Disposable Equipment Research Articles

1226 PERIOPERATIVE COST COMPARISON OF ROBOTIC AND OPEN RADICAL CYSTECTOMY FOR BLADDER CANCER

You have accessJournal of UrologyTechnology & Instruments: Robotics - Malignant Disease & Benign Disease I1 Apr 20121226 PERIOPERATIVE COST COMPARISON OF ROBOTIC AND OPEN RADICAL CYSTECTOMY FOR BLADDER CANCER Stephen F. Kappa, Todd M. Morgan, R. Lawrence Van Horn, Sam S. Chang, Peter E. Clark, Michael S. Cookson, Rodney Davis, David F. Penson, Joseph A. Smith, Chaochen You, and Daniel A. Barocas Stephen F. KappaStephen F. Kappa Nashville, TN More articles by this author , Todd M. MorganTodd M. Morgan Nashville, TN More articles by this author , R. Lawrence Van HornR. Lawrence Van Horn Nashville, TN More articles by this author , Sam S. ChangSam S. Chang Nashville, TN More articles by this author , Peter E. ClarkPeter E. Clark Nashville, TN More articles by this author , Michael S. CooksonMichael S. Cookson Nashville, TN More articles by this author , Rodney DavisRodney Davis Nashville, TN More articles by this author , David F. PensonDavid F. Penson Nashville, TN More articles by this author , Joseph A. SmithJoseph A. Smith Nashville, TN More articles by this author , Chaochen YouChaochen You Nashville, TN More articles by this author , and Daniel A. BarocasDaniel A. Barocas Nashville, TN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1516AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Previous studies have reached conflicting conclusions comparing the costs of robotic-assisted radical cystectomy (RRC) versus open radical cystectomy (ORC) for bladder cancer. Beyond the fixed cost and maintenance fee associated with the robot itself, we sought to determine if there were operative, postoperative, or total perioperative cost differences between the robotic and open approaches. METHODS Using a hospital billing database at a single tertiary care center, we compared the costs associated with RRC versus ORC for bladder cancer patients from December 2007 to May 2011. Demographics, clinical characteristics, and postoperative complications were compared between groups. Operative, postoperative, and total perioperative costs were calculated for each group and converted to percentage differences given the proprietary nature of internal billing data. RESULTS Eighty-six (86) patients underwent RRC while 319 underwent ORC. Preoperatively, RRC patients were disproportionately male (p<0.001), had a significantly lower mean body mass index (p=0.005), and had less severe disease (clinical stage T2 or higher) (p=0.036) compared to ORC patients. There were no significant differences in comorbidities (p=0.22). ORC was associated with 13.4% lower perioperative costs compared to RRC (p<0.001). Within the perioperative period, open surgery was associated with 20.4% lower operative costs (p<0.001), but robotic surgery was associated with 21.6% lower postoperative-90 day costs (p<0.001). CONCLUSIONS RRC is associated with significantly higher total perioperative costs than ORC. This difference largely reflects the increased variable costs associated with robotic surgery, such as longer operative time and greater disposable equipment use. However, the 90-day postoperative period for robotic surgery is associated with lower costs compared to open surgery, reflecting lower downstream utilization of healthcare resources, such as emergency care. This study does not account for the selection bias of healthier patients with less severe disease for robotic surgery, nor the potential advantages associated with minimally-invasive surgery, such as more rapid return to baseline functional status. Nevertheless, this study suggests that costs for RRC significantly exceed those of ORC for bladder cancer, although postoperative cost savings related to robotic surgery do exist. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e496 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stephen F. Kappa Nashville, TN More articles by this author Todd M. Morgan Nashville, TN More articles by this author R. Lawrence Van Horn Nashville, TN More articles by this author Sam S. Chang Nashville, TN More articles by this author Peter E. Clark Nashville, TN More articles by this author Michael S. Cookson Nashville, TN More articles by this author Rodney Davis Nashville, TN More articles by this author David F. Penson Nashville, TN More articles by this author Joseph A. Smith Nashville, TN More articles by this author Chaochen You Nashville, TN More articles by this author Daniel A. Barocas Nashville, TN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparing the Estimated and Actual Cost of Disposable Surgical Equipment

In the current financial climate the NHS faces budget cuts. A good knowledge of the costs of the equipment used in theatres will allow more cost-efficient allocation of resources. The equipment used is dependent on the consultant surgeon leading the operation, with individual surgeons having their own preferences. For the efficient running of a department one would assume that the surgeons would have a working knowledge of the cost of equipment. This study looked at the awareness of surgeons of the cost of disposable equipment. It aimed to highlight the difference between the estimated and actual cost of disposable items, providing feedback to the surgeons so they become more aware of the real cost of their choices in order to help optimise use of equipment. This will hopefully lead to more cost-effective theatres.

A cost analysis of reusable and disposable flexible optical scopes for intubation

Intubation using a flexible optical scope (FOS) is a cornerstone technique for managing the predicted and unpredicted difficult airway. The term FOS covers both fibre-optic scopes and videoscopes. The total costs of using flexible scopes for intubation are unknown. The recent introduction of a disposable flexible scope for intubation merits closer scrutiny of the total costs associated with both modalities. The costs incurred during intubations using FOSs at a large anaesthesia department were identified, and a series of intubations using a disposable scope were analyzed for comparison. Recognized health-economic methodology was applied. During a 1-year period, 360 FOS intubations were performed. In this clinical setting, the average cost of an intubation using a reusable FOS was €177.7. When using the disposable Ambu(®) aScope (Ambu A/S, Ballerup, Denmark), the cost was €204.4. The break-even point, i.e. the number of intubations per month where the cost of using disposable and non-disposable equipment is identical, was 22.5/month. A subgroup analysis looking solely at intubations performed with flexible videoscopes revealed that the cost per intubation was equal for disposable and reusable videoscopes. At our institution, the total cost of an intubation is greater when using disposable compared with reusable equipment (€204.4 vs. €177.7). If video equipment with an external monitor is considered mandatory, the expenses are of equal magnitude. The cost analysis is particularly sensitive to the actual number of flexible optic intubations performed; with fewer intubations, the total cost will begin to favour disposable equipment.

Predicting restoration of kidney function during CRRT-free intervals

BackgroundRenal failure is common in critically ill patients and frequently requires continuous renal replacement therapy (CRRT). CRRT is discontinued at regular intervals for routine changes of the disposable equipment or for replacing clogged filter membrane assemblies. The present study was conducted to determine if the necessity to continue CRRT could be predicted during the CRRT-free period.Materials and methodsIn the period from 2003 to 2006, 605 patients were treated with CRRT in our ICU. A total of 222 patients with 448 CRRT-free intervals had complete data sets and were used for analysis. Of the total CRRT-free periods, 225 served as an evaluation group. Twenty-nine parameters with an assumed influence on kidney function were analyzed with regard to their potential to predict the restoration of kidney function during the CRRT-free interval. Using univariate analysis and logistic regression, a prospective index was developed and validated in the remaining 223 CRRT-free periods to establish its prognostic strength.ResultsOnly three parameters showed an independent influence on the restoration of kidney function during CRRT-free intervals: the number of previous CRRT cycles (medians in the two outcome groups: 1 vs. 2), the "Sequential Organ Failure Assessment"-score (means in the two outcome groups: 8.3 vs. 9.2) and urinary output after the cessation of CRRT (medians in two outcome groups: 66 ml/h vs. 10 ml/h). The prognostic index, which was calculated from these three variables, showed a satisfactory potential to predict the kidney function during the CRRT-free intervals; Receiver operating characteristic (ROC) analysis revealed an area under the curve of 0.798.ConclusionRestoration of kidney function during CRRT-free periods can be predicted with an index calculated from three variables. Prospective trials in other hospitals must clarify whether our results are generally transferable to other patient populations.

Anesthetic equipment, facilities and services available for pediatric anesthesia in Nigeria

Facilities and equipment are known to contribute to improved patient care and outcome. Hospitals for sub-specialized pediatric anesthetic service are routinely available worldwide. In Nigeria, such hospitals now exist. It is therefore relevant to study the facilities and equipment available for pediatric anesthetic service to measure the quality of care in a health institution. A prospective study of the anesthetic equipment, facilities and services available for pediatric anesthesia was carried out in Nigerian hospitals using anonymously administered questionnaires from October, 2008 to October, 2009, after relevant ethics approval. Ten of the 30 hospitals studied had intensive care unit facilities (33.3%) and only three of them had organized ambulatory anesthesia units for pediatric patients (10%). Facilities available for pediatric anesthetic care were service delivery oriented and not information technology based (automated anesthesia information management services - AIMS). A quarter of the hospitals studied (7) had their facilities and equipment updated recently. Also, there were no reception rooms nor post anesthetic care units specifically designed for pediatric patients. Equipment for acute pain service such as infusion pumps and patient controlled analgesia pumps (PCA pumps) and for capnography were found in only two hospitals (6.6%) at the time of the study. The anesthetic equipment used did not conform to the same standards (98%) even in the same hospital. Also, the use of disposable anesthetic equipment was low. We conclude that anesthetic services for pediatric patients should be based on the use of automated anesthesia information technology service. Anesthetic equipment should conform to the same standards and should be computerized. Disposable anesthetic equipment should also be used where applicable to minimize the incidence of nosocomial infections. This would result in improved peri-operative care in pediatric patients.

Prevention of healthcare-associated infections in general practice: Current practice and drivers for change in a French study

Purpose: The fight against Healthcare-associated infections is a public health priority and a major challenge for the safety and quality of care. The objective was to assess hygiene in general practitioners’ (GPs’) office and identify barriers to and drivers for better practice. Materials and Methods: We performed a cross-sectional study in which a questionnaire was sent to a randomly selected, representative sample of 800 GPs. We used a self-administered questionnaire. The first part assessed current practice and the second part focused on barriers and motivating factors for better practice. We performed a descriptive statistical analysis of the responses to closed questions and a qualitative analysis of the responses to open-ended questions. Results: Only a third of the GPs were aware of the current guidelines. Disposable equipment was used by 31% of the GPs. For the remainder, only 38% complied with the recommended procedures for sterilisation or disinfection. Seventy-two percent of the GPs washed their hands between consultations in the office. A significant minority of physicians disregarded the guidelines by never wearing gloves to perform sutures (11%), treat wounds (10%), fit intrauterine devices (18%) or perform injections (18%). The main barriers to good practice were the high cost of modifications and lack of time/space. Two third of the GPs did not intend to change their practices. The drivers for change were pressure from patients (4.8 on a scale of 1 to 7), inspection by the health authorities (4.8) and the fear of legal action (4.4). Conclusions: Our results show that there are significant differences between current practice and laid-down professional guidelines. Policies for improvement of hygiene must take into account barriers and motivating factors..

Bacterial contamination of anesthesia machines' internal breathing-circuit-systems.

Background: Bacterial contamination of anesthesia breathing machines and their potential hazard for pulmonary infection and cross-infection among anesthetized patients has been an infection control issue since the 1950s. Disposable equipment and bacterial filters have been introduced to minimize this risk. However, the machines’ internal breathing-circuit-system has been considered to be free of micro-organisms without providing adequate data supporting this view. The aim of the study was to investigate if any micro-organisms can be yielded from used internal machines’ breathing-circuit-system. Based on such results objective reprocessing intervals could be defined.Methods: The internal parts of 40 anesthesia machines’ breathing-circuit-system were investigated. Chi-square test and logistic regression analysis were performed. An on-site process observation of the re-processing sequence was conducted.Results: Bacterial growth was found in 17 of 40 machines (43%). No significant difference was ascertained between the contamination and the processing intervals. The most common contaminants retrieved were coagulase negative Staphylococci, aerobe spore forming bacteria and Micrococcus species. In one breathing-circuit-system, Escherichia coli, and in one further Staphylococcus aureus were yielded.Conclusion: Considering the availability of bacterial filters installed on the outlet of the breathing-circuit-systems, the type of bacteria retrieved and the on-site process observation, we conclude that the contamination found is best explained by a lack of adherence to hygienic measures during and after re-processing of the internal breathing-circuit-system. These results support an extension of the re-processing interval of the anesthesia apparatus longer than the manufacturer’s recommendation of one week. However, the importance of adherence to standard hygienic measures during re-processing needs to be emphasized.

Cost Analysis of Abdominal, Laparoscopic, and Robotic-Assisted Myomectomies

Study Objective To perform a cost-minimization analysis of abdominal, traditional laparoscopic and robotic-assisted myomectomy. Design Cost analysis (Canadian Task Force Classification III). Setting Academic medical center. Patients Women undergoing myomectomy by various surgical approaches. Interventions We developed a decision model to compare the costs ($2009) of different approaches to myomectomy from a healthcare system perspective. The model included operative time, conversion risk, transfusion risk, and length of stay (LOS) for each modality. Baseline estimates and ranges were based on reported values extracted from existing literature. We analyzed two different models: #1) Existing Robot model and #2) Robot Purchase model. Measurements and Main Results In the baseline analysis for the Existing Robot model, abdominal myomectomy (AM) was the least expensive at $4937 compared with laparoscopic myomectomy (LM) at $6219 and robotic-assisted laparoscopic myomectomy (RM) at $7299. The abdominal route remained the least expensive when varying all parameters and costs except for two cases in which LM became least expensive: 1) If AM length of stay was greater than 4.6 days, and 2) If the surgeon’s fee for AM was greater than $2410. When comparing LM to RM, the cost of RM was consistently higher unless the robotic disposable equipment costs were less than $1400. In the Robot Purchase model, only the RM costs increased while AM and LM costs remained the same. Conclusion In this cost-minimization analysis, abdominal myomectomy is the least expensive approach when compared to laparoscopy and robotic-assisted laparoscopy.

Supplies and equipment for pediatric emergency mass critical care

Epidemics of acute respiratory disease, such as severe acute respiratory syndrome in 2003, and natural disasters, such as Hurricane Katrina in 2005, have prompted planning in hospitals that offer adult critical care to increase their capacity and equipment inventory for responding to a major demand surge. However, planning at a national, state, or local level to address the particular medical resource needs of children for mass critical care has yet to occur in any coordinated way. This paper presents the consensus opinion of the Task Force regarding supplies and equipment that would be required during a pediatric mass critical care crisis. In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. The Task Force endorsed the view that supplies and equipment must be available for a tripling of capacity above the usual peak pediatric intensive care unit capacity for at least 10 days. The recommended size-specific pediatric mass critical care equipment stockpile for two types of patients is presented in terms of equipment needs per ten mass critical care beds, which would serve 26 patients over a 10-day period. Specific recommendations are made regarding ventilator capacity, including the potential use of high-frequency oscillatory ventilation and extracorporeal membrane oxygenation. Other recommendations include inventories for disposable medical equipment, medications, and staffing levels.

Comparative cost-efficiency of the EVOTECH endoscope cleaner and reprocessor versus manual cleaning plus automated endoscope reprocessing in a real-world Canadian hospital endoscopy setting

BackgroundReprocessing of endoscopes generally requires labour-intensive manual cleaning followed by high-level disinfection in an automated endoscope reprocessor (AER). EVOTECH Endoscope Cleaner and Reprocessor (ECR) is approved for fully automated cleaning and disinfection whereas AERs require manual cleaning prior to the high-level disinfection procedure. The purpose of this economic evaluation was to determine the cost-efficiency of the ECR versus AER methods of endoscopy reprocessing in an actual practice setting.MethodsA time and motion study was conducted at a Canadian hospital to collect data on the personnel resources and consumable supplies costs associated with the use of EVOTECH ECR versus manual cleaning followed by AER with Medivators DSD-201. Reprocessing of all endoscopes was observed and timed for both reprocessor types over three days. Laboratory staff members were interviewed regarding the consumption and cost of all disposable supplies and equipment. Exact Wilcoxon rank sum test was used for assessing differences in total cycle reprocessing time.ResultsEndoscope reprocessing was significantly shorter with the ECR than with manual cleaning followed by AER. The differences in median time were 12.46 minutes per colonoscope (p < 0.0001), 6.31 minutes per gastroscope (p < 0.0001), and 5.66 minutes per bronchoscope (p = 0.0040). Almost 2 hours of direct labour time was saved daily with the ECR. The total per cycle cost of consumables and labour for maintenance was slightly higher for EVOTECH ECR versus manual cleaning followed by AER ($8.91 versus $8.31, respectively). Including the cost of direct labour time consumed in reprocessing scopes, the per cycle and annual costs of using the EVOTECH ECR was less than the cost of manual cleaning followed by AER disinfection ($11.50 versus $11.88).ConclusionsThe EVOTECH ECR was more efficient and less costly to use for the reprocessing of endoscopes than manual cleaning followed by AER disinfection. Although the cost of consumable supplies required to reprocess endoscopes with EVOTECH ECR was slightly higher, the value of the labour time saved with EVOTECH ECR more than offset the additional consumables cost. The increased efficiency with EVOTECH ECR could lead to even further cost-savings by shifting endoscopy laboratory personnel responsibilities but further study is required.

Questioning the Universality of Medical Ethics: Dilemmas Raised Performing Surgery around the Globe

Performing surgery in the developing world presents unique challenges and dilemmas for the visiting physician from an industrialized country. Language barriers, widespread, profound pathology, and lack of adequate facilities are obvious hurdles. more subtle problem, though every bit as significant, is that the principles and procedures we routinely utilize at home to uphold ethical standards of care and to aid us in decision-making are often poorly applicable in the developing world. Acknowledging that cultural factors play a primary role in every aspect of their interaction with patients, physicians must scrutinize and even modify the tools they employ when attempting to deliver ethical care in foreign environments. Over the past two decades, I have routinely taken time from clinical practice to teach, practice, and perform eye surgery in remote locations. I've enjoyed the privilege of vastly broadening both my professional skills and global perspective while working with some of the most devoted and selfless health care workers I've encountered in my career. From Mongolia to points along the ancient Silk Route, to the deep Himalayas, to Southeast Asia, to sub-Saharan Africa, many of the locations where I've worked lack basic facilities including potable water, reliable electricity, and proper sanitation. Nearly all lack what an ophthalmologist considers requisite for even the most basic intraocular surgery: adequate illumination and magnification. If available at all, the precise instrumentation necessary to manipulate tissue within the eye is usually worn or broken due to overuse and repeated repair. Cutting instruments are blunt; forcep tips no longer meet. Disposable equipment acquired through donation is meticulously cleaned and reused far beyond its intended lifespan, and medications are routinely expired or implicitly understood to be the best available. Surgical gloves and sutures are resterilized and used as long as possible. Dressings are ingeniously fashioned from material of every imaginable sort. Indeed, resourcefulness and ingenuity are the unique and necessary attributes of doctors and their staff throughout the developing world. I am always presented with highly advanced pathology when working abroad, due in part to a chronic shortage of trained medical personnel and resources. Whether their ailments are secondary to trauma or to neglected or indolent disease, indigent patients usually seek care only when there is no alternative. The numbers are shocking: According to the most recent World Health Organization estimates, approximately 87 percent of the 314 million visually impaired live in developing countries; roughly 45 million are completely blind. (1) About 85 percent of all visual impairment and 75 percent of blindness could be prevented or cured. (2) While procedures performed to save or restore sight do not directly save lives, they are nevertheless crucial to survival in subsistence-level societies. blind person often represents an untenable responsibility for both the family and the community. It is believed that 60 percent to 80 percent of children who become blind in the developing world die within two years. (3) Nepalese proverb conveys the economic reality most concisely: A blind person has a mouth but no hands. In all of medicine, there is a unique burden associated with the decision to perform surgery. This arises, I suspect, from the very nature of an operation's invasiveness, and is compounded by the unpredictable perils of intraoperative and postoperative complications. In the industrialized world, a surgeon's decision to operate is not only strongly supported by well-defined ethical principles, but also facilitated by procedural tools that help to ensure the maintenance of these principles in daily practice. The most well-known is perhaps the Hippocratic edict to do no harm. Every graduating medical student is required to recite this commandment and implicitly understands it to be the sine qua non of ethical practice. …

Robotic surgery in gynecologic oncology

The objective of this article is to review the recently published literature on the use of robotic surgery in the management of gynecologic malignancies. Retrospective data collected from many institutions support the use of robotic surgery in the management of cervical, endometrial, and early-stage ovarian cancer. Benefits to robotic surgery include decreased blood loss, fewer perioperative complications, and decreased length of hospital stay, especially when compared to an open cohort. Disadvantages include costs associated with the robotic system and disposable equipment, accessibility to robotic surgical systems, loss of haptic sensation with the device, and lack of prospective trials validating its use in gynecologic oncology. Current evidence establishes a role for the use of robotic surgery in the treatment of gynecologic malignancies. Further research should be implemented to validate the use of robotic surgery in gynecologic malignancies and to compare its outcomes to those of open and laparoscopic surgery.

Cost-efficiency of laparoscopic versus open colon surgery in a tertiary care center

Real-world cost analysis of elective laparoscopic versus open colon resection in a tertiary Canadian teaching hospital was performed to evaluate the financial impact of minimally invasive surgery with the appointment of an experienced laparoscopic surgeon in a single-payer system. A retrospective review of elective laparoscopic and open segmental colectomies (2005-2010) was performed. Combined cases and procedures performed for inpatients were excluded to minimize cost variation. The hospital case-costing system was used to calculate the hourly cost of operating room time and the daily hospital ward stay. The cost of disposable equipment was calculated manually. A cost-minimization analysis was performed from the hospital perspective, which excludes physician payment. Cases were analyzed on an intention-to-treat basis. For this study, 470 right-side colectomies (322 open and 148 laparoscopic) and 266 left-side colectomies (181 open and 85 laparoscopic) were found to match the inclusion criteria. The operating room time was longer for the laparoscopic procedures than for the open procedures: 203.4 versus 173.4 min (P = 0.1) for right and extended right hemicolectomy (RC) and 287.4 versus 173.4 min (P = 0.009) for left and sigmoid colectomy (LC). This resulted in higher operating room costs: $4,094.10 versus $3312.11 for RC and $5,784.88 versus $4,582.55 for LC. The median hospital stay for an index admission was shorter for both sides: 5 days versus 8 days (P = 0.01) for RC and 4 days versus 6 days (P = 0.04). This resulted in lower ward costs: $4,556.07 versus $6,632.82 for RC and $3,297.24 versus $5,949.09 for LC. The cost of care per index admission after laparoscopic versus open resection was $10,097.93 versus $10,444.69 for RC and $11,067.72 versus. $11,146.56 for LC. The introduction of laparoscopic surgery has saved our institution $58,021.43 over 5 years. The reasons for observed differences in operating room time and length of hospital stay were uncontrolled and may be multifactorial. However, the results demonstrate that adopting a laparoscopic approach for elective colon surgery resulted in progressive financial savings.

Active surveillance vs. treatment for low-risk prostate cancer: A cost comparison

ObjectiveRadical prostatectomy (RP) and radiation therapy are standard curative approaches for low-risk prostate cancer (PC). Active surveillance (AS) is becoming an increasingly accepted management alternative for low-risk PC. Our aim is to compare the cumulative medical costs of treatment vs. AS. Methods and materialsWe collected data on the cumulative medical costs of open radical retropubic prostatectomy (RRP), robotic-assisted radical prostatectomy (RARP), external beam radiotherapy (EBRT), brachytherapy (BT), and AS at our institution. For physicians' reimbursements, Medicare values of our region were used to maintain uniformity. For inpatient costs other than reimbursements, we used the mean cost at our institution. The costs of RRP and RARP involve preoperative investigations, medical clearance, physicians' fees, inpatient costs, and pathologic examination of prostatectomy specimen and follow-up. The inpatient costs include the operating room, disposable equipment, anesthesia, post-anesthesia care, transfusion, and hospital stay. The cost of EBRT involves the cost of consultation, planning, simulation and treatment sessions, and follow-up. BT costs involved radiotherapy planning as well as inpatients costs. AS protocol involves regular visits, transrectal ultrasound guided biopsies, prostate specific antigen (PSA) testing. To evaluate the cost of treating complications, treatment after AS, and treatment for recurrence, we created a Markov model based on recent studies and our experience. ResultsThe cumulative costs of RRP are $9,732 (1 year), $10,360 (2 years), $12,209 (5 years), and $15,084 (10 years). While for RARP, the costs are $17,824 (1 year), $18,308 (2 years), $20,117 (5 years), and $22,762 (10 years). The costs of EBRT are $20,730 (1 year), $20,969 (2 years), $22,043 (5 years), and $23,953 (10 years). BT costs are $14,061 (1 year), $14,300 (2 years), $15,374 (5 years), and $17,284 (10 years). The costs of AS are $1,154 (1 year), $2,308 (2 years), $8,761 (5 years), and $13,116 (10 years). ConclusionsThe cumulative medical costs of RARP and EBRT are much higher than BT, RRP, and AS. AS is associated with a different cost distribution in which the initial cost is low and relatively higher cost of follow-up. Despite the higher follow-up cost, AS remains the most cost effective alternative for low-risk PC.

ASID/AICA position statement – Infection control guidelines for patients with Clostridium difficile infection in healthcare settings

Since 2000 there has been an increase in the rates of Clostridium difficile infection (CDI) in many healthcare facilities in the United States, Canada and Europe. This increase is associated with an epidemic strain of C. difficile and this strain (PCR ribotype 027) has recently been identified in Australia. All healthcare services should have in place an optimal evidence-based programfor CDI prevention and control. Management principles include the following. • All healthcare organisations, including residential aged care facilities, must give CDI prevention and control the highest priority, even if the prevailing incidence of CDI is low. • Surveillance should be integrated into quality improvement programs to optimise prevention, control and clinical care of CDI. • Antimicrobial stewardship programs aimed at minimising the frequency and duration of antibiotic use and promoting a narrow spectrum antibiotic policy should be implemented. • Emphasis should be placed on compliance with hand disinfection using alcohol-based hand rub and glove use for CDI patient care to minimise spore contamination. • Contact precautions should be in place for symptomatic CDI patients, including the donning of gowns/aprons and gloves on entry to patient rooms. • The use of sporocidal environmental cleaning and disinfection in high-risk areas such as toilets, bathrooms, and CDI patient rooms should be implemented. There should be the limination of other potential fomites by either using disposable equipment or ensuring that equipment is adequately cleaned and disinfected before re-use. • Education of all healthcare staff, patients and visitors about C. difficile disease, its prevention and management should be implemented.

A Prospective Randomized Comparison of Traditional Laparoendoscopic Single-Site Surgery with Needlescopic-Assisted Laparoscopic Nephrectomy in the Porcine Model

Laparoendoscopic single-site (LESS) surgery produces virtually no scar but is technically challenging because of the loss of triangulation. The objective of this study is to compare classic transumbilical LESS nephrectomy with needlescopic-assisted laparoscopy (NAL) surgery. In doing so, we evaluated whether the addition of a single 2-mm subcostal port could restore triangulation while not jeopardizing recovery or cosmetic outcome in the porcine model. Ten female farm pigs were randomized to laparoscopic nephrectomy with either LESS or NAL. In LESS, a TriPort was placed through a single 2.5-cm umbilical incision. In NAL, 5- and 10-mm ports were placed in the umbilicus and a 2-mm port was placed in the midclavicular line. Preoperative, perioperative, and postoperative parameters were compared. Variables were analyzed with the Wilcoxon signed-rank test and two-tailed Fisher exact test. Cosmesis was evaluated objectively using the Vancouver Scar Scale and subjectively by a blinded dermatologist. A cost analysis was performed. Estimated blood loss was minimal in both groups (28.8 mL in LESS and 9.4 mL in NAL). Operative time was significantly shorter in NAL (103 vs 150 min; P<0.001). There was no difference in complications (2 vs 1; P=0.500), objective cosmesis (3.9 vs 3.8; P>0.2), or subjective cosmesis (2 vs 3; P=0.500). The NAL protocol had significantly lower disposable equipment costs ($363 vs $1696). The addition of a 2-mm subcostal port and the restoration of triangulation in the NAL protocol enable shorter operative times, increased surgeon comfort, improved technical ease, and lower costs while maintaining the scarless cosmesis of the traditional LESS protocol.

The impact of robotic surgery on gynecologic oncology

The objective of this article was to review the published scientific literature pertaining to robotic surgery and its applications in gynecologic malignancies and to summarize the impact of robotic surgery on the field of gynecologic oncology. Summarizing data from different gynecologic disease-sites, robotic-assisted surgery is safe, feasible, and demonstrates equivalent histopathologic and oncologic outcomes. In general, benefits to robotic surgery include decreased blood loss, fewer perioperative complications and decreased length of hospital stay. Disadvantages include accessibility to robot surgical systems, decreased haptic sensation and fixed cost as well as cost of disposable equipment. As robotic surgery becomes readily available it will be imperative to develop standardized training modalities. Further research is needed to validate the role of robotic surgery in the treatment of gynecologic malignancies.

A Tandem Mass Spectrometry Triplex Assay for the Detection of Fabry, Pompe, and Mucopolysaccharidosis-I (Hurler)

We sought to develop a tandem mass spectrometry assay in which the enzymatic activities of 3 lysosomal enzymes (α-glucosidase, α-galactosidase A, and α-l-iduronidase) could be quantified in dried blood spots by using a single assay buffer. A 3-mm dried blood spot punch was incubated in a single assay buffer with 3 different substrates and internal standards. The sample was processed by a simple liquid-liquid extraction by using ethyl acetate. The extract was dried down and resuspended in solvent for injection into the tandem mass spectrometer. Products and internal standards were monitored by multiple reaction monitoring. Assay for the 3 lysosomal enzymes was successfully achieved with acceptable statistics. The assay can be performed by using a minimal quantity of disposable supplies and equipment. The entire procedure fits into a 48-h cycle including data analysis. Data from 5990 anonymous newborn dried blood spots showed an approximate bell-shaped distribution of enzymatic activities (mean values of 19.0, 11.5, and 3.5 μmol · h(-1) · (L blood)(-1) for α-glucosidase, α-galactosidase A, and α-l-iduronidase, respectively. Blank values obtained in the absence of blood were 0.13, 0.24, and 0.45 μmol · h(-1) · (L blood)(-1), respectively). By assaying 3 enzymes at once, problematic samples are spotted for reanalysis if enzyme activity values are low for all enzymes (for example, if insufficient blood is present in the assay). This method demonstrates that a triplex assay in a single buffer and with minimal supplies and labor can be adapted to a high-throughput newborn screening laboratory for the analysis of Pompe, Fabry, and mucopolysaccharidosis-I (Hurler) diseases.

Cost analysis of robotic versus open radical cystectomy for bladder cancer

J Urol. 2010; 183: 505-9Purpose: Recently robotic approaches to cystectomy have been reported, and while clinical and oncological efficacy continues to be evaluated, potential financial costs have not been clearly evaluated. In this study we present a financial analysis using current cost structures and clinical outcomes for robotic and open cystectomy for bladder cancer. Materials and Methods: The financial costs of robotic and open radical cystectomy were categorized into oper-ating room and hospital components, and further divided into fixed and variable costs for each. Fixed operating room costs for open cases involved base cost as well as disposable equipment costs while robotic fixed costs included the amortized machine cost as well as equipment and maintenance. Variable operating room costs were directly related to length of surgery. Variable hospital costs were directly related to transfusion require-ment and length of stay. The means of the prior 20 cases of robotic and open cystectomy were used to perform a comparative cost analysis. Results: Mean fixed operating room costs for robotic cases were $1,634 higher than for open cases. Operat-ing room variable costs were also higher by a difference of $570, directly related to increased operating room time. Hospital costs were nearly identical for the fixed component while variable costs were $564 higher for the open approach secondary to higher transfusion costs and longer mean length of stay. Based on these find-ings robotic cystectomy is associated with an overall higher financial cost of $1,640 (robotic $16,248 vs open $14,608). Cost calculators were constructed based on these fixed and variable costs for each surgical approach to demonstrate the expected total costs based on varying operating room time and length of stay. Conclusions: Robotic assisted laparoscopic radical cystectomy is associated with a higher financial cost (+$1,640) than the open approach in the perioperative setting. However, this analysis is limited by its single institution design and a multicenter followup study is required to provide a more comprehensive analysis.

Cost Analysis of Robotic Versus Open Radical Cystectomy for Bladder Cancer

Recently robotic approaches to cystectomy have been reported, and while clinical and oncological efficacy continues to be evaluated, potential financial costs have not been clearly evaluated. In this study we present a financial analysis using current cost structures and clinical outcomes for robotic and open cystectomy for bladder cancer. The financial costs of robotic and open radical cystectomy were categorized into operating room and hospital components, and further divided into fixed and variable costs for each. Fixed operating room costs for open cases involved base cost as well as disposable equipment costs while robotic fixed costs included the amortized machine cost as well as equipment and maintenance. Variable operating room costs were directly related to length of surgery. Variable hospital costs were directly related to transfusion requirement and length of stay. The means of the prior 20 cases of robotic and open cystectomy were used to perform a comparative cost analysis. Mean fixed operating room costs for robotic cases were $1,634 higher than for open cases. Operating room variable costs were also higher by a difference of $570, directly related to increased operating room time. Hospital costs were nearly identical for the fixed component while variable costs were $564 higher for the open approach secondary to higher transfusion costs and longer mean length of stay. Based on these findings robotic cystectomy is associated with an overall higher financial cost of $1,640 (robotic $16,248 vs open $14,608). Cost calculators were constructed based on these fixed and variable costs for each surgical approach to demonstrate the expected total costs based on varying operating room time and length of stay. Robotic assisted laparoscopic radical cystectomy is associated with a higher financial cost (+$1,640) than the open approach in the perioperative setting. However, this analysis is limited by its single institution design and a multicenter followup study is required to provide a more comprehensive analysis.