basis. Multivariable logistic regression with backward stepwise selection of variables was done to assess the factors associated with conversion to radical nephrectomy. RESULTS: Overall conversion rate was 25 of 501 (5%). Patients converted to radical nephrectomy were older (median age [interquartile range] 66.0 [61.0-74.0] vs 59.0 [50.0-68.0], P = .012), had higher body mass index (BMI) (median 32.8 [24.9-40.9] vs 27.8 [24.6-31.5] kg/m2, P = .031), higher age-adjusted Charlson comorbidity score (median 6.0 [4.0-7.0] vs 4.0 [3.0-5.0], P <.001), higher American Society of Anesthesiologists score (score ≥3; 13/25 (52.0%) vs 130/476 (27.3%), P = .021), Preoperative estimated glomerular filtration rate (P = .141), clinical tumor stage (P = .145), tumor location (P = .140), multifocality (P = .483), and RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, and anterior/posterior location relative to polar lines) nephrometry score (P = .125) were not significantly different between the groups. On multivariable analysis, independent predictors for conversion were BMI (odds ratio [95% confidence interval]; 1.070 [1.018-1.124]; P = .007) and Charlson score (odds ratio [95% confidence interval]; 1.459 [1.179-1.806]; P = .001). CONCLUSION: RAPN was associated with a low rate of conversion. Independent predictors of conversion were BMI and Charlson score. Tumor factors such as clinical stage, location, multifocality, or RENAL score were not associated with increased risk of conversion.

'Trifecta' outcomes of robot-assisted partial nephrectomy in solitary kidney: a Vattikuti Collective Quality Initiative (VCQI) database analysis.

OBJECTIVES: To analyse the outcomes of robot-assisted partial nephrectomy (RAPN) in patients with a solitary kidney in a large multi-institutional database. PATIENTS AND METHODS: In all, 2755 patients in the Vattikuti Collective Quality Initiative database underwent RAPN by 22 surgeons at 14 centres in nine countries. Of these patients, 74 underwent RAPN with a solitary kidney between 2007 and 2016. We retrospectively analysed the functional and oncological outcomes of these 74 patients. A 'trifecta' of outcomes was assessed, with trifecta defined as a warm ischaemia time (WIT) of <20 min, negative surgical margins, and no complications intraoperatively or within 3 months of RAPN. RESULTS: All 74 patients underwent RAPN successfully with one conversion to radical nephrectomy. The median (interquartile range [IQR]) operative time was 180 (142-230) min. Early unclamping was used in 11 (14.9%) patients and zero ischaemia was used in 12 (16.2%). Trifecta outcomes were achieved in 38 of 66 patients (57.6%). The median (IQR) WIT was 15.5 (8.75-20.0) min for the entire cohort. The overall complication rate was 24.1% and the rate of Clavien-Dindo grade ≤II complications was 16.3%. Positive surgical margins were present in four cases (5.4%). The median (IQR) follow-up was 10.5 (2.12-24.0) months. The median drop in estimated glomerular filtration rate at 3 months was 7.0 mL/min/1.72 m2 (11.01%). CONCLUSION: Our findings suggest that RAPN is a safe and effective treatment option for select renal tumours in solitary kidneys in terms of a trifecta of negative surgical margins, WIT of <20 min, and low operative and perioperative morbidity.

Use of Main Renal Artery Clamping Predominates Over Minimal Clamping Techniques During Robotic Partial Nephrectomy for Complex Tumors.

INTRODUCTION: Hilar clamping is often performed to facilitate robotic partial nephrectomy (RPN). Minimal clamping techniques may reduce renal ischemia, including early unclamping, selective clamping, and off-clamp RPN. We assess the utilization of clamping techniques in a large international consortium of surgeons performing RPN for complex tumors. METHODS: We retrospectively evaluated 721 patients with complex tumors, who underwent RPN at 11 centers worldwide between 2008 and 2014. Complex tumors were defined as renal masses with a nephrometry score >6. Total clamping was defined as complete clamping of the main renal artery. Minimal clamping techniques included early unclamping, selective clamping, and off-clamp RPN. Clamping techniques were additionally assessed in patients with estimated glomerular filtration rate (eGFR) <60 and in patients with a solitary kidney. Two-tailed t-tests (p < 0.05) were used to statistically analyze differences in mean warm ischemia time (WIT). RESULTS: Most patients underwent complete clamping (75.1%). Minimal clamping (24.9%) included early unclamping (10.8%), selective clamping (8.7%), and off-clamp (5.4%). Mean WIT of total clamping, selective clamping, and early unclamping was 22.2, 21.2, and 17.3 minutes, respectively. Of patients with an eGFR <60 (n = 90), 26.6% underwent minimal clamping, including 15.5% early unclamping, 4.4% selective clamping, and 6.7% off-clamp. Of patients with solitary kidneys (n = 12), 10 (83%) were performed with total clamping with mean WIT of 14.9 minutes. CONCLUSIONS: In this large international series of RPN for complex tumors, most patients underwent total clamping of the main renal artery. Minimal clamping techniques, including early unclamping, selective clamping, and off-clamp techniques, were used in a minority of cases. There was no significant increase in use of minimal clamping, even in patients with chronic kidney disease or solitary kidneys. However, mean WIT was low (<23 minutes) in all patient groups.

PADUA and R.E.N.A.L. nephrometry scores correlate with perioperative outcomes of robot-assisted partial nephrectomy: analysis of the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database.

OBJECTIVES: To evaluate and compare the correlations between Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) and R.E.N.A.L. [Radius (tumour size as maximal diameter), Exophytic/endophytic properties of the tumour, Nearness of tumour deepest portion to the collecting system or sinus, Anterior (a)/posterior (p) descriptor and the Location relative to the polar line] nephrometry scores and perioperative outcomes and postoperative complications in a multicentre, international series of patients undergoing robot-assisted partial nephrectomy (RAPN) for masses suspicious for renal cell carcinoma (RCC). PATIENTS AND METHODS: We retrospectively evaluated the clinical records of patients who underwent RAPN between 2010 and 2013 for clinical N0M0 renal tumours in four international centres that completed all the data required for the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database. All patients underwent preoperative computed tomography or magnetic resonance imaging to define the clinical stage and anatomical characteristics of the tumours. PADUA and R.E.N.A.L. scores were retrospectively assessed in each centre. Univariate and multivariate analyses were used to evaluate the correlations between age, gender, Charlson comorbidity index, clinical tumour size, PADUA and R.E.N.A.L. complexity group categories and warm ischaemia time (WIT) of >20 min, urinary calyceal system closure, and grade of postoperative complications. RESULTS: Overall, 277 patients were evaluated. The median (interquartile range) tumour size was 33.0 (22.0-43.0) mm. The median PADUA and R.E.N.A.L. scores were eight and seven, respectively; 112 (40.4%), 86 (31.0%) and 79 (28.5%) patients were classified in the low-, intermediate- or high-complexity group according to PADUA score, while 118 (42.5%), 139 (50.1%) and 20 (7.2%) were classified in the low-, intermediate- or high-complexity group according to R.E.N.A.L. score, respectively. Both nephrometry tools significantly correlated with perioperative outcomes at univariate and multivariate analyses. CONCLUSION: A precise stratification of patients before PN is recommended to consider both the potential threats and benefits of nephron-sparing surgery. In our present analysis, both PADUA and R.E.N.A.L. were significantly associated with predicting prolonged WIT and high-grade postoperative complications after RAPN.

Updates of prostate cancer staging: Prostate-specific membrane antigen.

The ability to accurately stage prostate cancer in both the primary and secondary staging setting can have a major impact on management. Until recently radiological staging has relied on computer tomography, magnetic resonance imaging, and nuclear bone scans to evaluate the extent of disease. However, the utility of these imaging technologies has been limited by their sensitivity and specificity especially in detecting early recurrence. Functional imaging using positron-emission tomography with a radiolabeled ligand targeted to prostate-specific membrane antigen has transformed the prostate cancer imaging landscape. Initial results suggest that it is a substantial improvement over conventional imaging in the setting of recurrence following primary therapy by having a superior ability to detect disease and to do so at an earlier stage. Additionally, it appears that the benefits seen in the secondary staging setting may also exist in the primary staging setting.

The Australian laparoscopic non robotic radical prostatectomy experience - analysis of 2943 cases (USANZ supplement).

OBJECTIVES: To analyse the Australian experience of high-volume Fellowship-trained Laparoscopic Radical Prostatectomy (LRP) surgeons. MATERIALS AND METHODS: 2943 LRP cases were performed by nine Australian surgeons. The inclusion criteria were a prospectively collected database with a minimum of 100 consecutive LRP cases. The surgeons' LRP experience commenced at various times from July 2003 to September 2009. Data were analysed for demographic, peri-operative, oncological and functional outcomes. RESULTS: The mean age of patients were 61.5 years and mean preoperative PSA 7.4 ng/ml. Mean operating time was 168 minutes with conversion to open surgery in 0.5% and a blood transfusion rate of 1.1%. Overall mean length of stay was 2.5 days. 73.6% of pathological specimens were pT2 and 86.3% had Gleason Score >7. Overall positive surgical margins (PSM) occurred in 15.9% with pT2 PSM 9.8%, pT3a PSM 30.8% and pT3b PSM 39.2%. Mean urinary continence at 12 months was 91.4% (data available from five surgeons). Mean 12 months potency after bilateral nerve spare was 47.2% (data available from four surgeons). Biochemical recurrence occurred in 10.6% (mean follow up 17 months). CONCLUSION: The Australian experience of Fellowship trained surgeons performing LRP demonstrates favourable peri-operative, oncological and functional outcomes in comparison to published data for open, laparoscopic and robotic assisted radical prostatectomy. In our Australian centres, LRP remains an acceptable minimally invasive surgical treatment for prostate cancer despite the increasing use of robotic assisted surgery.

Developing and evaluating Robocare; an innovative, nurse-led robotic prostatectomy care pathway.

PURPOSE: A Robotic Prostatectomy Care Pathway ("Robocare"), aiming to prepare men for robotic-assisted radical prostatectomy (RARP) and manage side-effects and long-term follow-up in a multidisciplinary fashion was established. The pathway enhances patient care by providing adequate information and support and optimizes efficiency by reducing length of stay and minimizing hospital visits. Our study assesses the pathway for patient satisfaction, co-ordination of care between disciplines, length of stay and readmission rates. METHOD: We analysed our database of all patients undergoing RARP with Robocare between July 2012 and December 2013 at Peter MacCallum Cancer Centre, Australia (PMCC). Compliance, Length of Stay and Postoperative Course were analysed. Patient satisfaction was assessed. RESULTS: Overall 124 patients underwent RARP with 105 (85%) being discharged day 1 post-op (mean 1.3 days). Post-operative support phone calls were received by >95% of patients. Thereafter, 74 patients (60%) were followed in the long-term follow-up phone clinic. Twenty-nine complications were identified of which 19 (66%) were resolved by the nurse specialist. Eighteen patients had psychologist, 44 sexual health and 44 physiotherapist referral. Patient satisfaction in 74 (60%) returned surveys revealed 71 (96%) being well/very well supported. CONCLUSIONS: The Robocare pathway is safe with high patient satisfaction. It contributes to reducing post-operative length of stay and readmission rates as well as the outpatient follow-up. A true multidisciplinary approach that is nurse-led likely improves care and outcomes for RARP patients and may lower impact on hospital resources.

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.

Robot-assisted partial nephrectomy in cystic tumours: analysis of the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database.

OBJECTIVE: To evaluate the outcomes of robot-assisted partial nephrectomy (RAPN) in cystic tumours, analysing a large, multi-institutional, retrospective series of RAPN, as limited data are available about the outcome of RAPN in cystic tumours. PATIENTS AND METHODS: We evaluated 465 patients who received RAPN for either cystic or solid tumours from 2010 to 2013 and included in the multi-institutional, retrospective Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database. Univariable and multivariable linear and logistic regression models addressed the association of cystic tumours with perioperative outcomes. RESULTS: In all, 54 (12%) tumours were cystic. Cystic tumours were associated with significantly lower operative time (t -3.9; P < 0.001), once adjusted for the effect of covariates, whereas blood loss and warm ischaemia time were similar. Postoperative any grade complications were recorded in 66 solid (16%) and nine cystic (17%) tumours (P = 0.08). In multivariable analysis, cystic tumours were not associated with a significantly lower risk of any grade postoperative complications [odds ratio (OR) 0.9; P = 0.8]. Similarly, presence of tumours with cystic features was not associated with a significantly different risk of high-grade postoperative complications (OR 2.2; P = 0.1). Prevalence of cancer histology and positive surgical margin rates were similar in cystic and solid tumours. Cystic tumours were not associated with significantly different postoperative estimated glomerular filtration rate (t 0.4; P = 0.7), once adjusted for the effect of covariates. CONCLUSIONS: RAPN can be performed in cystic renal tumours with perioperative, pathological, and functional outcomes similar to those achievable in solid tumours.

Sepsis and 'superbugs': should we favour the transperineal over the transrectal approach for prostate biopsy?

OBJECTIVE: To determine the rate of hospital re-admission for sepsis after transperineal (TP) biopsy using both local data and worldwide literature, as there is growing interest in TP biopsy as an alternative to transrectal ultrasonography (TRUS)-guided biopsy for patients undergoing repeat prostate biopsy. PATIENTS AND METHODS: Pooled prospective databases on TP biopsy from multiple centres in Melbourne were queried for rates of re-admission for infection. A literature review of PubMed and Embase was also conducted using the search terms: 'prostate biopsy, fever, infection, sepsis, septicaemia and complications'. RESULTS: In all, 245 TP biopsies were performed (111 at Alfred Health, 92 at Epworth Healthcare, 38 at Peter MacCallum Cancer Centre, and four at other institutions). The rate of hospital re-admission for infection was zero. The literature review showed that the rate of sepsis after TRUS biopsy appears to be rising with increasing rates of multi-resistant bacteria found in rectal flora, and is as high as 5%. However, the rate of sepsis from published series of TP biopsy approached zero. CONCLUSIONS: Both local and international data suggest a negligible rate of sepsis with TP biopsy. This compares to a concerning rise in the rate of sepsis after TRUS biopsy due to the increasing prevalence of multi-resistant bacteria in rectal flora. Although TRUS biopsy is convenient, cheap and quick to perform, we think that TP biopsy should now be offered as an option, not only to patients undergoing repeat prostate biopsy, but to all patients in whom a prostate biopsy is indicated.

Outcomes of artificial urinary sphincter implantation in the irradiated patient.

OBJECTIVES: To present the outcomes of men undergoing artificial urinary sphincter (AUS) implantation. To determine the impact a history of radiation therapy has on the outcomes of prosthetic surgery for stress urinary incontinence. PATIENTS AND METHODS: A cohort of 77 consecutive men undergoing AUS implantation for stress urinary incontinence after prostate cancer surgery, including 29 who had also been irradiated, were included in a prospective database and followed up for a mean period of 21.2 months. Continence rates and incidence of complications, revision and cuff erosion were evaluated, with results in irradiated men compared with those of men who had undergone radical prostatectomy alone. The effect of co-existing hypertension, diabetes mellitus and surgical approach on outcomes were also examined. RESULTS: Overall, the rate of social continence (0-1 pad/day) was 87% and similar in irradiated and non-irradiated men (86.2 vs 87.5%). Likewise, the incidence of infection (3.4 vs 0%), erosion (3.4 vs 2.0%) and revision surgery (10.3 vs 12.5%) were not significantly different between the groups. There was a far greater incidence of co-existing urethral stricture disease in irradiated patients (62.1 vs 10.4%) which often complicated management; however, AUS implantation was still feasible in these men and, in four such cases, a transcorporal cuff placement was used. There were poorer outcomes in patients with diabetes, and a greater re-operation rate in those men who underwent a transverse scrotal rather than perineal surgical approach, although the differences did not reach statistical significance. CONCLUSIONS: Previous irradiation in patients may increase the complexity of treatment because of a greater incidence of co-existing urethral stricture disease; however, these patients are still able to achieve a level of social continence similar to that of non-irradiated patients, with no discernable increase in complication rates, cuff erosion or the need for revision surgery. AUS implantation remains the 'gold standard' for management of moderate-to-severe stress urinary incontinence in both irradiated and non-irradiated patients after prostate cancer treatment.

Laparoscopic pyeloplasty outcomes of elderly patients.

BACKGROUND AND PURPOSE: Laparoscopic pyeloplasty (LP) has been described as the new gold standard operation for patients with ureteropelvic junction obstruction (UPJO). As life expectancy continues to increase, we will be faced with the need to counsel older patients on the risks and benefits of undergoing surgery. It is clear that laparoscopic renal surgery has significant benefits over open renal surgery. Avoidance of open surgery would seem particularly beneficial in elderly patients who receive a diagnosis of this condition, although results in this group have not been formally studied. We compared the perioperative and medium-term outcomes of LP for primary UPJO in patients who are 70 years and older with those who are under age 70. PATIENTS AND METHODS: Between January 2006 and June 2009, 74 consecutive patients underwent LP for UPJO performed by one surgeon. A four-port extraperitoneal approach was used in all but one case. Patient demographic and perioperative data were recorded prospectively. Outcome measures were success rate at a median follow-up of 12 months, complications, and length of hospital stay. RESULTS: Fifteen (20%) patients were aged 70 years or older. Older patients had a higher median American Society of Anesthesiologists score (2 vs 1). Moreover, older patients often presented with compromised renal function than their younger counterparts (median split renal function on the affected kidney 35% vs 45%, serum creatinine level 130 vs 90 µmol/L, P < 0.001). The success rate in the older group was 87%, with no treatment failures in the younger patients. Median hospital stay was longer for older patients (3 days vs 2 days, P = 0.01). Frequency of complications were not significantly different between the groups; however, there was a postoperative death in an elderly patient with a solitary kidney and preoperative renal failure. CONCLUSIONS: LP is feasible with generally good results for managing UPJO in patients 70 years or older. Older patients, however, are likely to need a longer hospital stay compared with their younger counterparts, and their co-morbidities should be carefully assessed preoperatively to minimize morbidity. Advanced chronologic age should not be a contraindication for LP in patients with symptomatic UPJO.