Invasive Radical Prostatectomy Research Articles

Radical Prostatectomy Trends in the United States: 1998 to 2011

ObjectiveTo determine the incidence and distribution of radical prostatectomy (RP) in the United States over time. Patients and MethodsWe conducted a serial cross-sectional analysis of time trends using the Nationwide Inpatient Sample of adult men older than 45 years who underwent RP between January 1, 1998, and December 31, 2011. ResultsWeighted estimates revealed that 962,917 men underwent RP during the study period. The annual rate of RP remained relatively stable, from 1425 RPs per million in the period 1998 to 1999 to 1330 RPs per million in the period 2010 to 2011 (7% decrease; P=.90). The annual rate of open RP decreased from 1424 per million to 435 per million (P<.001), whereas the annual rate of minimally invasive RP increased from less than 1 per million to 895 per million (P<.001). Since 2006, hospitals providing open RP decreased by 18% (from 2288 to 1870; P<.001), whereas hospitals providing minimally invasive RP increased by 191% (from 341 to 993; P<.001). The median open RP caseload per hospital decreased by 7% (from 68 to 63; P<.001), whereas the median caseload for hospitals providing minimally invasive RP declined by 17% (from 122 to 101; P<.001). The hospitals providing fewer than 50 minimally invasive RPs per year increased from 12% to 26% (from 144 of 1240 to 3020 of 11,644; P<.001). ConclusionPer capita utilization of RP in the United States has remained stable from 1998 to 2011. Rapid expansion of the use of minimally invasive RP has reduced open RP utilization rates and median annual hospital caseload.

Editorial Comment

This well-written analysis clearly demonstrates that the overall number of simple prostatectomies being performed for benign prostatic hyperplasia is trending downwards. 1 Pariser J.J. Pearce S.M. Patel S.G. Bales G.T. National trends of simple prostatectomy for benign prostatic hyperplasia with an analysis of risk factors for adverse perioperative outcomes. Urology. 2015; 86: 721-726 Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar The incremental increase seen in the use of minimally invasive surgical techniques has not stopped the overall decline. National Trends of Simple Prostatectomy for Benign Prostatic Hyperplasia With an Analysis of Risk Factors for Adverse Perioperative OutcomesUrologyVol. 86Issue 4PreviewTo examine the national trends of simple prostatectomy (SP) for benign prostatic hyperplasia (BPH) focusing on perioperative outcomes and risk factors for complications. Full-Text PDF ReplyUrologyVol. 86Issue 4PreviewSimilar to our findings, insidious racial disparities have been reported across multiple urologic procedures. For example, black race has been associated with worse perioperative outcomes during open and minimally invasive radical prostatectomy.1,2 Interestingly, for radical prostatectomy, black men have a markedly lower use of high volume hospitals and surgeons.2 More specifically, for benign prostatic hyperplasia, non-Caucasian race has been shown to be an independent predictor of increased morbidity and mortality during endoscopic surgery. Full-Text PDF

The Impact of Surgical Technique on Unplanned Reoperation after Open and Minimally Invasive Radical Prostatectomy: Analysis of the NSQIP Database

RESULTS: The results are demonstrated in Table 1 including subgroups of Yes1⁄4those with a fellowship in urology and No1⁄4those whose primary focus is oncology but have no fellowship. Table 1 demonstrates the income, hours worked, and satisfaction stratified by primary special interest areas of the respondents (could choose up to 3 areas). Sex 1⁄4 male (M); female (F); practice type 1⁄4 self-employed (“private practice”) (S); employed (E); academic (A); location 1⁄4 rural (R); suburban (S); urban (U); practice size 1⁄4 mean urologists in your practice; % satisfied 1⁄4 % answered “very satisfied” or “somewhat satisfied” with current work; % choose urology again 1⁄4 % who would choose urology again.

Unexpected Long-term Improvements in Urinary and Erectile Function in a Large Cohort of Men with Self-reported Outcomes Following Radical Prostatectomy

BackgroundIt is generally assumed that if a man does not regain urinary continence or erectile function within 12 mo of radical prostatectomy (RP), then the chance of subsequent recovery is low. ObjectiveTo determine the probability of achieving good urinary function (UF) or erectile function (EF) up to 48 mo postoperatively in men who reported poor UF or EF at 12 mo after RP. Design, setting, and participantsWe identified 3187 patients who underwent RP from 2007 through 2013 at a tertiary institution and had extended multidisciplinary follow-up with patient-reported UF and EF scores at ≥12 mo. InterventionOpen or minimally invasive RP. Outcome measurements and statistical analysisPrimary outcome was good UF as defined by a urinary score ≥17 (range: 0–21) or good EF as defined by a modified International Index of Erectile Function-6 score ≥22 (range: 1–30). The probability of functional recovery beyond 12 mo was determined by Kaplan-Meier analyses. Results and limitationsAmong patients incontinent at 12 mo, the probability of achieving good UF at 24, 36, and 48 mo was 30%, 49%, and 59%. In patients experiencing erectile dysfunction at 12 mo, the probability of recovering EF at 24, 36, and 48 mo was 22%, 32%, and 40%. On multivariable analyses, 12-mo functional score and age were associated with recovery, but only score was consistently significant. ConclusionsMen with incontinence or erectile dysfunction at 12 mo have higher than anticipated rates of subsequent functional improvement. Probability of recovery is strongly influenced by score at 12 mo. Further research should address the impact of ongoing multidisciplinary follow-up care on our observed rates of recovery. Patient summaryMany prostate cancer patients continue to recover urinary and erectile function after 12 mo. The level of functional recovery by 12 mo is associated with long-term recovery and should be discussed by the physician and patient when deciding on rehabilitative interventions.

Assessing the Impact of Barbed Suture on Vesicourethral Anastomosis During Minimally Invasive Radical Prostatectomy: A Systematic Review and Meta-analysis

To examine the effectiveness of barbed suture (BS) compared with conventional sutures for vesicourethral anastomosis (VUA) during minimally invasive radical prostatectomy (RP). Relevant studies comparing the safety and efficacy of BS with conventional sutures during minimally invasive RP were identified through a literature search using MEDLINE, EMBASE, and the Cochrane Library. The outcome measures included baseline characteristics, primary outcomes, and secondary outcomes. Ten studies (378 cases and 369 controls) were included. No significant differences between the 2 groups were detected in any of the baseline variables except for age (P = .02). The BS group had a shorter operation time (mean difference [MD], 10.54; 95% confidence interval [CI], -14.38 to -6.69; P <.01), a shorter VUA time (MD, -5.35; 95% CI, -7.44 to -3.25; P <.01), and a shorter posterior reconstruction time (MD, -0.56; 95% CI, -1.10 to -0.02; P = .04) than those in the conventional sutures group. No significant differences were detected between the 2 groups in other outcomes of interest. In subgroup and sensitivity analyses, there was no change in the significance of any of the outcomes. This meta-analysis indicates that VUA using BS as opposed to conventional suture is associated with a shorter operative time, comparable postoperative complication rate, and convenience for manipulation, which is of benefit to the surgeon learning robot-assisted RP and laparoscopic RP. Given that the inherent limitations, future well-designed randomized controlled trials are required to confirm our findings.

Faulty Analysis in Study of Robotic-Assisted Minimally Invasive Radical Prostatectomy

Faulty Analysis in Study of Robotic-Assisted Minimally Invasive Radical Prostatectomy

MP4-11 RADICAL PROSTATECTOMY TRENDS IN THE UNITED STATES: 1998–2011

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History I1 Apr 2015MP4-11 RADICAL PROSTATECTOMY TRENDS IN THE UNITED STATES: 1998–2011 Mark Tyson, Paul Andrews, Erik Castle, and Alexander Parker Mark TysonMark Tyson More articles by this author , Paul AndrewsPaul Andrews More articles by this author , Erik CastleErik Castle More articles by this author , and Alexander ParkerAlexander Parker More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.154AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical prostatectomy (RP) is one of many treatment options available for men with clinically localized prostate cancer. It is unknown how the per capita volume and distribution of RP in the US have changed over time. The purpose of this study is to examine national trends in RP rates using a serial, cross-sectional analytic design. METHODS The Nationwide Inpatient Sample (NIS) was used for this study. Adult men older than age 45 years who underwent RP between 1998 and 2011 were included in the study. The main outcome measure was annual RP rates (minimally invasive RP [MI-RP] and open RP). Negative binomial regression was used to study the trends in the annual rates of open RP and MI-RP. RP count was the dependent variable and calendar-year quarter of hospital discharge was the independent variable, with the size of the population at risk for prostate cancer surgery as the offset term (as determined from intercensal population estimates). RESULTS Weighted estimates revealed that 962,917 adult males older than age 45 years underwent RP in the US during the study period. The annual rate of RP remained relatively stable during the study period from 1,425 RP per million in 1998–1999 to 1,330 RP per million in 2010–2011 (p=0.90). The annual rate of open RP decreased from 1,424 per million in 1998–1999 to 435 per million in 2010–2011 (P<.001), whereas the annual rate of MI-RP increased from <1 per million in 1998–1999 to 895 per million in 2010–2011 (P<.001). Since 2006, the estimated number of hospitals providing open RP has decreased by 18% (P<.001), while the number of hospitals providing MI-RP has increased by 191% (P<.001). The median open RP case load per hospital has decreased by 7% (P<.001), while the median case load for hospitals providing MI-RP has declined by 17% (P<.001). The percentage of hospitals providing fewer than 50 MI-RPs per year increased from 12% to 26% since 2006 (P<.001). CONCLUSIONS The per capita utilization rate for RP in the US has remained stable from 1998 to 2011. The rapid expansion of MI-RP has led to a considerable reduction in open RP utilization rates and in the median annual hospital case load. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e30-e31 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mark Tyson More articles by this author Paul Andrews More articles by this author Erik Castle More articles by this author Alexander Parker More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Surgical margins and biochemical recurrence risk at 2 years for robotic prostatectomy: Comprehensive evaluation and CUSUM analysis of oncological outcomes.

80 Background: To evaluate the learning curve of Minimally Invasive Radical Prostatectomy (MIRP) in our institution and apply the cumulative summation (CUSUM) analytical technique to identify salient learning curve transition points in terms of oncological outcomes. Methods: Clinical, pathologic, and oncological outcome data were collected from our prospectively collected MIRP database to estimate Positive Surgical margin (PSM) and Biochemical Recurrence (BCR) trends during a 15 year period from 1998 to 2013. All the RPs (laparoscopic (LRP) / Robotic Assisted [RARP]) were performed by 9 surgeons. PSM was defined as presence of cancer cells at inked margins. BCR was defined as serum Prostate Specific Antigen (PSA) &gt;0.2 ng/ml and rising or start of secondary therapy. Surgical learning curve was assessed with the application of Kaplan-Meier curves, Cox regression model, CUSUM and logistic model in order to define the “transition point” of surgical improvement. Results: We identified 5,547 patients with localized prostate cancer treated with MIRP (3,846 - LRP and 1,701 – RARP). Patient characteristics of LRP and RARP were similar. The overall risk of PSM in LRP was 25%, 20% and 17% for the first 50, 50 to 350 and &gt;350 cases, respectively. For the same population, the 5-year BCR rate decreased from 21.5% to 16.7%. RARP started 3 years after the LRP program (after approximately 250 LRP). The PSM rate for RARP decreased from 21.8% to 20.4% and the corresponding 5-year BCR rate decreased from 17.6% to 7.9%. The CUSUM analysis showed significantly lower PSM and BCR at 2 years occurred at the transition point of 350 cases for LRP and 100 cases for RARP. In multivariable analysis, predictors of BCR were PSA, Gleason score, extra prostatic disease, seminal vesicle invasion and number of operations (p &lt; 0.05). Patients harboring PSM showed higher BCR risk (23% vs. 8%, p &lt; 0.05). Conclusions: Learning curve trends of MIRP in our large, single center experience showed significant reduction in PSM and BCR risk at 2 years are noted after the initial 350 cases and 100 cases of LRP and RARP, respectively.

Ambulatory Extended Recovery: Safely Transitioning to Overnight Observation for Minimally Invasive Prostatectomy

IntroductionWe evaluated the safety and efficacy of a clinical pathway designed and implemented to transition inpatient minimally invasive radical prostatectomy to a procedure with overnight observation. MethodsIn April 2011 ambulatory extended recovery was implemented at our institution. This was a multidisciplinary program of preoperative teaching and postoperative care for patients undergoing minimally invasive radical prostatectomy. We compared the risk of requiring a more than 1-night hospital stay by patients treated with surgery the year before the program vs those treated after the program was initiated, adjusting for age, ASA® status and surgery type. We also examined the rates of readmission and urgent care visits within 48 hours, and 7 and 30 days before and after the program began. ResultsThe proportion of patients who stayed longer than 1 night was 53% in the year before initiating the ambulatory extended recovery program vs 8% during the program, representing an adjusted absolute risk decrease of 45% (95% CI 39–50, p <0.0001). There was no important predictor of a greater than 1-night length of stay among ambulatory extended recovery patients. Rates of readmission and urgent care visits were slightly lower during the ambulatory extended recovery phase with no significant difference between the groups. ConclusionsThe ambulatory extended recovery program successfully transitioned most patients to a 1-night hospital stay without resulting in an increased rate of readmission or urgent care visits.

Population Based Analysis of Incidence and Predictors of Open Conversion during Minimally Invasive Radical Prostatectomy

We used population based data to measure the rates and risk factors of open conversion during minimally invasive radical prostatectomy in the United States. We retrospectively analyzed the records of 87,415 patients in the NCDB who underwent minimally invasive radical prostatectomy between 2010 and 2011. We compared surgical outcomes and treatment facility characteristics between converted and nonconverted cases. Multivariable analysis was done to evaluate conversion risk factors. There were 82,338 robot-assisted (94%) and 5,077 laparoscopic (6%) radical prostatectomies, and 1,080 conversions (1.2%). Fewer robot-assisted cases were converted than laparoscopic cases (0.9% vs 6.5%, p <0.001). The median yearly treatment facility volume of minimally invasive radical prostatectomy was 32 (IQR 10-72). Patients who underwent conversion were more likely to be rehospitalized within 30 days (4.4% vs 2.7%, p = 0.002) and have a postoperative hospital stay of greater than 2 days (40.4% vs 15.1%, p <0.001) than those without conversion. Facilities in the lowest quartile of the yearly volume of the minimally invasive procedure represented 3.8% of minimally invasive radical prostatectomies but accounted for 22.9% of conversions. The second, third and fourth quartiles of yearly treatment facility minimally invasive volume predicted a lower likelihood of conversion compared to the first quartile (each p <0.001). Facility type (eg academic or community) did not predict conversion. Black race (vs white OR 1.52, 95% CI 1.24-1.86, p <0.001) and laparoscopic radical prostatectomy (OR 4.68, 95% CI 3.79-5.78, p <0.001) predicted higher odds of conversion. Open conversion during minimally invasive radical prostatectomy is a rare event. However, it is significantly more likely for pure laparoscopic surgery, in black men and at low volume facilities. Facility type did not affect conversion rates.

Recent Developments in Minimally Invasive Radical Prostatectomy

Minimally invasive surgery has gained a dominant status in prostate cancer surgery during the last decade. The benefits of minimally invasive prostatectomy were demonstrated by pioneers of conventional laparoscopic prostatectomy, however, the real domination of laparoscopy in radical prostatectomy (RP) started after the dissemination of robotic surgery. Robot-assisted surgery still remains the most widespread method to perform minimally invasive RP, although the recent evolution of laparoscopic technology and instruments has evoked interest in conventional laparoscopy again. The recent developments in the technique of RP are focused on decreasing invasiveness and complications. The recent methods to improve postoperative functional outcome of RP can be utilised without compromising the oncological results.

Is Radical Perineal Prostatectomy a Viable Therapeutic Option for Intermediate- and High-risk Prostate Cancer?

The aim of this study was to investigate a single-institution experience with radical perineal prostatectomy (RPP), radical retropubic prostatectomy (RRP) and minimally invasive radical prostatectomy (MIRP) with respect to onco-surgical outcomes in patients with intermediate-risk (IR; PSA 10-20 ng/mL, biopsy Gleason score bGS 7 or cT2b-2c) and high-risk (HR; PSA >20 ng/mL, bGS ≥8, or ≥cT3) prostate cancer (PCa). We retrospectively reviewed data from 2,581 men who underwent radical prostatectomy for IR and HR PCa (RPP, n = 689; RRP, n = 402; MIRP, n = 1,490 [laparoscopic, n = 206; robot-assisted laparoscopic, n = 1,284]). The proportion of HR PCa was 40.3%, 46.8%, and 49.5% in RPP, RRP, and MIRP (P < 0.001), respectively. The positive surgical margin rate was 23.8%, 26.1%, and 18.7% (P = 0.002) overall, 17.5%, 17.8%, and 8.8% (P < 0.001) for pT2 disease and 41.9%, 44.4%, and 40.0% (P = 0.55) for pT3 disease in men undergoing RPP, RRP, and MIRP, respectively. Biochemical recurrence-free survival rates among RPP, RRP, and MIRP were 73.0%, 70.1%, and 76.8%, respectively, at 5 yr (RPP vs. RPP, P = 0.02; RPP vs. MIRP, P = 0.23). Furthermore, comparable 5-yr metastases-free survival rates were demonstrated for specific surgical approaches (RPP vs. RPP, P = 0.26; RPP vs. MIRP, P = 0.06). RPP achieved acceptable oncological control for IR and HR PCa.

The diffusion of minimally invasive radical prostatectomy in the United States: a case study of the introduction of new surgical devices.

The diffusion of minimally invasive radical prostatectomy (MIRP) in the United States may have led to adverse patient outcomes due to rapid surgeon adoption and collective inexperience. We hypothesized that throughout the early period of minimally invasive surgery, MIRP patients had inferior outcomes as compared with those who had open radical prostatectomy (ORP). We used the Surveillance, Epidemiology and End RESULTS-Medicare dataset and identified men who had ORP and MIRP for prostate cancer from 2003-2009. Study endpoints were receipt of subsequent cancer treatment, and evidence of postoperative voiding dysfunction, erectile dysfunction (ED) and bladder outlet obstruction. We used proportional hazards regression to estimate the impact of surgical approach on each endpoint, and included an interaction term to test for modification of the effect of surgical approach by year of surgery. ORP (n=5362) and MIRP (n=1852) patients differed in their clinical and demographic characteristics. Controlling for patient characteristics and surgeon volume, there was no difference in subsequent cancer treatments (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.76-1.05), although MIRP was associated with a higher risk of voiding dysfunction (HR 1.31, 95% CI 1.20-1.43) and ED (HR 1.43, 95% CI 1.31-1.56), but a lower risk of bladder outlet obstruction (HR 0.86, 95% CI 0.75-0.97). There was no interaction between approach and year for any outcome. When stratifying the analysis by year, MIRP consistently had higher rates of ED and voiding dysfunction with no substantial improvement over time. MIRP patients had adverse urinary and sexual outcomes throughout the diffusion of minimally invasive surgery. This may have been a result of the rapid adoption of robotic surgery with inadequate surgeon preparedness.

Enhanced recovery pathway for radical prostatectomy: Implementation and evaluation in a universal healthcare system.

Enhanced recovery pathways are standardized, multidisciplinary, consensus-based tools that provide guidelines for evidence-based decision-making. This study evaluates the impact of the implementation of a clinical care pathway on patient outcomes following radical prostatectomy in a universal healthcare system. Medical charts of 200 patients with prostate cancer who underwent open and minimally invasive radical prostatectomy at a single academic hospital from 2009 to 2012 were reviewed. A group of 100 consecutive patients' pre-pathway implementation was compared with 99 consecutive patients' post-pathway implementation. Duration of hospital stay, complications, post-discharge emergency department visits and readmissions were compared between the 2 groups. Length of hospital stay decreased from a median of 3 (inter-quartile range [IQR] 4 to 3 days) days in the pre-pathway group to a median of 2 (IQR 3 to 2 days) days in the post-pathway group regardless of surgical approach (p < 0.0001). Complication rates, emergency department visits and hospital readmissions were not significantly different in the pre- and post-pathway groups (17% vs. 21%, p = 0.80; 12% vs. 12%, p = 0.95; and 3% vs. 7%, p = 0.18, respectively). These findings were consistent after stratification by surgical approach. Limitations of our study include lack of assessment of patient satisfaction, and the retrospective study design. The implementation of a standardized, multidisciplinary clinical care pathway for patients undergoing radical prostatectomy improved efficiency without increasing complication rates or hospital readmissions.

Tissue quality assessment using a novel direct elasticity assessment device (the E-finger): a cadaveric study of prostatectomy dissection.

IntroductionMinimally invasive radical prostatectomy (RP) (robotic and laparoscopic), have brought improvements in the outcomes of RP due to improved views and increased degrees of freedom of surgical devices. Robotic and laparoscopic surgeries do not incorporate haptic feedback, which may result in complications secondary to inadequate tissue dissection (causing positive surgical margins, rhabdosphincter damage, etc). We developed a micro-engineered device (6 mm2 sized) [E-finger]) capable of quantitative elasticity assessment, with amplitude ratio, mean ratio and phase lag representing this. The aim was to assess the utility of the device in differentiating peri-prostatic tissue types in order to guide prostate dissection.Material and MethodsTwo embalmed and 2 fresh frozen cadavers were used in the study. Baseline elasticity values were assessed in bladder, prostate and rhabdosphincter of pre-dissected embalmed cadavers using the micro-engineered device. A measurement grid was created to span from the bladder, across the prostate and onto the rhabdosphincter of fresh frozen cadavers to enable a systematic quantitative elasticity assessment of the entire area by 2 independent assessors. Tissue was sectioned along each row of elasticity measurement points, and stained with haematoxylin and eosin (H&E). Image analysis was performed with Image Pro Premier to determine the histology at each measurement point.ResultsStatistically significant differences in elasticity were identified between bladder, prostate and sphincter in both embalmed and fresh frozen cadavers (p = <0.001). Intra-class correlation (ICC) reliability tests showed good reliability (average ICC = 0.851). Sensitivity and specificity for tissue identification was 77% and 70% respectively to a resolution of 6 mm2.ConclusionsThis cadaveric study has evaluated the ability of our elasticity assessment device to differentiate bladder, prostate and rhabdosphincter to a resolution of 6 mm2. The results provide useful data for which to continue to examine the use of elasticity assessment devices for tissue quality assessment with the aim of giving haptic feedback to surgeons performing complex surgery.

Perioperative outcomes and hospital reimbursement by type of radical prostatectomy: results from a privately insured patient population.

With the increasing use of robotic surgery in the United States, the comparative effectiveness and differences in reimbursement of minimally invasive radical prostatectomy (MIRP) and open prostatectomy (ORP) in privately insured patients are unknown. Therefore, we sought to assess the differences in perioperative outcomes and hospital reimbursement in a privately insured patient population who were surgically treated for prostate cancer. Using a large private insurance database, we identified 17,610 prostate cancer patients who underwent either MIRP or ORP from 2003 to 2010. The primary outcomes were length of stay (LOS), perioperative complications, 90-day readmissions rates and hospital reimbursement. Multivariable regression analyses were used to evaluate for differences in primary outcomes across surgical approaches. Overall, 8981 (51.0%) and 8629 (49.0%) surgically treated prostate cancer patients underwent MIRP and ORP, respectively. The proportion of patients undergoing MIRP markedly rose from 11.9% in 2003 to 72.5% in 2010 (P<0.001 for trend). Relative to ORP, MIRP was associated with a shorter median LOS (1.0 day vs 3.0 days; P<0.001) and lower adjusted odds ratio of perioperative complications (OR: 0.82; P<0.001). However, the 90-day readmission rates of MIRP and ORP were similar (OR: 0.99; P=0.76). MIRP provided higher adjusted mean hospital reimbursement compared with ORP (US $19,292 vs. US $17,347; P<0.001). Among privately insured patients diagnosed with prostate cancer, robotic surgery rapidly disseminated with over 70% of patients undergoing MIRP by 2009-2010. Although MIRP was associated with shorter LOS and modestly better perioperative outcomes, hospitals received higher reimbursement for MIRP compared with ORP.

Safety of minimally invasive radical prostatectomy in patients with prior abdominopelvic or inguinal surgery.

Despite the widespread use of minimally invasive radical prostatectomy (MIRP), there remain concerns regarding its safety in patients with a history of prior abdominopelvic or inguinal surgery. A prospective database of 1165 MIRP procedures performed by a single surgeon at a high-volume tertiary care center from 2001 to 2013 was analyzed. After an initial period of transperitoneal MIRP (TP), an extraperitoneal (EP) approach was used preferentially beginning in 2005 (for both laparoscopic and robotic cases), and robotics were used preferentially beginning in 2010. Overall perioperative complications, major complications (Clavien-Dindo III or IV), and abdominal complications (e.g., ileus, bowel/organ injury, or vascular injury) were compared for patients with and without a prior surgical history. Uni- and multivariate logistic regression were used to control the impact of robotics, approach, operative time, estimated blood loss, case number, prostate weight, and primary Gleason on complications. Three hundred patients undergoing MIRP had prior abdominopelvic or inguinal surgery (25.8%). Of these, 102 (34%) underwent TP and 198 (66%) EP MIRP. Robotics was used in 286 cases (24.6%) and pure laparoscopy in 879 (75.4%). Complications occurred in 111 patients (9.5%) from the total cohort, with major complications in 32 (2.75%) and abdominal complications in 19 (1.63%). Prior surgery was not associated with overall, major, or abdominal complications. Of the controlling factors, only increasing operative time was associated with postoperative abdominal complications (most of which were ileus) on multivariate analysis. In this large single-surgeon series where both EP and TP approaches to MIRP are utilized, prior abdominopelvic or inguinal surgery was not associated with an increased risk of perioperative complications.

This Month in Adult Urology

No AccessJournal of UrologyThis Month in Adult Urology1 Dec 2014This Month in Adult Urology William D. Steers William D. SteersWilliam D. Steers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.09.040AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Adult Urology." The Journal of Urology, 192(6), pp. 1589–1590 References 1 : Robotic intracorporeal orthotopic neobladder during radical cystectomy in 132 patients. J Urol2014; 192: 1734. Link, Google Scholar 2 : Feasibility of intraoperative navigation to the sentinel node in the groin using preoperatively acquired single photon emission computerized tomography data: transferring functional imaging to the operating room. J Urol2014; 192: 1810. Link, Google Scholar 3 : New modalities for evaluation and surveillance of complex renal cysts. J Urol2014; 192: 1604. Abstract, Google Scholar 4 : Open conversion during minimally invasive radical prostatectomy: impact on perioperative complications and predictors from national data. J Urol2014; 192: 1657. Link, Google Scholar 5 : Bladder instillation of liposome encapsulated onabotulinumtoxinA improves overactive bladder symptoms: a prospective, multicenter, double-blind, randomized trial. J Urol2014; 192: 1743. Link, Google Scholar 6 : Phase II trial of intravesical nanoparticle albumin bound paclitaxel for the treatment of nonmuscle invasive urothelial carcinoma of the bladder after bacillus Calmette-Guérin treatment failure. J Urol2014; 192: 1633. Link, Google Scholar © 2014 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 192Issue 6December 2014Page: 1589-1590 Advertisement Copyright & Permissions© 2014 by American Urological Association Education and Research, Inc.MetricsAuthor Information William D. Steers More articles by this author Expand All Advertisement PDF downloadLoading ...

Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy.

Surgical innovations disseminate in the absence of coordinated systems to ensure their safe integration into clinical practice, potentially exposing patients to increased risk for medical error. To investigate associations of patient safety with the diffusion of minimally invasive radical prostatectomy (MIRP) resulting from the development of the da Vinci robot. A cohort study of 401 325 patients in the Nationwide Inpatient Sample who underwent radical prostatectomy during MIRP diffusion between January 1, 2003, and December 31, 2009. We used Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs), which measure processes of care and surgical provider performance. We estimated the prevalence of MIRP among all prostatectomies and compared PSI incidence between MIRP and open radical prostatectomy in each year during the study. We also collected estimates of MIRP incidence attributed to the manufacturer of the da Vinci robot. Patients who underwent MIRP were more likely to be white (P = .004), have fewer comorbidities (P = .02), and have undergone surgery in higher-income areas (P = .005). The incidence of MIRP was substantially lower than da Vinci manufacturer estimates. Rapid diffusion onset occurred in 2006, when MIRP accounted for 10.4% (95% CI, 10.2-10.7) of all radical prostatectomies in the United States. In 2005, MIRP was associated with an increased adjusted risk for any PSI (adjusted odds ratio, 2.0; 95% CI, 1.1-3.7; P = .02) vs open radical prostatectomy. Stratification by hospital status demonstrated similar patterns: rapid diffusion onset among teaching hospitals occurred in 2006 (11.7%; 95% CI, 11.3-12.0), with an increased risk for PSI for MIRP in 2005 (adjusted odds ratio, 2.7; 95% CI, 1.4-5.3; P = .004), and onset among nonteaching hospitals occurred in 2008 (27.1%; 95% CI, 26.6-27.7), with an increased but nonsignificant risk for PSI in 2007 (adjusted odds ratio, 2.0; 95% CI, 0.8-5.2; P = .14). During its initial national diffusion, MIRP was associated with diminished perioperative patient safety. To promote safety and protect patients, the processes by which surgical innovations disseminate into clinical practice require refinement.

Management of Bladder Neck Stenosis Secondary to Radical Prostatectomy or Radiation Treatment

Bladder neck stenosis (BNS) and posterior urethral stenosis (PUS) are uncommon but problematic complications of treatment for localized prostate cancer. Overall, BNS is less common following minimally invasive radical prostatectomy than open. Patients who develop PUS following radiation therapy (RT) (especially salvage RT) pose a greater challenge and tend to present longer after treatment. Regardless of etiology, treatment begins conservatively with endoscopic management but quickly progresses to more aggressive intervention if refractory. Urethral stents have been used with acceptable results. In patients who fail conservative therapy after radical prostatectomy (RP), open reconstruction should be considered. After RT, patients may ultimately benefit from urinary diversion or salvage prostatectomy. After treatment, many patients will require implantation of artificial urinary sphincter (AUS) for management of incontinence. Patient counseling prior to treatment selection for initial prostate cancer therapy is important; complications, future management, and potential for return to normal quality of life vary widely.