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.

Long-term durability of laparoscopic decortication of symptomatic renal cysts.

OBJECTIVES: To assess the long-term results of patient symptoms and radiologic outcomes of laparoscopic renal cyst decortication in the treatment of symptomatic simple renal cysts. Renal cysts are common in the adult population. Symptomatic renal cysts have traditionally been treated by percutaneous aspiration with or without injection of sclerosant agents; however, this has a high rate of recurrence. METHODS: From April 1994 through July 2005, 45 patients underwent laparoscopic decortication of symptomatic simple renal cysts with renal cyst wall excision and fulguration of the epithelial lining. Complex renal cysts were excluded. Of the 45 patients, 24 (53.3%) had undergone previous cyst aspiration with injection of sclerosant material for intended ablation. The Wong-Baker pain scale was used to assess the preoperative and postoperative pain scores. Radiologic success was indicated as no recurrence on the most recent computed tomography scan. RESULTS: Of the 45 procedures, 44 were completed laparoscopically. One patient (1.8%) underwent open conversion because of excessive bleeding. The mean operative time was 89 minutes (range 48 to 170). Symptomatic success was achieved in 91.1% of patients, with a median follow-up of 52 months (range 3 to 132), and radiographic success was achieved in 95.5% of patients, with a median follow-up of 39 months (range 3 to 96). CONCLUSIONS: Long-term follow-up has confirmed that laparoscopic cyst decortication is an effective and durable treatment option for symptomatic simple renal cysts during long-term follow-up. The greater and durable success rates of this minimally invasive technique may favor this treatment option over other treatment modalities.

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.

Positive surgical margins in robotic-assisted radical prostatectomy: impact of learning curve on oncologic outcomes.

OBJECTIVE: The presence of positive surgical margins following radical prostatectomy is a known risk factor for disease recurrence and may lead to adjuvant treatment. Our goal was to assess the incidence of positive surgical margins in our series of robotic-assisted radical prostatectomy (RARP) and its relationship to our learning curve. METHODS: Between February 2003 and August 2005, 140 patients underwent RARP by the same surgical team at our institution. The records of our first 100 consecutive RARPs were retrospectively reviewed. The patients were divided into three groups based on the time of surgery: group I included the first 33 cases; group II included the second 33 cases; and group III comprised the last 34 cases. We compared the incidence and location of positive surgical margins among the groups. Additional variables evaluated included the patient's prostate-specific antigen (PSA) level, preoperative/postoperative Gleason score, clinical/pathologic stage, and pathologic tumour volume. RESULTS: The positive margin rates were 45.4%, 21.2%, and 11.7% for groups I, II, and III, respectively. The difference in positive margin rates in the three groups was statistically significant (p=0.0053). Positive margin rates declined specifically at the apex and bladder neck when comparing the first 33 patients to the last 34 patients. Patient demographics and preoperative staging variables were comparable among all three groups, with no statistically significant differences among them. CONCLUSIONS: This study illustrates that experience gained with time led to a decrease in the incidence of positive surgical margins. We do not feel that a selection bias affected our results because clinical and pathologic staging was evenly distributed within the three study groups. A steady reduction in positive surgical margin rates demonstrates a learning curve, of approximately 30 patients, associated with RARP, and suggests that oncologic outcome is affected by the experience of the robotic surgeon.

Role of robotics in the management of secondary ureteropelvic junction obstruction.

Patients with recurrent ureteropelvic junction obstruction (UPJO) present a treatment dilemma to urologists. Second-line therapies have previously been shown to fail at a higher rate than the initial therapeutic procedure. We report our experience with robotic-assisted, dismembered pyeloplasty in patients with secondary UPJO. Since November 2002, 44 robotic-assisted laparoscopic pyeloplasties (RALPs) have been performed at our institution. Of these, seven patients had undergone previous definitive treatment for UPJO. Anderson-Hynes-dismembered pyeloplasty was the preferred reconstructive technique in all patients. The patients were divided into two groups: primary pyeloplasty patients (group 1) and secondary pyeloplasty patients (group 2). Variables examined include operative time, estimated blood loss (EBL), length of hospital stay (LOS) and success rates. All operations were completed laparoscopically, and there were no conversions to open surgery in either group. Mean operative time was 60 min longer in the secondary pyeloplasty group compared with primary cases, but the EBL, LOS and success rates were similar. A patent UPJ was confirmed in both groups by renal scan and/or excretory urography (intravenous pyelogram) examinations. RALP is a viable option in select patients with recurrent UPJO after previous endoscopic or open surgical repair. As expected, operative times were longer in these patients due to a more challenging dissection (p < 0.05). However, the magnification afforded by the robot allows for a precise dissection, and subsequently, there was no significant increase in blood loss, hospital stay or perioperative morbidity in our series (p > 0.05).

Concomitant management of renal calculi and pelvi-ureteric junction obstruction with robotic laparoscopic surgery.

OBJECTIVE: To present technical recommendations for robotic-assisted laparoscopic pyeloplasty (RALP) and stone extraction, as patients with kidney stones proximal to a pelvi-ureteric junction obstruction (PUJO) present a technical challenge, and have traditionally been managed with open surgery or percutaneous antegrade endopyelotomy. PATIENTS AND METHODS: From November 2002 to April 2005, 55 patients had RALP for PUJO; eight of these had concomitant renal calculi. Stone burden and location were assessed with a preoperative radiological examination. Before completing the PUJO repair, one robot working arm (cephalad one) was temporarily undocked to allow passage of a flexible nephroscope into the renal pelvis and collecting systems under direct vision. Stones were extracted with graspers or basket catheters and removed via the port. The surgical-assistant port in the subxiphoid area was used to introduce laparoscopic suction and other instruments. RESULTS: The Anderson-Hynes dismembered pyeloplasty was the preferred reconstructive technique in all patients. Operations were completed robotically with no conversions to open surgery. All patients were rendered stone-free, confirmed by imaging, and there were no intraoperative or delayed complications during a mean (range) follow-up of 12.3 (4-22) months. The mean operative time was 275.8 min, 61.7 min longer than in patients who did not have concomitant stone removal. CONCLUSIONS: Concurrent stone extraction and PUJO repair can be successful with RALP. Operative times are longer than in patients with isolated PUJO repair, but this is to be expected as there is an additional procedure.

Multi-institutional validation study of neural networks to predict duration of stay after laparoscopic radical/simple or partial nephrectomy.

PURPOSE: We developed models to predict post-laparoscopic radical or simple nephrectomy (LapNx) and post-laparoscopic partial nephrectomy (LapPNx) hospital duration of stay (DOS). MATERIALS AND METHODS: We performed a retrospective review (design group) of all 726 patients (July 1997 to April 2004) who underwent LapNx or LapPNx at the Cleveland Clinic Foundation (CCF). Preoperative findings were recorded. Neural network algorithms were designed to predict the DOS before surgery. The models were then tested on a separate 252 patients from 6 different institutions, namely Tulane University Medical School, University of Arkansas for Medical Sciences, Cedars-Sinai Medical Center, University of Iowa, Mayo Clinic at Scottsdale and CCF. RESULTS: In the CCF design groups, the LapNx model accuracy was 73% to 74% and the LapPNx model 73% to 83%. Overall accuracy in the test groups at all 6 institutions was 72% (area under ROC 0.6 to 0.7) for the LapNx model and 52% to 81% (ROC 0.5 to 0.7) for the LapPNx model. CONCLUSIONS: The LapNx model provides 72% accuracy in predicting the DOS at all 6 institutions. The LapPNx model provided fair accuracy only at CCF and Tulane University Medical School. These models may streamline the delivery of care and continued testing will allow for further refinement.

Robotic assisted laparoscopic pyeloplasty in children.

PURPOSE: Historically, open pyeloplasty has been the gold standard of treatment for ureteropelvic junction obstruction in the pediatric age group. The prospect of using technology such as the robot in this age group has been a concern. Several non-urological robotic procedures have been performed in children. We undertook a retrospective study to evaluate the feasibility and outcomes of robotic assisted laparoscopic pyeloplasty in the pediatric population. MATERIALS AND METHODS: Seven patients 6 to 15 years old underwent robotic assisted laparoscopic pyeloplasty at our institution between June 2003 and November 2004. All patients underwent dismembered pyeloplasty (Anderson-Hynes). Variables analyzed included length of stay, estimated blood loss, operative time, anastomosis time and docked robotic time. RESULTS: Mean followup was 10.9 months (range 2 to 18). Mean length of stay was 1.2 days (range 1 to 3). Mean operative time was 184 minutes (range 165 to 204), with a mean robotic anastomosis time of 39.5 minutes (30 to 46). Mean estimated blood loss was 31.4 ml (range 10 to 50). Stent size varied from 3.8Fr to 6Fr. Six of the 7 patients have had followup studies demonstrating improved drainage, symptom resolution and no evidence of obstruction on diuretic renal scans or excretory urogram. The remaining patient is awaiting 3-month followup evaluation. CONCLUSIONS: Robotic assisted pyeloplasty can be safely performed in the pediatric population. The precision in dissection, incision and suturing allows for comparable results to open pyeloplasty in this age group.

Small bowel motility and transit after aortic surgery.

OBJECTIVE: The inability to tolerate feedings after aortic surgery prolongs hospitalization. The aim of this study was to define jejunal manometric and small bowel transit characteristics associated with the ileus that follows transperitoneal aortic surgery. METHODS: Five male patients who underwent transperitoneal infrarenal aortobifemoral bypass had intraoperative placement of a jejunal multilumen catheter. The open abdomen allowed precise placement of pressure recording ports at 20, 22, 24, 26, 28, and 38 cm past the ligament of Treitz. Three-hour manometric studies were done after surgery and for 3 postoperative days. The migrating motor complex was identified visually on the manometric tracings, and pressure waves were identified with computer and a motility index calculated. Motility data were compared with healthy control data previously reported in the literature. Small bowel transit was determined with barium and serial abdominal radiographs. RESULTS: All patients had ileus develop with return of bowel sounds at 2 to 7 days (median, 6 days) and flatus at 3 to 9 days (median, 7 days) after surgery. Jejunal motor activity was present within 6 hours of surgery, but the motility index was less in patients then in control subjects. The postoperative migrating motor complexes differed from control subjects in having more phase I, less phase II, and more frequent phase IIIs. Phase III retrograde migration was common in the patients but not in the control subjects. Small bowel transit was 2 days or greater in all patients. CONCLUSION: Motor activity is present in the jejunum shortly after aortic surgery. However, the activity is decreased in intensity and the fasting cycle differs from control subjects. Retrograde migration of phase III is the most likely abnormality, resulting in delayed small bowel transit. The data would predict a high rate of enteral feeding intolerance early after surgery. Future studies should focus on pharmacologic manipulation to rapidly return small bowel motility to a more normal state after aortic surgery.