Minimally Invasive Radical Prostatectomy Research Articles

Arguments against investing widely in robotic prostatectomy in Canada: a wrong focus on tool box rather than surgical expertise

The introduction of robotic-assisted minimally invasive radical prostatectomy (MIRP) in the United States is by far the most rapid adoption of an expensive new surgical device in medical history. Recent surveys reveal that robotic MIRP increased from 1% in 2001 to almost 70% of radical prostatectomies (RP), resulting recently in a 25% to 75% decline in open radical prostatectomy (ORP).1 The pressure is on in Canada to follow this pace, assuming that our patients receive suboptimal and out-dated treatment. In my opinion, there is no evidence to support such a statement and, to the contrary, there is growing evidence that a similar frenetic adoption of this technology in Canada would lead to disastrous results and would be disadvantageous for most prostate cancer patients. Here is why.

Robotic surgery techniques for obese patients

The current article reviews a single surgeon, single institution robotic assisted radical prostatectomy (RARP) outcomes of 153 cases in which outcomes were stratified based on the World Health Organization cutoff body mass index (BMI) values for normal-weight, overweight and obese.1 Significant findings included increased length of stay (4.3 vs. 2.9 days) during the initial 50 cases, however this was not observed when analyzing the entire cohort. Unfortunately, there is no clear explanation as to why obese men had a prolonged hospital stay during the initial learning curve. Overall operating room time and blood loss were statistically comparable between the 2 groups, however a trend toward increased values was seen in the obese cohort. Recently, Wiltz and colleagues reported on their evaluation of BMI impact on perioperative functional and oncological outcomes in a large RARP cohort.2 In their study, 945 men were included with all patients evaluated with the UCLA-PCI-SF36v2 validated, quality-of-life questionnaire preoperatively and postoperatively to 24 months. A similar BMI stratification was used for outcomes analysis. Their data demonstrated that, preoperatively, obese men had a significantly greater percentage of medical comorbidities (p < 0.01) as well as a baseline erectile dysfunction (lower mean baseline SHIM score p = 0.01] and UCLA-PCI-SF36v2 sexual function domain scores [p = 0.01]). Compared with the current study, the Wilts study demonstrated that operative time was significantly longer in obese patients when compared with normal and overweight men (234 min vs. 217 min vs. 214 min; p = 0.0003). This result was particularly pronounced during the initial 100 robotic-case experiences. No difference in mean hospital stay was noted. Although overall complication rates were comparable between groups, a greater incidence of case abortion caused by pneumoperitoneal pressure with excessive airway pressures was noted in obese men. Interestingly, urinary continence and potency outcomes were significantly lower for obese men at both 12 and 24 months (all p < 0.05). The authors conclude that surgeons early in their RARP learning curve should proceed cautiously with surgery in these technically more difficult patients or reserve such cases until the learning curve has been surmounted. These details, including inferior urinary and sexual outcomes, should be discussed with obese patients during preoperative counselling. Minimally invasive radical prostatectomy (MIRP) in obese men can be more challenging for several technical reasons. These include the potential for restricted instrument range of motion and reach due to a thicker abdominal wall (Fig. 1), as well as decreased intra-pelvic working space due to increased omental fat. Troubleshooting due to excess subcutaneous fat and/or visceral fat can help explain the increase in surgical time. Newer generations of the DaVinci console, with longer instrument reach, may help minimize such limitations. Exposure and closure of the specimen extraction site are often challenging in obese men. Moreover, variation in equipment (bariatric instruments and longer trocars) is often required. Fig 1 Impact of abdominal wall thickness (skin to peritoneal distance) on trocar range of motion. A) In the lean male, the rigid trocar has a greater range of motion with less tissue resistance compared to B) male with thick “belly fat” which ... Unfortunately, when using BMI to group patients into obesity categories (which is often the case in published MIRP outcomes series), one must be aware of the limitations of this measure.3 In essence, BMI assesses the entire body mass without differentiating between its components, namely muscle, visceral fat, subcutaneous fat, bone and fluid. It does not help specify those men with thick abdominal walls or those with excess omental/visceral fat. Waist-to-hip ratio (WHR) and waist circumference (WC) are other simple measurements to determine obesity. Waist circumference, 1 of the 5 specific criteria of the metabolic syndrome, has an important advantage over BMI; WC can be appreciated after a patient commits to resistance exercise or weight training. An increase in muscle mass from exercise can actually cause an increase in BMI (and actually facilitate MIRP). However, this does not occur when using WHR or WC. These measures, more so in WHR, better reflect an increase in visceral fat and a relative lack of gluteal muscle.4 Because WHR and WC are more sensitive markers for central obesity, they may better indicate risk associated with obesity with robotic surgical outcomes. Future studies should be encouraged to confirm the consistency of these results in RARP patients.

131 AN ANALYSIS OF ACADEMIC DIFFUSION OF SURGICAL INNOVATIONS IN UROLOGY

INTRODUCTION AND OBJECTIVES: Diffusion is the process by which innovations spread through social constructs. The diffusion of surgical innovations in the urological literature, and its association with diffusion of innovations into urological practice, has not been described. We analyzed the academic diffusion patterns of three major surgical innovations – minimally-invasive radical prostatectomy (MIRP), nephrectomy, and partial nephrectomy ? in the academic literature and compared them with corresponding practice diffusion patterns. METHODS: We tabulated publications focusing on MIRP and minimally-invasive radical and partial nephrectomy from 1998 to 2009 using 4 independent methods within PubMed: an unrestricted search; a restricted PubMed search including only articles with abstracts; a restricted PubMed search excluding letters, editorials, and comments; and a National Library of Medicine Medical Subject Headings (MeSH) search. The publication total for each minimally invasive surgery was divided by the corresponding surgery total (minimally-invasive and open) to obtain the proportion of publications discussing a minimallyinvasive surgery for each year. We compared year-by-year proportions in published PubMed articles to year-by-year proportions of surgeries performed as measured by the Nationwide Inpatient Sample. RESULTS: The 4 PubMed searches produced similar results (Figure 1). For each of the three surgical innovations, the onset of academic diffusion preceded the onset of clinical diffusion (Figure 2). For MIRP, clinical diffusion outpaced academic diffusion within 10 years (Figure 2). For minimally-invasive radical and partial nephrectomy, academic and clinical diffusion evinced similar patterns (Figure 2). CONCLUSIONS: While the clinical and academic diffusion patterns of radical and partial nephrectomy were similar, clinical diffusion of MIRP substantially outpaced its academic diffusion. These data further confirm that, in contrast to other surgical innovations, the clinical diffusion of MIRP preceded the publication of robust data. Source of Funding: None

Contemporaneous comparison of open vs minimally‐invasive radical prostatectomy for high‐risk prostate cancer

To analyze pathological and short-term oncological outcomes in men undergoing open and minimally-invasive radical prostatectomy (MIRP) for high-risk prostate cancer (HRPC; prostate-specific antigen level [PSA] >20 ng/mL, ≥ cT2c, Gleason score 8-10) in a contemporaneous series. In total, 913 patients with HRPC were identified in the Johns Hopkins Radical Prostatectomy Database subsequent to the inception of MIRP at this institution (2002-2011) Of these, 743 (81.4%) underwent open radical retropubic prostatectomy (ORRP), 105 (11.5%) underwent robot-assisted laparoscopic radical prostatectomy (RALRP) and 65 (7.1%) underwent laparoscopic radical prostatectomy (LRP) for HRPC. Appropriate comparative tests were used to evaluate patient and prostate cancer characteristics. Proportional hazards regression models were used to predict biochemical recurrence. Age, race, body mass index, preoperative PSA level, clinical stage, number of positive cores and Gleason score at final pathology were similar between ORRP and MIRP. On average, men undergoing MIRP had smaller prostates and more organ-confined (pT2) disease (P = 0.02). The number of surgeons and surgeon experience were greatest for the ORRP cohort. Overall surgical margin rate was 29.4%, 34.3% and 27.7% (P = 0.52) and 1.9%, 2.9% and 6.2% (P = 0.39) for pT2 disease in men undergoing ORRP, RALRP and LRP, respectively. Biochemical recurrence-free survival among ORRP, RALRP and LRP was 56.3%, 67.8% and 41.1%, respectively, at 3 years (P = 0.6) and the approach employed did not predict biochemical recurrence in regression models. At an experienced centre, MIRP is comparable to open radical prostatectomy for HRPC with respect to surgical margin status and biochemical recurrence.

Outcomes after minimally invasive radical prostatectomy (MIRP) versus open radical prostatectomy (OPRP) in patients older than 70

Outcomes after minimally invasive radical prostatectomy (MIRP) versus open radical prostatectomy (OPRP) in patients older than 70

Patterns of minimally invasive radical prostatectomy (MIRP) versus open radical retropubic prostatectomy (ORP) in patients older than 70

Patterns of minimally invasive radical prostatectomy (MIRP) versus open radical retropubic prostatectomy (ORP) in patients older than 70

Anastomotic Stricture After Minimally Invasive Radical Prostatectomy: What Should Be Expected from the Van Velthoven Single-Knot Running Suture?

Patients with localized prostate cancer (PCa) who are treated by radical prostatectomy (RP) have a good overall survival rate. Their quality of life, however, can deteriorate because of the incidence of bladder neck contracture (BNC). Our aim was to evaluate the incidence and the risk factors of BNC after minimally invasive radical prostatectomy (MIRP) with a single-knot running suture also known as the Van Velthoven technique (VVT). From 2003 to 2010, 2115 patients underwent extraperitoneal, transperitoneal, or robot-assisted RP for localized PCa. A single-knot running suture according to the VVT was performed for the vesicourethral anastomosis. Follow-up was scheduled and standardized for all patients and recorded into a prospective database. BNC was defined by a reduction of the lumen that does not allow the passage of an 18F fibroscope. Mean follow-up of the patients was 43 (6-144) months. Of all, 1342, 241, and 532 had extraperitoneal, transperitoneal, and robot-assisted prostatectomy, respectively. BNC was diagnosed in 30 (1.4%) patients. Among them, 78% had the diagnosis within the first year of follow-up. Previous transurethral resection of the prostate (TURP) and external beam radiotherapy were independent risk factors of BNC. BNC incidence after MIRP using the single-knot running suture for the vesicourethral anastomosis is low. Previous TURP and external beam radiotherapy are identified as risk factors. This technique showed satisfying results regardless of the classic laparoscopic or robot-assisted approach.

334 FACTORS ASSOCIATED WITH THE ADOPTION OF MINIMALLY-INVASIVE RADICAL PROSTATECTOMY IN THE UNITED STATES

You have accessJournal of UrologyProstate Cancer: Epidemiology and Natural History II1 Apr 2012334 FACTORS ASSOCIATED WITH THE ADOPTION OF MINIMALLY-INVASIVE RADICAL PROSTATECTOMY IN THE UNITED STATES William Ulmer, Sandip Prasad, Keith Kowalczyk, Xiangmei Gu, Christopher Dodgion, Stuart Lipsitz, and Jim Hu William UlmerWilliam Ulmer Boston, MA More articles by this author , Sandip PrasadSandip Prasad Chicago, IL More articles by this author , Keith KowalczykKeith Kowalczyk Washington DC, DC More articles by this author , Xiangmei GuXiangmei Gu Boston, MA More articles by this author , Christopher DodgionChristopher Dodgion Boston, MA More articles by this author , Stuart LipsitzStuart Lipsitz Boston, MA More articles by this author , and Jim HuJim Hu Boston, MA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.395AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Minimally invasive radical prostatectomy (MIRP) has supplanted retropubic radical prostatectomy (RRP) in popularity despite the absence of comparative effectiveness data demonstrating superiority. We examined the influence of patient, surgeon, and hospital characteristics on the utilization of MIRP vs. RRP. METHODS Using Surveillance, Epidemiology and End Results-Medicare linked data, we identified 6,880 men diagnosed with prostate cancer from 2002-2005 who subsequently underwent radical prostatectomy. We assessed the relative contribution of patient, surgeon and hospital characteristics on the likelihood of undergoing MIRP vs. RRP using multi-level logistic regression mixed models. RESULTS Hospital factors (28.5%) contributed most to the use of MIRP vs. RRP, followed by patient (25.3%) and surgeon (12.5%) factors. Among patient-specific factors, Asian race (vs. white: odds ratio [OR] 1.86, 95% confidence interval [CI] 1.27–2.72; p=0.001), stage T1 tumors (vs. T3/T4: OR 2.71, 95% CI 1.60–4.57, p<0.001), and obtaining a second opinion (OR 3.41, 95% CI 2.67-4.37, p<0.001) were associated with increased MIRP utilization while lower median income was associated with decreased MIRP utilization. Among surgeon- and hospital-specific factors, increasing surgeon volume (OR 1.022, 95% CI 1.015-1.028, p<0.001), surgeon age less than 50 (OR 2.68, 95% CI 1.69–4.24, p<0.001), and hospital bed size (OR 1.001, 95% CI 1.001-1.002, p<0.001) were associated with increased MIRP utilization, while surgeons employed in a solo or two physician practice was associated with decreased MIRP utilization (OR 0.48, 95% CI 0.27–0.86, p=0.013). CONCLUSIONS The rapid adoption of MIRP vs. RRP is multi-factorial and associated with specific patient-, surgeon-, and hospital-related factors. Men receiving a second opinion are over three times more likely to undergo MIRP, which may reflect the influence of direct-to consumer advertising on utilization of MIRP. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e136 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information William Ulmer Boston, MA More articles by this author Sandip Prasad Chicago, IL More articles by this author Keith Kowalczyk Washington DC, DC More articles by this author Xiangmei Gu Boston, MA More articles by this author Christopher Dodgion Boston, MA More articles by this author Stuart Lipsitz Boston, MA More articles by this author Jim Hu Boston, MA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1806 PREDICTORS OF THE CONTEMPORARY USE OF MINIMALLY INVASIVE RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized IX1 Apr 20121806 PREDICTORS OF THE CONTEMPORARY USE OF MINIMALLY INVASIVE RADICAL PROSTATECTOMY Gurdarshan S. Sandhu, Seth A. Strope, Adam S. Kibel, Pamela L. Owens, Youssef S. Tanagho, Dorina Kallogjeri, Sam B. Bhayani, and Kenneth G. Nepple Gurdarshan S. SandhuGurdarshan S. Sandhu St. Louis, MO More articles by this author , Seth A. StropeSeth A. Strope St. Louis, MO More articles by this author , Adam S. KibelAdam S. Kibel Boston, MA More articles by this author , Pamela L. OwensPamela L. Owens St. Louis, MO More articles by this author , Youssef S. TanaghoYoussef S. Tanagho St. Louis, MO More articles by this author , Dorina KallogjeriDorina Kallogjeri St. Louis, MO More articles by this author , Sam B. BhayaniSam B. Bhayani St. Louis, MO More articles by this author , and Kenneth G. NeppleKenneth G. Nepple St. Louis, MO More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1872AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The surgical approach to the treatment of prostate cancer has changed dramatically with the introduction and adoption of new surgical technology. Clinical and socioeconomic factors may influence the utilization of minimally invasive radical prostatectomy (MIRP). Using a population-based sample from the United States, we evaluated predictors of the choice of MIRP compared to open radical retropubic prostatectomy (RRP). METHODS Hospital discharge information (State Inpatient Databases from the Healthcare Cost and Utilization Project) from ten states (Arizona, California, Florida, Iowa, Maryland, Michigan, Nebraska, New Jersey, New York, Washington) was evaluated for 2009. Using ICD-9 procedural coding, patients who underwent radical prostatectomy for prostate cancer were identified. Prostatectomy was classified as MIRP based on the presence of a secondary code for laparoscopic or robotic surgery. Demographic and socioeconomic variables assessed were age, race, insurance type, geographic location (urban vs. rural) and median income by zip code. Medical comorbidity was evaluated by the modified Elixhauser method using the Agency for Healthcare Research and Quality (AHRQ) comorbidity measure. Predictors of MIRP were assessed by univariable logistic regression, and factors with p<0.10 were included in a multivariable model. RESULTS 27,399 radical prostatectomies were performed in 10 states in 2009, of which 18,185 were MIRP (66.4%). Differences were present in patients who underwent MIRP vs. RRP (Table 1). On multivariate analysis (Table 2), MIRP was less likely to be performed in men who were older, from rural or lower income areas, or had medical comorbidities. Table 1. Differences in patients undergoing MIRP and RRP Variable MIRP RRP p value Age (mean) 61.1 61.5 <0.0001 Race <0.0001 White 76.8% 72.2% Black 10.4% 11.5% Other 12.8% 16.4% Insurance <0.0001 Private 65.3% 59.8% Medicare 30.1% 31.9% Other 4.7% 8.4% Income quartile <0.0001 1st 15.8% 19.7% 2nd 21.3% 24.6% 3rd 27.1% 26.0% 4th 35.9% 29.7% Rural location 10.1% 14.3% <0.0001 Table 2. Predictors of MIRP in 2009 based on multivariate logistic regression analysis Variable Odds Ratio 95% CI p value Age (per year older) 0.99 0.99-0.99 0.02 Black race (vs. white) 0.95 0.86-1.04 0.28 Other race (vs. white) 0.77 0.71-0.84 <0.001 Medicare (vs. private) 0.99 0.92-1.07 0.85 Other payer (vs. private) 0.59 0.53-0.67 <0.001 Income quartile 1 (vs 4) 0.80 0.73-0.87 <0.001 Income quartile 2 (vs. 4) 0.83 0.77-0.89 <0.001 Income quartile 3 (vs. 4) 0.93 0.86-0.99 0.04 Rural (vs. urban) 0.71 0.64-0.77 <0.001 Chronic blood loss anemia 0.33 0.21-0.53 <0.001 Chronic deficiency anemia 0.50 0.43-0.58 <0.001 COPD 0.88 0.79-0.97 0.01 Diabetes complicated 0.65 0.48-0.86 0.003 Electrolyte abnormality 0.71 0.60-0.84 <0.001 Hypertension 0.93 0.88-0.99 0.02 Peripheral vascular disease 0.72 0.55-0.94 0.01 CONCLUSIONS Choice of surgical approach appears to be influenced by both demographic, socioeconomic, and clinical factors. Disparities may exist in access to robotic surgery, and/or younger patients with fewer comorbidities may be offered or pursue robotic surgery as their treatment. This analysis is limited by the lack of pathologic features in this administrative data source. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e729 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gurdarshan S. Sandhu St. Louis, MO More articles by this author Seth A. Strope St. Louis, MO More articles by this author Adam S. Kibel Boston, MA More articles by this author Pamela L. Owens St. Louis, MO More articles by this author Youssef S. Tanagho St. Louis, MO More articles by this author Dorina Kallogjeri St. Louis, MO More articles by this author Sam B. Bhayani St. Louis, MO More articles by this author Kenneth G. Nepple St. Louis, MO More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

509 OUTCOMES OF RADICAL PROSTATECTOMY IN VERY OBESE MEN USING AN EXTRAPERITONEAL MINIMALLY-INVASIVE APPROACH

You have accessJournal of UrologyProstate Cancer: Localized II1 Apr 2012509 OUTCOMES OF RADICAL PROSTATECTOMY IN VERY OBESE MEN USING AN EXTRAPERITONEAL MINIMALLY-INVASIVE APPROACH Debasish Sundi, Adam C. Reese, Bruce J. Trock, Lynda Z. Mettee, and Christian P. Pavlovich Debasish SundiDebasish Sundi Baltimore, MD More articles by this author , Adam C. ReeseAdam C. Reese Baltimore, MD More articles by this author , Bruce J. TrockBruce J. Trock Baltimore, MD More articles by this author , Lynda Z. MetteeLynda Z. Mettee Baltimore, MD More articles by this author , and Christian P. PavlovichChristian P. Pavlovich Baltimore, MD More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.580AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Extremely obese men with prostate cancer pose a significant surgical challenge. Studies of minimally invasive radical prostatectomy (MIRP) have shown higher BMI to correlate with worse operative and pathologic outcomes; thus the super-obese are often referred for radiation therapy. With the ability to offer MIRP to the super-obese, new challenges potentially arise, so we queried our database for any effects of excessive BMI on surgical outcome. METHODS Preoperative characteristics and short-term outcomes of men from a single-surgeon series of 1,023 consecutive MIRP from 2001-2011 were analyzed using BMI as a categorical (Chi-square) and continuous (one-way ANOVA) variable. Analyses were repeated after grouping men in the two highest BMI categories. Multivariable logistic regression analyses were performed to create predictive models of operating time (OT), length of stay (LOS), and pathologic stage. RESULTS 231 men had BMI <25, 563 BMI >25 and <30, 152 BMI >30 and <35 (class I obesity), 28 BMI >35 and <40 (class II obesity), and 13 BMI >40 (class III obesity). Baseline clinicopathologic parameters were similar across BMI categories, but men in higher BMI categories had higher AUA symptom scores (p=0.032). 83% of the class II- and class III- obese men were operated on in the last 4-years (p<0.001). An extraperitoneal approach was used in 64% of men, and in 78% of men with BMI >35 (p=0.054). There were no differences in EBL, pathologic grade, stage, capsular incisions, positive margins, or perioperative complications across BMI categories. However, men with BMI >35 underwent underwent pelvic lymphadenectomy less often (p=0.026), and had shorter LOS (1.4 versus 1.7 days, p=0.039). BMI was not associated with higher pathologic stage, capsular incisions, or positive surgical margins when controlling for preoperative variables. Longer OT was predicted by perioperative complications, greater EBL, greater number of nerves spared, and transperitoneal (as opposed to extraperitoneal) approach, but not increasing BMI. Longer LOS was also associated with complications and transperitoneal approach, but not increasing BMI. CONCLUSIONS Class II- and III-obese men account for a greater proportion of patients in a MIRP series. Even in these extreme obesity categories, MIRP can be performed safely, with perioperative and oncologic outcomes that compare favorably to those of other men when employing an extraperitoneal approach. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e209 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Debasish Sundi Baltimore, MD More articles by this author Adam C. Reese Baltimore, MD More articles by this author Bruce J. Trock Baltimore, MD More articles by this author Lynda Z. Mettee Baltimore, MD More articles by this author Christian P. Pavlovich Baltimore, MD More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Venous thromboembolism after radical prostatectomy: the effect of surgical caseload

What's known on the subject? and What does the study add? Several risk factors increase VTE after RP: advanced age, comorbidities such as cardiopulmonary disease, rheumatologic diseases, prior history of VTE, more advanced prostate cancer, and simultaneous pelvic lymph node dissection. To date, the effect of annual surgical caseload (ASC), an established determinant of various RP outcomes, has not been tested. A previous study showed in adjusted analyses that patients operated for colorectal cancer by very high ASC surgeons were 60% less likely to suffer a VTE than those operated by low ASC surgeons. Moreover, some authors hypothesized that laparoscopy may contribute to a higher risk of VTE, due to peritoneal insufflation, reverse Trendelenburg position and prolonged operative time. The VTE rates reported in the current population-based study closely reflect those reported in institutional series. Moreover, we validated the practice-makes-perfect concept, since ASC was linked to VTE. We could not detect statistically significantly differences between minimally invasive radical prostatectomy (MIRP) patients and others. Our results indicate that lower rates of VTE should be expected in patients treated by high ASC surgeons. Our findings suggest that VTE-specific processes of care need to be improved, with the intent of reaching the level recorded in patients treated by high ASC surgeons. Finally, MIRP seems to be no risk factor for VTE. To examine the effect of annual surgical caseload (ASC) on the likelihood of venous thromboembolism (VTE) after radical prostatectomy (RP). Between 1999 and 2008, 36 699 RPs were performed in the state of Florida. Logistic regression models predicting the likelihood of VTE were fitted. Covariates included year of surgery, age, race, baseline Charlson Comorbidity Index (CCI), lymph node dissection, ASC and surgical approach. The overall VTE rate was 0.3%. It was higher in patients operated within the low (0.4%) and intermediate (0.3%) ASC tertile than in those operated within the high-ASC tertile (0.1%, P < 0.001). Mortality rate was 6.0% in patients with VTE vs 0.1% in others (P < 0.001). Median length of stay and median total hospital charges were 9 vs 3 days (P < 0.001) and $51 571 vs $24 943 (P < 0.001) in patients with VTE vs others, respectively. In multivariable analyses predicting VTE, patients operated on by low-ASC surgeons were at higher risk of VTE than those operated on by high-ASC surgeons (odds ratio [OR] = 3.78, P < 0.001). Additionally, black patients were more likely to experience a VTE (OR = 1.80, P = 0.023). Patients with CCI ≥ 1 were also more likely to experience a VTE than others (OR = 1.65, P = 0.016). Conversely, patients who had undergone minimally invasive radical prostatectomy were not more likely to experience a VTE than those who had undergone open RP (OR = 1.97, P = 0.086). RP by high-ASC surgeons exerts a protective effect on the likelihood of VTE. Additionally, VTE is associated with higher mortality, prolonged length of stay and increased hospital charges.

Editorial Comment

The present study is a comprehensive examination of transfusion rates after radical prostatectomy (RP) performed in the US between the years 1998 and 2007. Unlike other reported studies that have analyzed the SEER Medicare linked cohort, which is limited to RP performed in men >65 years of age (Ref 24, 25 in the manuscript), the present study uses the Nationwide Inpatient Sample (NIS) discharge records, which includes 119,966 RPs performed at hospitals within the US unrestricted to an age cohort. The lack of an age restriction in the present study is a major strength that makes the observations and conclusions more reflective of outcomes after RP in the US. Blood Transfusions in Radical Prostatectomy: A Contemporary Population-based AnalysisUrologyVol. 79Issue 2PreviewTo examine the homologous blood transfusion (HBT), autologous blood transfusion (ABT) and intraoperative blood conservation technique (IOBCT) rates and trends at open (ORP) and minimally invasive radical prostatectomy (MIRP). Full-Text PDF ReplyUrologyVol. 79Issue 2PreviewWe read with great interest the comment, which pertained to our recent report. Since the advent of minimally invasive approach in radical prostatectomy (MIRP) in the context of patients diagnosed with prostate cancer, the comparisons between MIRP and open RP (ORP) are vast, among which is the subject of blood loss. In this regard, 2 principal observations were recorded within our study. First, the overall rates of homologous blood transfusion (HBT), autologous blood transfusion (ABT), and intraoperative blood conservation techniques were persistently lower for MIRP-treated patients compared with ORP, regardless of hospital caseload, even after the adjustment for all other available covariates. Full-Text PDF

Blood Transfusions in Radical Prostatectomy: A Contemporary Population-based Analysis

To examine the homologous blood transfusion (HBT), autologous blood transfusion (ABT) and intraoperative blood conservation technique (IOBCT) rates and trends at open (ORP) and minimally invasive radical prostatectomy (MIRP). The Nationwide Inpatient Sample was queried. Multivariable logistic regression models focused on all three transfusion types. Covariables consisted of procedure specific annual hospital caseload (AHC), year of surgery, age, Charlson Comorbidity Index, and region. Overall, 119,966 patients underwent radical prostatectomy between 1998 and 2007. The HBT, ABT, and IOBCT rates were 6.2%, 6.0%, and 1.2%, respectively. HBT rates ranged from 5.1-5.1% between 1998 and 2007 (P=.49) vs 9.4-2.7% (P<.001) for ABT vs 1.9-0.9% (P=.003) for IOBCT in the same time period, respectively. In multivariable analyses, ORP patients treated at intermediate (odds ratio [OR] 1.48, P=.003) and low (OR 2.73, P<.001) AHC institutions were more likely to receive an HBT than ORP patients treated at high AHC institutions. Conversely, MIRP patients treated at high (OR 0.46, P=.040), intermediate (OR 0.27, P=.001), and low (OR 0.59, P=.015) AHC institutions were less likely to receive an HBT than ORP patients treated at high AHC institutions. Our results indicate that the overall transfusion rate at radical prostatectomy decreased within the last decade because of a substantial decline in ABT use. Moreover, MIRP protects from HBT, even when performed at low AHC Centers.

877 Positive surgical margins after minimally-invasive radical prostatectomy in pT2 and pT3a population could be considered as pathological upstaging

877 Positive surgical margins after minimally-invasive radical prostatectomy in pT2 and pT3a population could be considered as pathological upstaging

Perioperative Outcomes of Robot-Assisted Radical Prostatectomy Compared With Open Radical Prostatectomy: Results From the Nationwide Inpatient Sample

BackgroundPrior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates. ObjectiveAssess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARP's supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique. Design, setting, and participantsAs of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP (n=11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients (n=7389). InterventionAll patients underwent RARP or ORP. MeasurementsWe compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score–matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors. Results and limitationsOf 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score–matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.28–0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31–0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77–0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26–0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up. ConclusionsRARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes.

Temporal National Trends of Minimally Invasive and Retropubic Radical Prostatectomy Outcomes from 2003 to 2007: Results from the 100% Medicare Sample

BackgroundAlthough the use of minimally invasive radical prostatectomy (MIRP) has increased, there are few comprehensive population-based studies assessing temporal trends and outcomes relative to retropubic radical prostatectomy (RRP). ObjectiveAssess temporal trends in the utilization and outcomes of MIRP and RRP among US Medicare beneficiaries from 2003 to 2007. Design, setting, and participantsA population-based retrospective study of 19 594 MIRP and 58 638 RRP procedures was performed from 2003 to 2007 from the 100% Medicare sample, composed of almost all US men ≥65 yr of age. InterventionMIRP and RRP. MeasurementsWe measured 30-d outcomes (cardiac, respiratory, vascular, genitourinary, miscellaneous medical, miscellaneous surgical, wound complications, blood transfusions, and death), cystography utilization within 6 wk of surgery, and late complications (anastomotic stricture, ureteral complications, rectourethral fistulae, lymphocele, and corrective incontinence surgery). Results and limitationsFrom 2003 to 2007, MIRP increased from 4.9% to 44.5% of radical prostatectomies while RRP decreased from 89.4% to 52.9%. MIRP versus RRP subjects were younger (p<0.001) and had fewer comorbidities (p<0.001). Decreased MIRP genitourinary complications (6.2–4.1%; p = 0.002), miscellaneous surgical complications (4.7–3.7%; p=0.030), transfusions (3.5–2.2%; p=0.005), and postoperative cystography utilization (40.3–34.1%; p<0.001) were observed over time. Conversely, overall RRP perioperative complications increased (27.4–32.0%; p<0.001), including an increase in perioperative mortality (0.5–0.8%, p=0.009). Late RRP complications increased, with the exception of fewer anastomotic strictures (10.2–8.8%; p=0.002). In adjusted analyses, RRP versus MIRP was associated with increased 30-d mortality (odds ratio [OR]: 2.67; 95% confidence interval [CI], 1.55–4.59; p<0.001) and more perioperative (OR: 1.60; 95% CI, 1.45–1.76; p<0.001) and late complications (OR: 2.52; 95% CI, 2.20–2.89; p<0.001). Limitations include the inability to distinguish MIRP with versus without robotic assistance and also the lack of pathologic information. ConclusionsFrom 2003 to 2007, there were fewer MIRP transfusions, genitourinary complications, and miscellaneous surgical complications, whereas most RRP perioperative and late complications increased. RRP versus MIRP was associated with more postoperative mortality and complications.

Costs of medical care after open or minimally invasive prostate cancer surgery

Evidence suggests that minimally invasive radical prostatectomy (MRP) and open radical prostatectomy (ORP) have similar short-term clinical and functional outcomes. MRP with robotic assistance is generally more expensive than ORP, but it is not clear whether subsequent costs of care vary by approach. In the Surveillance, Epidemiology, and End Results (SEER) cancer registry linked with Medicare claims, men aged 66 years or older who received MRP or ORP in 2003 through 2006 for prostate cancer were identified. Total cost of care was estimated as the sum of Medicare payments from all claims for hospital care, outpatient care, physician services, home health and hospice care, and durable medical equipment in the first year from the date of surgical admission. The impact of surgical approach on costs was estimated, controlling for patient and disease characteristics. Of 5445 surgically treated prostate cancer patients, 4454 (82%) had ORP and 991 (18%) had MRP. Mean total first-year costs were more than $1200 greater for MRP compared with ORP ($16,919 vs $15,692; P = .08). Controlling for patient and disease characteristics, MRP was associated with 2% greater mean total payments, but this difference was not statistically significant. First-year costs were greater for men who were older, black, lived in the Northeast, had lymph node involvement, more advanced tumor stage, or greater comorbidity. In this population-based cohort of older men, MRP and ORP had similar economic outcomes. From a payer's perspective, any benefits associated with MRP may not translate to net savings compared with ORP in the first year after surgery.

15 A population-based analysis of temporal peri-operative complication rates after minimally invasive radical prostatectomy

Existing population-based reports on complication rates after minimally invasive radical prostatectomy (MIRP) did not address temporal trends.To examine contemporary temporal trends in perioperative MIRP outcomes.Between 2001 and 2007, 4387 patients undergoing MIRP were identified using the Nationwide Inpatient Sample.To examine the rates and trends of intraoperative and postoperative complications, transfusion rates, length of stay in excess of the median, and in-hospital mortality. We tested the effect of the late (2006-2007) versus the early (2001-2005) study period on all outcomes using multivariable logistic regression models controlled for clustering among hospitals.Intraoperative and postoperative complications decreased from 7.0% to 0.8% (p < 0.001) and from 28.5% to 8.7% (p < 0.001), respectively. Transfusion rates decreased from 3.5% to 2.1% (p = 0.3). Hospital length of stay >2 d decreased from 56% to 15% (p < 0.001). In multivariable analyses, intraoperative (odds ratio [OR]: 0.41; p = 0.002) and postoperative (OR: 0.65; p = 0.007) complications were less frequent in the late versus the early study period. Late study period patients were less likely to stay >2 d than early study period patients (OR: 0.34; p > 0.001). Limitations of these findings include the lack of adjustment for several patient variables including disease characteristics, surgeon variables including surgeon caseload, and the restriction to in-hospital events.Our analyses demonstrate that in-hospital complication rates and length of stay after MIRP decreased over time. This implies that temporal differences specific to complication rates after MIRP must be considered when comparisons are made with other radical prostatectomy techniques.

Comparison of Extraperitoneal and Transperitoneal Pelvic Lymph Node Dissection During Minimally Invasive Radical Prostatectomy

Pelvic lymph node dissection (PLND) during radical prostatectomy (RP) has prognostic and possible therapeutic benefits. We assessed whether an extraperitoneal minimally invasive RP (MiRP) allows for standard-template PLND comparable to transperitoneal MiRP+PLND. A retrospective clinicopathologic study of 914 consecutive patients who underwent MiRP (laparoscopic or Da Vinci robot-assisted laparoscopic) with bilateral PLND by one surgeon (CPP) from 2001 to 2010 was performed. Low-risk patients generally received a limited dissection (external iliac nodes) when PLND was performed. Those with intermediate- and high-risk disease generally received a standard PLND (external iliac and obturator nodes). Patients were stratified into groups based on operative approach (extraperitoneal vs transperitoneal) for most analyses. Overall, 192 patients had transperitoneal MiRP+PLND, and 377 had extraperitoneal MiRP+PLND. The extraperitoneal group had higher body mass index (P=0.03), a higher percentage of low-risk (P=0.003), and a lower percentage of intermediate-risk disease (P=0.006). Lymph node yield (LNY) was higher with extraperitoneal PLND overall (6.5 vs 5.3, P=0.003). When stratified by risk category, LNY was greater in the extraperitoneal group for patients with low-risk disease only (6.6 vs 4.9, P=0.008). There was no difference in nodal yield in intermediate/high-risk patients receiving standard PLND by either the transperitoneal or extraperitoneal approach (6.0 vs 5.5, P=0.36 and 8.0 vs 5.8, P=0.14, respectively). Lymph node involvement was rare overall. Estimated blood loss and complication rates were comparable between operative approaches. The extraperitoneal MiRP approach does not compromise the oncologic efficacy or safety of routine PLND.

Improvement of racial disparities with respect to the utilization of minimally invasive radical prostatectomy in the United States

Race represents an established barrier to health care access in the United States and elsewhere. We examined whether race affects the utilization rate of minimally invasive radical prostatectomy (MIRP) in a population-based sample of individuals from the United States. Within the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS), we focused on patients in whom MIRP and open radical prostatectomy (ORP) were performed between 2001 and 2007. We assessed the proportions and temporal trends in race distributions between MIRP and ORP. Multivariable logistic regression analyses further adjusted for age, year of surgery, baseline Charlson Comorbidity Index, annual hospital caseload tertiles, hospital region, insurance status, and median zip code income. Of 65,148 radical prostatectomies, 3581 (5.5%) were MIRPs. African Americans accounted for 11.4% of patients versus 78.8% for Caucasians versus 9.9% for others. Between 2001 and 2007, the annual proportions of Caucasian patients treated with MIRP were 2.2%, 0.9%, 2.6%, 7.2%, 4.7%, 9.3%, and 11.6%, respectively (chi-square trend p<0.001). For the same years in African American patients, the proportions were 0.8, 0.3, 1.4, 4.4, 3.5, 9.0 and 8.4% (chi-square trend P < .001). In multivariable analyses relative to Caucasian patients, African American patients were 14% less likely to undergo MIRP (P = .01). After period stratification between years 2001-2005 versus 2006-2007, African Americans were 22% less likely to undergo a MIRP in the early period (P = .007) versus 11% less likely to have a MIRP in the contemporary period (P = .1). The racial discrepancies in MIRP utilization rates are gradually improving.