Minimally Invasive Radical Prostatectomy Research Articles

Patient’s safety and satisfaction on same day discharge after robotic and laparoscopic radical prostatectomy versus discharge after 24 or 48 h: a longitudinal randomized prospective study

BackgroundThere is a tendency of prompted global health systems to reduce the length of hospital stay without compromising patient safety or satisfaction. We evaluated the safety and viability of early discharge in patients undergoing minimally invasive radical prostatectomy (MIRP), as well as patient satisfaction with this strategy.MethodsThis longitudinal prospective study included 72 patients who underwent MIRP for prostate cancer. Three groups were performed according to the day of hospital discharge following surgery: same day (G1), first day after (G2), and second day after (G3). Satisfaction, adverse events, and readmission were analyzed for each group. Associations between clinicopathologic variables and same-day discharge were analyzed by comparing data between G1 patients who did and did not achieve same-day discharge.Results16.7% of patients were not discharged according to randomization (10 randomized to G1). 80% of G1 patients who did not achieve same-day discharge had Gleason scores of 3 + 4 or 4 + 3, which were observed in 35.7% of patients discharged on the same day (P < 0.05). Average prostate weight was significantly lower in patients who achieved same-day discharge than in those who did not (P < 0.01). Univariable logistic regression points to Gleason scores of 3 + 4 or 4 + 3 as the main factors associated with unsuccessful same-day discharge (P < 0.05). There were no significant differences in satisfaction scores.ConclusionsSame-day discharge was both safe and feasible and does not appear to affect satisfaction in a subset of patients with prostate cancer. Surgeons should consider the Gleason score when determining whether same-day discharge is appropriate.

Ex vivo assessment of surgical margins with confocal laser microscopy during minimally-invasive radical prostatectomy: Our first 50 cases

Ex vivo assessment of surgical margins with confocal laser microscopy during minimally-invasive radical prostatectomy: Our first 50 cases

MP57-18 RATE OF BLADDER NECK CONTRACTURE AFTER OPEN AND MINIMALLY INVASIVE RADICAL PROSTATECTOMY OVER 18 YEARS AT THE VETERANS HEALTH ADMINISTRATION

You have accessJournal of UrologyCME1 May 2022MP57-18 RATE OF BLADDER NECK CONTRACTURE AFTER OPEN AND MINIMALLY INVASIVE RADICAL PROSTATECTOMY OVER 18 YEARS AT THE VETERANS HEALTH ADMINISTRATION Mitch Hayes, Michael Conlin, Helen Hougen, and Ryan Kopp Mitch HayesMitch Hayes More articles by this author , Michael ConlinMichael Conlin More articles by this author , Helen HougenHelen Hougen More articles by this author , and Ryan KoppRyan Kopp More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002640.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The rate of vesicourethral anastomotic stricture (VUAS) rate is higher amongst patients who undergo open radical prostatectomy (RP) compared to robotic RP at high-volume academic centers. We sought to compare the VUAS rate between minimally invasive (MIS) and open RP cohorts amongst United States veterans. METHODS: We queried the Veterans Affairs (VA) Corporate Data Warehouse for patients who underwent retropubic RP between 2003 and 2021 by CPT code (55840, 55845, 55866) were included. Patients who did not have a biopsy at the VA. Possible selected covariates were age, preoperative prostate specific antigen (PSA), agent orange exposure, body mass index (BMI), selected comorbidities based on ICD codes, and MIS surgery defined by the CPT code 55866. The primary outcome was undergoing a transurethral incision of a postoperative bladder neck contracture (TUIBNC) within 2 years of surgery by CPT code (52640). The secondary outcome was undergoing any incontinence procedure within 2 years of RP by male sling and artificial urinary sphincter CPT codes. Multivariate logistic regression was performed on the primary and secondary outcome. Stepwise selection was used for model building and restricted cubic spline terms were used for continuous variables. All statistics were performed in R, version 4.0.5. RESULTS: 32,776 patients were included in the analysis. Median patient age was 62 years old and median PSA was 6.04. 57.8% underwent open RP, and 42.3% underwent MIS RP. Overall TUIBNC and incontinence procedure cases within 2 years of surgery were 292 (0.9%) and 725 (2.2%), respectively. Median time to TUIBNC was 8.0 months. On multivariate analysis, after adjusting for age, PSA, and a history of congestive heart failure (CHF), the risk of TUIBNC remained higher with open surgery (OR 7.1, CI 4.7-11.4 p <0.001). Figure 1 shows the rate of MIS RP, open RP, and TUIBNC over time. On multivariate analysis, after adjusting for age, BMI, a history of myocardial infarction, CHF, and diabetes, incontinence surgery within 2 years of surgery was higher after open RP (OR 1.29, CI 1.08-1.53, p 0.004). CONCLUSIONS: Compared to MIS RP, open RP was associated with a 7-fold increase in rate of VUAS and a 1.3-fold increase in the rate of incontinence requiring a procedure within 2 years of surgery at the VA. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e989 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mitch Hayes More articles by this author Michael Conlin More articles by this author Helen Hougen More articles by this author Ryan Kopp More articles by this author Expand All Advertisement PDF DownloadLoading ...

Influence of Preoperative and Postoperative Factors on Prolonged Length of Stay and Readmission After Minimally Invasive Radical Prostatectomy.

Background: The mean length of stay (LOS) after minimally invasive radical prostatectomy (MI-RP) is <2 days. Our main objective was to utilize the National Surgical Quality Improvement Program (NSQIP) database to evaluate preoperative factors that may contribute to prolonged hospital stay and readmission. Materials and Methods: Utilizing the NSQIP database, records for surgery with the Current Procedural Terminology code 55866 (prostatectomy) between 2007 and 2017 were evaluated. Chi-square and t-tests were used to assess the effects of preoperative factors on prolonged LOS and rates of hospital readmission within 30 days. Odds ratios (ORs), p-values, and confidence intervals were determined using multivariable logistic regression. Results: A total of 40,764 patients underwent MI-RP between 2007 and 2017. Of these, 11.7% reported an LOS of >2 days, whereas 3.9% of patients were readmitted to the hospital within 30 days. Preoperative congestive heart failure within 30 days of surgery was shown to be strongly associated with both prolonged LOS (OR = 6.16) and readmission (OR = 3.28). Bleeding requiring transfusion was demonstrated to be the most significant postoperative factor for prolonged LOS (OR = 23.9), whereas unplanned intubation was shown to be the most significant postoperative factor for readmission (OR = 57.1). Body mass index (BMI) >30 was associated with both prolonged LOS and increase in readmission. Conclusions: Upon NSQIP database analysis, cardiopulmonary factors and BMI were demonstrated to have negative impacts on postoperative quality indicators. Patients with comorbidities should be counseled preoperatively concerning their individual risk factors. Mitigation of these factors is important in ensuring optimal outcomes.

Surgical Complications Requiring Intervention in Open versus Minimally Invasive Radical Prostatectomy

Introduction: Injuries to surrounding structures during radical prostatectomy (RP) are rare but serious complications. However, it remains unknown if injuries to intestines, rectum, or vascular structures occur at different rates depending on the surgical approach. Methods: We compared the frequency of these outcomes in open RP (ORP) and minimally invasive RP (MIS-RP) using the national American College of Surgeons National Surgical Quality Improvement Program database (2012–2017). Along with important metrics of clinical and surgical outcomes, patients were identified as undergoing surgical repair of small or large bowel, vascular structures, or hernias based on Current Procedural Terminology codes. Results: In our propensity matched analysis, a total of 13,044 patients were captured. Bowel injury occurred more frequently in ORP than in MIS-RP (0.89 vs. 0.26%, p < 0.01). By intestinal segment, rectal and large bowel injuries were more common in ORP than MIS-RP (0.41 vs. 0.11% and 0.31 vs. 0.05%, both p < 0.01). However, there was no statistically significant difference between the groups for small bowel injury (0.17 vs. 0.11%, p = 0.39). Vascular injury was more common in MIS-RP (0.18 vs. 0.08%, p = 0.08). Hernias requiring repair were only identified in the MIS-RP group (0.12%). Conclusion: When considering surgical approach, rectal and large bowel injuries were more common in ORP, while vascular injuries and hernia repair were more common in MIS-RP. Our findings can be used in counseling patients and identifying risk factors and strategies to reduce these complications.

The role of body mass index on quality indicators following minimally-invasive radical prostatectomy

PurposeWe sought to determine the role of body mass index (BMI) on quality indicators, such as length of stay and readmission. The National Surgical Quality Improvement Program (NSQIP) database was queried to examine the effect of obesity, defined as BMI >30, on outcomes after Minimally Invasive Radical Retropubic Prostatectomy (MI-RRP).Materials and MethodsUtilizing the NSQIP database, patient records were identified using the Current Procedural Terminology (CPT) code 55866 (laparoscopy, surgical prostatectomy, radical retropubic) during a 10-year period (2007–2017). Obesity was classified according to the CDC classification. Chi-square tests were utilized to evaluate BMI distribution by surgery year. Logistic regression was used to evaluate the relationship of BMI with length of stay (LOS) and hospital readmission within 30 days, after controlling for preoperative variables.ResultsRecords of 49,238 patients who have undergone MI-RRP during 2007–2017 were evaluated. Mean yearly BMI rose from 28.5 to 29.2, while the percentage of surgical patients with BMI >30 rose by 5% (33% to 38%; p<0.0001) over the study period. Obese patients demonstrated higher morbidity, prolonged LOS, and increased readmission rates after MI-RRP. Obesity severity correlated negatively with quality indicators in a graded fashion.ConclusionsObesity rates in patients undergoing MI-RRP increased from 2007–2017. Obese patients are at increased risk of morbidity, prolonged LOS, and readmission within 30 days, following MI-RRP. These patients should not be excluded from MI-RRP; rather, physicians should discuss these increased risks with their patients. Proper weight loss strategies should be instituted preoperatively to mitigate these risks.

Effect of Robot-assisted Surgery on Anesthetic and Perioperative Management for Minimally Invasive Radical Prostatectomy under Combined General and Epidural Anesthesia.

Robot-assisted surgery and pure laparoscopic surgery are available for minimally invasive radical prostatectomy (MIRP). The differences in anesthetic management between these two MIRPs under combined general and epidural anesthesia (CGEA) remain unknown. This study therefore aimed to determine the effects of robot-assisted surgery on anesthetic and perioperative management for MIRP under CGEA. This retrospective observational study analyzed data from patients' electronic medical records. Data on demographics, intraoperative variables, postoperative complications, and hospital stays after MIRPs were compared between patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP) and those treated by pure laparoscopic radical prostatectomy (LRP). There were no differences in background data between the 102 who underwent RALP and 112 who underwent LRP. Anesthesia and surgical times were shorter in the RALP group than in the LRP group. Doses of anesthetics, including intravenous opioids, and epidural ropivacaine, were lower in the RALP group. Although estimated blood loss and volume of colloid infusion were lower in the RALP group, the volume of crystalloid infusion was larger. Intraoperative allogeneic transfusion was not required in either group. There was no difference between groups in the incidences of postoperative cardiopulmonary complications or postoperative nausea and vomiting. Hospital stays after the procedure were shorter in the RALP group. Robot-assisted surgery required varied consumption of anesthetics and infusion management during MIRP under GCEA. It also shortened postoperative hospital stays, without increasing rates of postoperative complications.

MP19-11 THE ROLE OF BMI ON HOSPITAL READMISSION AFTER MINIMALLY-INVASIVE RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I (MP19)1 Apr 2020MP19-11 THE ROLE OF BMI ON HOSPITAL READMISSION AFTER MINIMALLY-INVASIVE RADICAL PROSTATECTOMY Ethan Matz*, Ashok Hemal, Tim Craven, and Ram Pathak Ethan Matz*Ethan Matz* More articles by this author , Ashok HemalAshok Hemal More articles by this author , Tim CravenTim Craven More articles by this author , and Ram PathakRam Pathak More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000852.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Obesity is a significant problem in the United States, affecting approximately 60 million people. The number affected is projected to meet 50% of the population in 2030. Patient factors such as increased BMI can affect quality metrics like hospital readmission. Utilizing the National Surgical Quality Improvement Program Database (NSQIP), we sought to determine the relationship of BMI and readmission after minimally-invasive radical prostatectomy. METHODS: The Center for Disease Control (CDC) classifies obesity in a three-tiered manner based on Body Mass Index (BMI): I (30-34.9), II (34-39.9) and III (>40). Data for surgery years 2007-2017 were downloaded from the NSQIP and all records with Current Procedural Terminology (CPT) code 55866 were selected for inclusion. Association between BMI class and year of surgery was assessed using chi-square tests. Association between BMI (as a continuous measure) and readmission within 30 days was examined using logistic regression. RESULTS: A total of 49,238 patients over 10 years (2007-2017) underwent minimally-invasive prostatectomy. Mean BMI for all years ranged from 28.5 to 29.2. 37.3% of patients who underwent surgery had BMI > 30. of patients were at least a BMI of 30. There were 13,130 Class I, 4,040 Class 2 and 1,180 Class 3 BMI patients. From 2007 to 2017 the proportion of patients with BMI ≥30 kg/m2 increased from 32% in 2007 to 38% in 2017 (P <0.0001). Risk of hospital readmission also increased as BMI increased (OR 1.16 per standard deviation increase in BMI; 95% CI 1.11 - 1.21; P<0.0001). Increasing severity of BMI (Class I, II and III) corresponded to an increase in the odds ratio for readmission (Table 1). CONCLUSIONS: Over a span of 10 years, an increasing number of patients undergoing minimally-invasive prostatectomy have a BMI > 30, which directly influences hospital readmission. In summary, urologists are increasingly operating on more obese patients and obesity negatively impacts quality metrics. Preoperative patient optimization and weight loss may be appropriate in select patients. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e302-e302 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ethan Matz* More articles by this author Ashok Hemal More articles by this author Tim Craven More articles by this author Ram Pathak More articles by this author Expand All Advertisement PDF downloadLoading ...

Are We Improving Erectile Function Recovery After Radical Prostatectomy? Analysis of Patients Treated over the Last Decade

BackgroundThe last decade has seen several advances in radical prostatectomy (RP) technique and post-RP care that are relevant to erectile function (EF) recovery. ObjectiveWe examined whether these practice changes have led to observed improvements in EF rates over time. Design, setting, and participantsWe identified 2364 patients treated with either open or minimally-invasive RP at a single academic center in 2008–2015. To mitigate confounding by the surgical learning curve, only patients treated by surgeons who performed at least 100 procedures were considered. InterventionEF before and after RP was assessed by the International Index of Erectile Function 6 (IIEF-6), with recovery defined as IIEF-6 ≥24. Outcome measurements and statistical analysisWe analyzed EF recovery rates of patients treated with bilateral nerve-sparing surgery and free from adjuvant/salvage treatment at the time of EF assessment. Local polynomial regression analyses explored changes in the outcomes over time. Linear and logistic regression analyses were used to estimate the influence of year of surgery on baseline variables and EF recovery. Results and limitationsWe observed a significant decrease over time of the EF recovery rates at both 12 and 24mo post-RP (all p=0.01). However, patient's age at surgery increased over time (mean increase of 0.5 per year; p<0.01), with a resultant increase in risk of comorbidity (odds ratio [OR]=1.1, 95% confidence interval [CI]: 1.02–1.15; p=0.008) and thus decrease in baseline IIEF-6 score (0.35 points per year; p=0.0003). After accounting for baseline and pathological characteristics, urinary function, and type of surgery in a multivariable analysis, year of surgery was not associated with EF recovery (12mo: OR=0.97, 95% CI: 0.91–1.03, p=0.4; 24mo: OR=0.97, 95% CI: 0.91–1.03, p=0.3). ConclusionsFindings from a high-volume center suggest that, despite the advancements in surgical and postoperative care, EF outcomes after RP have not improved over the last decade. Additional strategies are required to improve EF recovery after RP. Patient summaryThe probability of regaining potency after surgery for prostate cancer did not improve over the last decade; more efforts are needed to improve patient's care after radical prostatectomy.

Concurrent Inguinal Hernia Repair in Patients Undergoing Minimally Invasive Radical Prostatectomy: A National Surgical Quality Improvement Program Study.

To compare perioperative 30-day outcomes between minimally invasive radical prostatectomy (MIRP) with and without concurrent inguinal hernia repair (IHR) using a national database. The National Surgical Quality Improvement Program database was queried for MIRP from 2012 to 2015. Concurrent IHR was identified using relevant Current Procedural Terminology codes. Primary outcomes were overall complications, reoperations, unplanned readmissions, and mortality within 30 days of MIRP. Secondary outcomes included operative time (OT), length of stay (LOS), prolonged length of stay (PLOS, >2 days), and discharged to continued care (DCC). Multivariable logistic regression was performed to identify the association between concurrent IHR and outcomes. A total of 18,065 patients were included; 375 (2.1%) had concurrent IHR. The unadjusted comparison showed no significant difference in overall complication, reoperation, unplanned readmission, or mortality rates between MIRP+IHR and MIRP only groups. OT was longer in the MIRP+IHR group (229 vs 195 minutes, p < 0.001) but no differences were found in LOS, PLOS, or DCC rates. Multivariable logistic regression showed concurrent IHR was not associated with increased odds of overall complication (odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.49-1.40, p = 0.479), reoperation (OR = 0.57, 95% CI = 0.14-2.30, p = 0.426), unplanned readmission (OR = 0.92, 95% CI = 0.51-1.64, p = 0.771), PLOS (OR = 1.19, 95% CI = 0.86-1.63, p = 0.297), or DCC (OR = 1.94, 95% CI = 0.70-5.34, p = 0.202). Concurrent IHR with MIRP was associated with longer OT, but there were no increased 30-day adverse outcomes within the National Surgical Quality Improvement Program (NSQIP) database. These data support the safety of performing concurrent IHR at the time of MIRP and it should be considered to spare men an additional procedure.

The association of lymph node dissection with 30-day perioperative morbidity among men undergoing minimally invasive radical prostatectomy: analysis of the National Surgical Quality Improvement Program (NSQIP).

The incremental morbidityof lymph node dissection (LND) among men undergoingradical prostatectomy remains uncertain. We therefore evaluated the association of LND with perioperative morbidity among men undergoing minimally invasive radical prostatectomy (MIRP). We identified 29,012 men aged 35-89 who underwent MIRP from 2010-2015 in the National Surgical Quality Improvement Program (NSQIP) database, of whom 47% underwent concomitant LND. The associations of LND with 30-day perioperative morbidity and mortality were evaluated using logistic regression, adjusted for patient features. Median age at surgery was 63 (IQR57, 67) years. There were statistically significant, but clinically insignificant, differences in several baseline characteristics stratified by performance of LND, including older age at surgery (p < 0.001), higher American Society of Anesthesiology (ASA) class (p < 0.001), and longer operative time (p < 0.001) for men who underwent LND. Overall, 30-day complications occurred in 4.3% of patients. There were no statistically significant differences in rates of 30-day complications (4.2 vs. 4.4%, p = 0.44), perioperative blood transfusion (1.7 vs. 1.7%, p = 0.99), hospital readmission (3.6 vs. 4.0%, p = 0.09), reoperation (1.1 vs. 1.1%, p = 0.80), or 30-day mortality (0.1 vs. 0.2%, p = 0.56) between patients who underwent MIRP alone or MIRP with LND, respectively. On multivariable analysis, LND was not significantly associated with an increased risk of perioperative morbidity or 30-day mortality. LND at the time of MIRP does not appear to be associated with an increased risk of perioperative morbidity.

Concurrent inguinal hernia repair in patients undergoing minimally-invasive radical prostatectomy: A national surgical quality improvement program study

Concurrent inguinal hernia repair in patients undergoing minimally-invasive radical prostatectomy: A national surgical quality improvement program study

Oncological Outcomes of High-Risk Prostate Cancer Patients between Robot-Assisted Laparoscopic Radical Prostatectomy and Laparoscopic Radical Prostatectomy in Taiwan

Objective: To compare pathological and oncological outcomes between robotic-assisted laparoscopic radical prostatectomy (RaLRP) and laparoscopic radical prostatectomy (LRP) among high-risk prostate cancer patient in a tertiary center in Taiwan. Materials and methods: From November 2003 to October 2013, 129 high-risk prostate cancer patients receiving minimally-invasive radical prostatectomy were included. The Kaplan–Meier analysis was used for measuring biochemical recurrence-free survival (BFS). Multivariate logistic regression models and Cox proportional hazards regression models were used to determine predictors of positive surgical margin and BFS. Results: Among the 129 high-risk prostate cancer patients included, 80 (62%) patients received LRP and 49 (38%) patients received RaLRP. There was no significant difference of positive surgical margin and biochemical recurrence rate between RaLRP and LRP group (P = 0.802 and 0.292). Higher pathological T stage predicted an increased likelihood of positive margins (OR = 3.44, 95% CI [1.45, 8.18], P = 0.005). Higher initial PSA level (HR = 2.88, 95% CI [1.04, 7.94], P = 0.041) and positive surgical margin (HR = 2.55, 95% CI [1.20, 5.44], P = 0.015) were poor prognostic factors for BFS. Conclusion: RaLRP can be considered among high-risk prostate cancer in Asian people with comparable oncological outcomes to LRP. Higher pathological T stage was associated with increased likelihood of positive margins, patients with higher iPSA level and positive surgical margin had worsen biochemical recurrence-free survival.

Oncological and functional outcomes of elderly men treated with HIFU vs. minimally invasive radical prostatectomy: A propensity score analysis

AimTo assess outcomes of whole gland high-intensity focused ultrasound (HIFU) as compared with minimally-invasive radical prostatectomy (MIRP) in elderly patients. Materials & methodsPatients aged ≥70 years with, cT1-cT2 disease, biopsy Gleason score (GS) 3 + 3 or 3 + 4 and preoperative PSA ≤10 ng/mL were submitted to either whole-gland HIFU or MIRP. Propensity-score matching analysis was performed to ensure the baseline equivalence of groups. Follow-up visits were routinely performed assessing PSA and urinary function according to the International Continence Score (ICS) and the International Prostatic Symptoms Score (IPSS) questionnaires. Estimated rates of salvage-treatment free survival (SFS) overall-survival (OS), cancer-specific survival (CSS) and metastasis-free survival (MTS) were assessed and compared. ResultsOverall, 84 (33.3%) and 168 (66.7%) patients were treated with HIFU and MIRP, respectively. MIRP was associated with a 5-yrs SFS of 93.4% compared to 74.8% for HIFU (p < 0.01). The two groups did not differ in terms of OS and MTS. No cancer-related deaths were registered. Patients treated with HIFU showed better short-term (6-mos) continence outcomes [mean-ICS: 1.7 vs. 4.8; p = 0.005] but higher IPSS mean scores at 12-mos assessment. A comparable rate of patients experiencing post-treatment Clavien-Dindo grade ≥III complications was observed within the two groups. ConclusionsWhole-gland HIFU is a feasible treatment in elderly men with low-to intermediate-risk PCa and could be considered for patients either unfit for surgery, or willing a non-invasive treatment with a low morbidity burden, although a non-negligible risk of requiring subsequent treatment for recurrence should be expected.

Positive surgical margins and biochemical recurrence following minimally-invasive radical prostatectomy \u2013 An analysis of outcomes from a UK tertiary referral centre

BackgroundPositive surgical margins are a strong prognostic marker of disease outcome following radical prostatectomy, though prior evidence is largely from a PSA-screened population. We therefore aim to evaluate the biochemical recurrence in men with positive surgical margins (PSM) after minimally-invasive radical prostatectomy (MIRP) in a UK tertiary centre.MethodsRetrospective study of men undergoing laparoscopic or robotic-assisted radical prostatectomy between 2002 and 2014. Men with positive surgical margins (PSM) were identified and their biochemical recurrence (BCR) rate compared with men without PSM. The primary outcome measures were BCR rates and time to BCR. Cox regression was used to estimate adjusted hazard ratios for biochemical recurrence rate (BCR), accounting for potential confounders.ResultsFive hundred ninety-two men were included for analysis. Pre-operative D’Amico risk stratification showed 37.5%, 53.3% and 9.3% of patients in the low, intermediate and high-risk groups, respectively. On final pathological analysis, the proportion of patients with local staging pT2, pT3a and pT3b was 68.8%, 25.2% and 6.1% respectively. Overall positive margin rate was 30.6%. On multivariate analysis, the only pre-operative factor associated with PSM was age >65years. Patients with PSM were more likely to have higher tumour volume and more advanced pathological local stage. The BCR rate was 10.7% in margin-positive patients and 5.1% in margin-negative patients, at median 4.4-year follow-up. Upon multivariate analysis, high pre-operative PSA and high Gleason group were the only significant predictors of BCR (P<0.05).ConclusionsIn comparison to patients with negative surgical margins, those with PSM do not translate into worse medium-term oncological outcomes in the majority of cases amongst our cohort. We found that high pre-operative PSA and high Gleason group were the only significant predictors of BCR.

Patient driven care in the management of prostate cancer: analysis of the United States military healthcare system

BackgroundPatient preferences are assumed to impact healthcare resource utilization, especially treatment options. There is limited data exploring this phenomenon. We sought to identify factors associated with patients transferring care for prostatectomy, from military to civilian facilities, and the receipt of minimally invasive radical prostatectomy (MIRP).MethodsRetrospective review of 2006-2010 TRICARE data identified men diagnosed with prostate cancer (ICD-9 185) receiving open radical prostatectomy (ORP; ICD-9: 60.5) or MIRP (ICD-9 60.5 + 54.21/17.42). Patients diagnosed at military facilities but underwent surgery at civilian facilities were defined as “transferring care”. Logistic regression models identified predictors of transferring care for patients diagnosed at military facilities. A secondary analysis identified the predictors of MIRP receipt at civilian facilities.ResultsOf 1420 patients, 247 (17.4%) transferred care. These patients were more likely to undergo MIRP (OR = 7.83, p < 0.01), and get diagnosed at low-volume military facilities (OR = 6.10, p < 0.01). Our secondary analysis demonstrated that transferring care was strongly associated with undergoing MIRP (OR = 1.51, p = 0.04).ConclusionsPatient preferences induced a demand for greater utilization of MIRP and civilian facilities. Further work exploring factors driving these preferences and interventions tailoring them, based on evidence and cost considerations, is required.

Oncological outcomes of high risk prostate cancer patients between robot-assisted laparoscopic radical prostatectomy and laparoscopic radical prostatectomy in Taiwan

ObjectiveTo compare pathological and oncological outcomes between robotic-assisted laparoscopic radical prostatectomy (RaLRP) and laparoscopic radical prostatectomy (LRP) among high-risk prostate cancer patient in a tertiary center in Taiwan. Materials and methodsFrom November 2003 to October 2013, 129 high-risk prostate cancer patients receiving minimally-invasive radical prostatectomy were included. The Kaplan–Meier analysis was used for measuring biochemical recurrence-free survival (BFS). Multivariate logistic regression models and Cox proportional hazards regression models were used to determine predictors of positive surgical margin and BFS. ResultsAmong the 129 high-risk prostate cancer patients included, 80 (62%) patients received LRP and 49 (38%) patients received RaLRP. There was no significant difference of positive surgical margin and biochemical recurrence rate between RaLRP and LRP group (P = 0.802 and 0.292). Higher pathological T stage predicted an increased likelihood of positive margins (OR = 3.44, 95% CI [1.45, 8.18], P = 0.005). Higher initial PSA level (HR = 2.88, 95% CI [1.04, 7.94], P = 0.041) and positive surgical margin (HR = 2.55, 95% CI [1.20, 5.44], P = 0.015) were poor prognostic factors for BFS. ConclusionRaLRP can be considered among high-risk prostate cancer in Asian people with comparable oncological outcomes to LRP. Higher pathological T stage was associated with increased likelihood of positive margins, patients with higher iPSA level and positive surgical margin had worsen biochemical recurrence-free survival.

The comparative analysis of results of retropubic and miniinvasive radical prostatectomy

The objective: is to conduct a comparative analysis of complications of retropubic radical prostatectomy (RRP) and minimally invasive radical prostatectomy (MIRP) in patients with prostate cancer by determining the frequency and severity of postoperative complications. Patients and methods. There were analyzed the medical history of 453 patients who underwent radical prostatectomy (RP) in conditions of SI «Institute of Urology of NAMS Ukraine» in 2013–2015 years and SI «V.K. Gusak’s Institute of Emergency and Recovery Surgery of NAMS Ukraine» during the 2006–2013 years. All patients were divided into two groups. Group I were consisted of 210 (46.4%) patients who underwent MIRP, and group II were included 243 (53.6%) patients after RRP. Complications were divided: by the number; by severity according to the scale P.A. Clavien et al. (2009); by type for G. Novara et al. (2010); by prognostic group formed by P.M. Pierorazio et al. (2013). Results. The group, which were performed MIRP, were dominated genitourinary complications in case of 64,8±3,3% to 50,2±3,2% in the group, which were performed RRP (ч2=9,736, df=1; p2 =0,004, df=1; p>0,05); and the number of infectious complications was higher in the group, which were performed RRP, and amounted 8,6±1,8 % than in the group, which were performed MIRP, with amount 3,3±1,2% (Χ 2 =5,474, df=1; p2 =1,152, df=1; p>0,05). Percentage absence of prostate cancer, according to the final postoperative histological study group, which were performed MIRP, composed 2,9±1,1%, while the group, which were performed RRP, 3,3±1,1%. Group I was illustrated statistically significantly more patients of II prognostic group: 30,5±3,2% to 22,2±2,7% (Χ 2 =3,984, df=1; p2 =8,176, df=1; p<0,01), the difference in other prognostic groups was not statistically significant. Conclusions. The number and nature of complications, which were recorded in study groups, demonstrates the need for further development of a set of measures aimed at preventing infectious complications and cardiocerebropulmonary group during RRP and genitourinary group during MIRP. The emergence of the vast number of complications of genitourinary group that were registered in the group, which were performed MIRP, depends on the stage of formation vesico-urethral anastamosis and can be substantially reduced by its improvement.

Incidence of incisional hernia after minimally invasive and open radical prostatectomy: a population-based nationwide study

Objective: Minimally invasive techniques (laparoscopic or robot-assisted laparoscopic) are gradually becoming the methods of choice for surgical treatment of prostate cancer. However, the impact of these techniques on the risk of developing incisional hernia has yet to be fully evaluated. The aim of this study was to compare the risk of incisional hernia after open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP).Materials and methods: From the National Prostate Cancer Register of Sweden, all men who underwent radical prostatectomy for prostate cancer between 2004 and 2013 were identified. These data were linked with the National Patient Register to determine comorbidity and subsequent diagnosis of incisional hernia or surgery for incisional hernia. The endpoint was diagnosis of or surgery for incisional hernia. Multivariate proportional Cox hazard regression analyses were performed to analyze risk factors.Results: In total, 19,743 men underwent radical prostatectomy during the study period. The cumulative incidence of incisional hernia was 1.4% [95% confidence interval (CI) 1.2–1.7%] and 2.3% (CI 1.9–2.7%) 5 years after ORP and MIRP, respectively (p < .05). For men undergoing ORP, age above the median was associated with increased risk of incisional hernia (p < .001). For men undergoing MIRP, age above the median, prostate volume above the median and lymph-node dissection were associated with increased risk of incisional hernia (p < .05).Conclusion: MIRP is associated with a significantly higher risk of developing an incisional hernia compared to ORP. Awareness of appropriate surgical technique may reduce this risk.

MP69-20 THE IMPACT OF STATE LAWS LIMITING MALPRACTICE AWARDS ON DIFFUSION OF SURGICAL INNOVATION: THE CASE OF MINIMALLY INVASIVE RADICAL PROSTATECTOMY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making III1 Apr 2017MP69-20 THE IMPACT OF STATE LAWS LIMITING MALPRACTICE AWARDS ON DIFFUSION OF SURGICAL INNOVATION: THE CASE OF MINIMALLY INVASIVE RADICAL PROSTATECTOMY Shyam Sukumar, Oluwakayode Adejoro, and Badrinath Konety Shyam SukumarShyam Sukumar More articles by this author , Oluwakayode AdejoroOluwakayode Adejoro More articles by this author , and Badrinath KonetyBadrinath Konety More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2316AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While previous studies have evaluated the impact of malpractice caps on health care utilization and physician density, their effect on the adoption of innovative technology is unknown. We examined whether such caps impacted the national diffusion of minimally invasive radical prostatectomy (MIRP) for prostate cancer (PCa). For comparison we also examined trends in the diffusion of two technologies that antedate MIRP and are in their post-dissemination era: laparoscopic radical nephrectomy (LRN) and laparoscopic partial nephrectomy (LPN) for renal cell carcinoma (RCC). METHODS We identified patients ≥66 years with non-metastatic PCa between 2003-2011 in the SEER-Medicare database. Our cohort (n=129,793) was classified based on the existence of a limit on non-economic damages in their geographical locations: states with a cap before and through our study period (cap states), states without cap before and through the study (non-cap states) and states whose cap was introduced during our study period (late-cap states). Multivariable logistic regression models were fitted to examine the influence of ′cap′ status on MIRP adoption while controlling for demographic and tumor characteristics. A similar analysis was performed for patients with non-metastatic RCC undergoing LRN and LPN. RESULTS Median age (IQR) of our PCa cohort was 74 years (70-79 years). 84% were White; 97% had T1/ T2 disease and 52% had high-grade disease. 17% were treated with radical prostatectomy (RP): 8.1% with MIRP and 8% with open RP (0.9%-unknown). Adoption of MIRP was quicker in cap-states than in non-cap and late-cap states (p<0.0001, Figure 1). On multivariable analysis, there was a 70% higher likelihood of receipt of MIRP in patients in a cap-state compared to a non-cap state (OR: 1.7, P<0.0001). In contrast to MIRP, the diffusion of LPN and LRN were not different between cap and non-cap states on multivariable modeling (P≥0.05). CONCLUSIONS In a contemporary national cohort of PCa patients, states with malpractice caps had higher MIRP adoption rates. Diffusion rates of background technologies (LRN, LPN) in their post dissemination phase were not different in such states, highlighting the primacy of malpractice caps in explaining the differential effect on MIRP diffusion rates. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e934 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Shyam Sukumar More articles by this author Oluwakayode Adejoro More articles by this author Badrinath Konety More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...