Radical Prostatectomy Volume Research Articles

Efficiency and productivity gains of robotic surgery: The case of the English National Health Service.

This paper examines the effect of new medical technology (robotic surgery) on efficiency gains and productivity changes for surgical treatment in patients with prostate cancer from the perspective of a public health sector organization. In particular, we consider three interrelated surgical technologies within the English National Health System: robotic, laparoscopic and open radical prostatectomy. Robotic and laparoscopic techniques are minimally invasive procedures with similar clinical benefits. While the clinical benefits in adopting robotic surgery over laparoscopic intervention are unproven, it requires a high initial investment cost and carries high on-going maintenance costs. Using data from Hospital Episode Statistics for the period 2000-2018, we observe growing volumes of prostatectomies over time, mostly driven by an increase in robotic-assisted surgeries, and further analyze whether hospital providers that adopted a robot see improved measures of throughput. We then quantify changes in total factor and labor productivity arising from the use of this technology. We examine the impact of robotic adoption on efficiency gains employing a staggered difference-in-difference estimator and find evidence of a 50% reduction in length of stay (LoS), 49% decrease in post-LoS and 44% and 46% decrease in postoperative visits after 1year and 2years, respectively. Productivity analysis shows the growth in radical prostatectomy volume is sustained with a relatively stable number of urology surgeons. The robotic technique increases total production at the hospital level between 21% and 26%, coupled with a 29% improvement in labor productivity. These benefits lend some, but not overwhelming support for the large-scale hospital investments in such costly technology.

Does Centralization of Radical Prostatectomy Reduce the Incidence of Postoperative Urinary Incontinence?

BackgroundOn the basis of previous analyses of the incidence of urinary incontinence (UI) after radical prostatectomy (RP), the hospital RP volume threshold in the Netherlands was gradually increased from 20 per year in 2017, to 50 in 2018 and 100 from 2019 onwards. ObjectiveTo evaluate the impact of hospital RP volumes on the incidence and risk of UI after RP (RP-UI). Design, setting, and participantsPatients who underwent RP during 2016–2020 were identified in the claims database of the largest health insurance company in the Netherlands. Incontinence was defined as an insurance claim for ≥1 pads/d. Outcome measurements and statistical analysisThe relationship between hospital RP volume (HV) and RP-UI was assessed via multivariable analysis adjusted for age, comorbidity, postoperative radiotherapy, and lymph node dissection. Results and limitationsRP-UI incidence nationwide and by RP volume category did not decrease significantly during the study period, and 5-yr RP-UI rates varied greatly among hospitals (19–85%). However, low-volume hospitals (≤120 RPs/yr) had a higher percentage of patients with RP-UI and higher variation in comparison to high-volume hospitals (>120 RPs/yr). In comparison to hospitals with low RP volumes throughout the study period, the risk of RP-UI was 29% lower in hospitals shifting from the low-volume to the high-volume category (>120 RPs/yr) and 52% lower in hospitals with a high RP volume throughout the study period (>120 RPs/yr for 5 yr). ConclusionsA focus on increasing hospital RP volumes alone does not seem to be sufficient to reduce the incidence of RP-UI, at least in the short term. Measurement of outcomes, preferably per surgeon, and the introduction of quality assurance programs are recommended. Patient summaryIn the Netherlands, centralization of surgery to remove the prostate (RP) because of cancer has not yet improved the occurrence of urinary incontinence (UI) after surgery. Hospitals performing more than 120 RP operations per year had better UI outcomes. However, there was a big difference in UI outcomes between hospitals.

Impact of Robotic Technologies on Prostate Cancer Patients' Choice for Radical Treatment.

Prostate cancer (PCa) surgery has a strong impact on men's social and sexual lives. For this reason, many patients ask for robotic surgery. To assess the rate of lost patients due to the lack of a robotic platform (RPl) at our center, we retrospectively selected 577 patients who underwent prostate biopsy between 2020 and 2021 who were eligible for radical prostatectomy (RP) (ISUP ≥ 2; age ≤ 70 yr). Patients eligible for surgery who decided to be operated received a phone call interview asking the reason for their choice. Overall, 230 patients (31.7%) underwent laparoscopic-assisted radical prostatectomy (LaRP) at our center, while 494 patients (68.3%) were not treated in our hospital. Finally, 347 patients were included: 87 patients (25.1%) underwent radiotherapy; 59 patients (17%) were already under another urologist's care; 113 patients (32.5%) underwent robotic surgery elsewhere; and 88 patients (25.4%) followed the suggestion of friends or relatives based on their surgical experience. Despite no surgical technique for RP having shown superiority in terms of oncological or functional outcomes, patients eligible for PCa treatment decided to be operated on elsewhere because of the lack of an RPl. Our results show how the presence of an RPl may increase the case volume of RP by 49% at our center.

MP48-10 ANDROGEN DEPRIVATION THERAPY FOR NODE-POSITIVE PROSTATE CANCER AT RADICAL PROSTATECTOMY AND PELVIC LYMPH NODE DISSECTION: CONTEMPORARY PRACTICE PATTERNS AND ASSOCIATED FACTORS

You have accessJournal of UrologyCME1 May 2022MP48-10 ANDROGEN DEPRIVATION THERAPY FOR NODE-POSITIVE PROSTATE CANCER AT RADICAL PROSTATECTOMY AND PELVIC LYMPH NODE DISSECTION: CONTEMPORARY PRACTICE PATTERNS AND ASSOCIATED FACTORS Leilei Xia, Ruchika Talwar, Raju Chelluri, Daniel Lee, and Thomas Guzzo Leilei XiaLeilei Xia More articles by this author , Ruchika TalwarRuchika Talwar More articles by this author , Raju ChelluriRaju Chelluri More articles by this author , Daniel LeeDaniel Lee More articles by this author , and Thomas GuzzoThomas Guzzo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002619.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Current guidelines recommend observation or adjuvant androgen deprivation therapy (ADT) with or without external beam radiation therapy (EBRT) for node-positive prostate cancer at radical prostatectomy (RP) and pelvic lymph node dissection (PLND). There is limited data on contemporary practice patterns and factors associated with the usage of ADT at the national level. METHODS: Patients with cT1-2N0M0 prostate cancer diagnosed between 2006 and 2015 who underwent RP and PLND and then were found to have pathologically positive lymph node (LN) were identified from National Cancer Database (NCDB). Patients were stratified into 3 cohorts based on the number of positive LNs (1 LN vs. 2 LNs vs. ≥3 LNs). Some of the covariables included hospital volume of RP (low vs. medium vs. high), more extended PLND (≥11 nodes vs. <11 nodes removed), positive surgical margin (PSM), and pT stage (pT3-4 vs. pT2). Primary outcome was ADT usage (with or without the EBRT). RESULTS: A total of 4,641 patients were included: 2,998 patients with 1 positive LN, 837 with 2 positive LNs, and 806 with ≥3 positive LNs. In the overall cohort, 56.4% did not receive ADT, 24.3% received ADT only, and 19.2% received ADT+EBRT. The distributions of observation vs. ADT vs. ADT+EBRT stratified by positive LNs, PSM, and pT stage are shown in the Figure. Multivariable logistic regressions showed that compared with 1 LN, 2 LNs (odds ratio [OR]=1.49, P <0.001) and ≥3 LNs (OR=1.83, P <0.001) were associated with higher odds of receiving ADT. Patients with PSM (OR=1.81, P <0.001) and pT3-4 cancer (OR=1.65, P <0.001) were significantly more likely to receive ADT. More extended PLND was associated with lower odds of receiving ADT (OR=0.76, P <0.001). Compared with low RP volume, patients who had RP at medium volume (OR=0.80, P=0.005) and high volume (OR=0.66, P <0.001) hospitals were less likely to receive ADT. CONCLUSIONS: This NCDB study suggests that clinicians have been selectively offering ADT based on adverse pathological features and extension of PLND. Variations of ADT usage among hospitals may be related to RP surgical volumes. These findings have implications for patient counseling, policymaking, and further trial design for these groups of aggressive and heterogeneous cancers. Source of Funding: NA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e824 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Leilei Xia More articles by this author Ruchika Talwar More articles by this author Raju Chelluri More articles by this author Daniel Lee More articles by this author Thomas Guzzo More articles by this author Expand All Advertisement PDF DownloadLoading ...

Association of surgeon and hospital volume with short-term outcomes after robot-assisted radical prostatectomy: Nationwide, population-based study.

Background and objectiveFew studies have investigated the association between surgical volume and outcome of robot-assisted radical prostatectomy (RARP) in an unselected cohort. We sought to investigate the association between surgical volume with peri-operative and short-term outcomes in a nation-wide, population-based study group.Methods9,810 RARP’s registered in the National Prostate Cancer Register of Sweden (2015–2018) were included. Associations between outcome and volume were analyzed with multivariable logistic regression including age, PSA-density, number of positive biopsy cores, cT stage, Gleason score, and extent of lymph node dissection.ResultsSurgeons and hospitals in the highest volume group compared to lowest group had shorter operative time; surgeon (OR 9.20, 95% CI 7.11–11.91), hospital (OR 2.16, 95% CI 1.53–3.06), less blood loss; surgeon (OR 2.58. 95% CI 2.07–3.21) hospital (no difference), more often nerve sparing intention; surgeon (OR 2.89, 95% CI 2.34–3.57), hospital (OR 2.02, 95% CI 1.66–2.44), negative margins; surgeon (OR 1.90, 95% CI 1.54–2.35), hospital (OR 1.28, 95% CI 1.07–1.53). There was wide range in outcome between hospitals and surgeons with similar volume that remained after adjustment.ConclusionsHigh surgeon and hospital volume were associated with better outcomes. The range in outcome was wide in all volume groups, which indicates that factors besides volume are of importance. Registration of surgical performance is essential for quality control and improvement.

Editorial Comment.

No AccessJournal of UrologyAdult Urology1 Jul 2020Editorial CommentThis article comments on the following:Staging Accuracy of Multiparametric Magnetic Resonance Imaging in Caucasian and African American Men Undergoing Radical Prostatectomy Brandon A. Mahal Brandon A. MahalBrandon A. Mahal Dana-Farber Cancer Institute, McGraw/Patterson Center for Population Sciences, Boston, Massachusetts More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000774.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 204(1), p. 89 Reference 1. : Active surveillance for low-risk prostate cancer in black patients. N Engl J Med 2019; 380: 2070. Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of UrologyJan 24, 2020, 12:00:00 AMStaging Accuracy of Multiparametric Magnetic Resonance Imaging in Caucasian and African American Men Undergoing Radical Prostatectomy Volume 204Issue 1July 2020Page: 89-89 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brandon A. Mahal Dana-Farber Cancer Institute, McGraw/Patterson Center for Population Sciences, Boston, Massachusetts More articles by this author Expand All Advertisement Loading ...

PD05-11 IS LOW VOLUME MAJOR SURGERY SET FOR EXTINCTION? EVIDENCE FROM THE RADICAL PROSTATECTOMY MARKET IN A STATE-WIDE REGISTRY

INTRODUCTION AND OBJECTIVE: Higher surgical volume is associated with improved outcomes leading some to suggest regionalization of care and minimum surgical volume standards. Prior work from 2005 in New York state suggested that 80% of urologists performing radical prostatectomy (RP) were low annual volume surgeons who accounted for over 24% of the total RP surgical volume. We assess the extent to which current market forces have limited low-volume major surgery in New York state through a case study of the radical prostatectomy (RP) market and characterize persistent low-volume surgeons. METHODS: We used the NY Statewide Planning and Research Cooperative System (SPARCS) database to determine surgeons’ annual RP and total surgical volume from 2010 to 2015. We fit a multivariate logistic regression to determine predictors of low volume surgeons (≤10 RP/year) accounting for robotic surgery, other major urologic oncology cases, career stage measured in years from medical school graduation, patient and hospital characteristics. RESULTS: Of 349 urologists who performed 23,568 RP for prostate cancer from 2010-2015, 78% performed a median of ≤10 RP/year but accounted for only 11.4% of the total RP surgical volume. Low-volume surgeons were more likely advanced career stage (16-30, and >30 years from medical school graduation), less likely to be robotic surgeons, rarely performed other major urologic oncology cases, and had low prior year volume (all p≤0.001). Among low-volume surgeons 31% were over 30 years from medical school graduation. Further, 57% of low-volume RP occurred in the New York City metro area and 46% occurred at hospitals in the top quartile of RP volume. CONCLUSIONS: While low-volume RP surgery is not set for complete extinction, its population impact is substantially reduced, now affecting roughly 11% of patients as compared to 24% in 2005. Existing market forces can promote significant consolidation for procedures such as RP and a nearly one third of remaining low-volume urologists performing RP are approaching retirement. Source of Funding: None

Associations between Hospital Volume and Outcomes of Robot-Assisted Radical Prostatectomy.

Robot-assisted radical prostatectomy has become the predominant surgical modality to manage localized prostate cancer in the U.S. However, there are few studies focusing on the associations between hospital volume and outcomes of robot-assisted radical prostatectomy. We identified robot-assisted radical prostatectomies for clinically localized (cT1-2N0M0) prostate cancer diagnosed between 2010 and 2014 in the National Cancer Database. We categorized annual average hospital robot-assisted radical prostatectomy volume into very low, low, medium, high and very high by most closely sorting the final included patients into 5 equal-sized groups (quintiles). Outcomes included 30-day mortality, 90-day mortality, conversion (to open), prolonged length of stay (more than 2 days), 30-day (unplanned) readmission, positive surgical margin and lymph node dissection rates. A total of 114,957 patients were included in the study, and hospital volume was categorized into very low (3 to 45 cases per year), low (46 to 72), medium (73 to 113), high (114 to 218) and very high (219 or more). Overall 30-day mortality (0.12%), 90-day mortality (0.16%) and conversion rates (0.65%) were low. Multivariable logistic regressions showed that compared with the very low volume group, higher hospital volume was associated with lower odds of conversion to open surgery (OR 0.23, p <0.001 for very high), prolonged length of stay (OR 0.25, p <0.001 for very high), 30-day readmission (OR 0.53, p <0.001 for very high) and positive surgical margins (OR 0.61, p <0.001 for very high). Higher hospital volume was also associated with higher odds of lymph node dissection in the intermediate/high risk cohort (OR 3.23, p <0.001 for very high). Patients undergoing robot-assisted radical prostatectomy at higher volume hospitals are likely to have improved perioperative and superior oncologic outcomes compared to lower volume hospitals.

Association of Social Media Presence with Online Physician Ratings and Surgical Volume Among California Urologists: Observational Study.

BackgroundUrologists are increasingly using various forms of social media to promote their professional practice and attract patients. Currently, the association of social media on a urologists’ practice is unknown.ObjectivesWe aimed to determine whether social media presence is associated with higher online physician ratings and surgical volume among California urologists.MethodsWe sampled 195 California urologists who were rated on the ProPublica Surgeon Scorecard website. We obtained information on professional use of online social media (Facebook, Instagram, Twitter, blog, and YouTube) in 2014 and defined social media presence as a binary variable (yes/no) for use of an individual platform or any platform. We collected data on online physician ratings across websites (Yelp, Healthgrades, Vitals, RateMD, and UCompareHealthcare) and calculated the mean physician ratings across all websites as an average weighted by the number of reviews. We then collected data on surgical volume for radical prostatectomy from the ProPublica Surgeon Scorecard website. We used multivariable linear regression to determine the association of social media presence with physician ratings and surgical volume.ResultsAmong our sample of 195 urologists, 62 (32%) were active on some form of social media. Social media presence on any platform was associated with a slightly higher mean physician rating (β coefficient: .3; 95% CI 0.03-0.5; P=.05). However, only YouTube was associated with higher physician ratings (β coefficient: .3; 95% CI 0.2-0.5; P=.04). Social media presence on YouTube was strongly associated with increased radical prostatectomy volume (β coefficient: 7.4; 95% CI 0.3-14.5; P=.04). Social media presence on any platform was associated with increased radical prostatectomy volume (β coefficient: 7.1; 95% CI –0.7 to 14.2; P=.05).ConclusionsUrologists’ use of social media, especially YouTube, is associated with a modest increase in physician ratings and prostatectomy volume. Although a majority of urologists are not currently active on social media, patients may be more inclined to endorse and choose subspecialist urologists who post videos of their surgical technique.

Influences of Surgical Volume on Perioperative and Oncological Outcomes Following Radical Prostatectomy

Introduction: The purpose of this study was to evaluate whether the number of radical prostatectomies per hospital per year is associated with stage distribution, surgical techniques or quality related outcome in Germany. Materials and Methods: A German Internet-based database was analyzed. Hospitals were categorized according to their yearly radical prostatectomy (RP) volume. Patient’s characteristics, RP techniques, and outcome-related parameters were compared between the different hospital volume categories. Results: A total of 6,447 patients were analyzed. The highest rate of organ-confined disease and the lowest rate of extracapsular invasion have been demonstrated in very low-volume centres (72.6% <pT3, 27% pT ≥3). High-volume centres had the highest rate of open (92%) and robot-assisted RP approaches (5.5%). Regarding outcome, the lowest rate of positive surgical margins (11.7%) and the lowest intraoperative blood loss (3.3 g/dL) have been observed in high-volume centres. Conclusion: A higher number or RPs per year was associated with better outcome regarding quality-related parameters like surgical margin status and blood loss. However, the tumour stage distribution did not significantly differ between the low, intermediate and high-volume centres suggesting that till date the allocation of patients to the different centres is not triggered by the tumour risk classification.

Nationwide, population-based study of post radical prostatectomy urinary incontinence correction surgery.

ObjectivesTo assess the use of post radical prostatectomy (RP) urinary incontinence (PPI) surgery and to investigate factors related to its use.MethodsCohort study in Prostate Cancer database Sweden (PCBaSe) of men who underwent primary RP between 1998 and 2012. PPI correction procedures were identified in the Patient Registry. Hazard ratios (HR) and 95% confidence intervals (CIs) of PPI surgeries were estimated.ResultsSeven hundred eighty‐two out of 26 280 (3%) men underwent PPI surgery at a median time of 3 years after RP. There was an eightfold increase in the absolute number of PPI surgeries during 2000‐2014 and a threefold increase in the number per 1000 RPs performed. Factors associated with high use PPI surgery were age >70, HR 1.96 (1.54‐2.50), and high hospital RP volume (>100 RPs/year), HR 0.81 (0.66‐0.99). There was a 10‐fold difference in use of PPI surgery per 1000 RPs between the county with the highest versus lowest use. In a subgroup of men with Patient‐Reported Outcome Measures (PROM); severe PPI was reported by 7% of men and 24% of them underwent PPI surgery.ConclusionsThree percent of all men received PPI surgery, with a 10‐fold variation among health care providers. Only a quarter of men with severe PPI underwent PPI surgery, suggesting that PPI surgery remains underutilized.

Access to high-volume surgeons and the opportunity cost of performing radical prostatectomy by low-volume providers

BackgroundEvidence suggests that redirecting surgeries to high-volume providers may be associated with better outcomes and significant societal savings. Whether such referrals are feasible remains unanswered. MethodsMedicare Provider Utilization and Payment Data, SEER 18, and US Incidence data were used to determine the geographic distribution and radical prostatectomy volume for providers. Access was defined as availability of a high-volume provider within driving distance of 100 miles. The opportunity cost was defined as the value of benefits achievable by performing the surgery by a high-volume provider that was forgone by not making a referral. The savings per referral were derived from a published Markov model for radical prostatectomy. ResultsA total of 14% of providers performed>27% of the radical prostatectomies with>30 cases per year and were designated high-volume providers. Providers with below-median volume (≤16 prostatectomies per year) performed>32% of radical prostatectomies. At least 47% of these were within a 100-mile driving distance (median = 22 miles), and therefore had access to a high-volume provider (>30 prostatectomies per year). This translated into a discounted savings of more than $24 million per year, representing the opportunity cost of not making a referral. The average volume for high- and low-volume providers was 55 and 13, respectively, resulting in an annual experience gap of 43 and a cumulative gap of 125 surgeries over 3 years. In 2014, the number of surgeons performing radical prostatectomy decreased by 5% while the number of high- and low-volume providers decreased by 25% and 11% showing a faster decline in the number of high-volume providers compared with low-volume surgeons. ConclusionsAbout half of prostatectomies performed by surgeons with below-median annual volume were within a 100-mile driving distance (median of 22 miles) of a high-volume surgeon. Such a referral may result in minimal additional costs and substantially improved outcomes.

Redefining and Contextualizing the Hospital Volume-Outcome Relationship for Robot-Assisted Radical Prostatectomy: Implications for Centralization of Care

Robot-assisted radical prostatectomy has undergone rapid dissemination driven in part by market forces to become the most frequently used surgical approach in the management of prostate cancer. Accordingly, a critical analysis of its volume-outcome relationship has important health policy implications. Therefore, we evaluated the association of hospital robot-assisted radical prostatectomy volume with perioperative outcomes, and examined the distribution of hospital procedure volume to contextualize the volume-outcome relationship. We identified 140,671 men who underwent robot-assisted radical prostatectomy from 2009 to 2011 in NIS (Nationwide Inpatient Sample). The associations of hospital volume with perioperative outcomes and total hospital costs were evaluated using multivariable logistic regression and generalized linear models. In 2011, 70% of hospitals averaged 1 robot-assisted radical prostatectomy per week or less, accounting for 28% of surgeries. Compared to patients treated at the lowest quartile hospitals, those treated at the highest quartile hospitals had significantly lower rates of intraoperative complications (0.6% vs 1.4%), postoperative complications (4.8% vs 13.9%), perioperative blood transfusion (1.5% vs 4.0%), prolonged hospitalization (4.3% vs 13.8%) and mean total hospital costs ($12,647 vs $15,394, all ptrend <0.001). When modeled as a nonlinear continuous variable, increasing hospital volume was independently associated with improved rates of each perioperative end point up to approximately 100 robot-assisted radical prostatectomies per year, beyond which there appeared to be marginal improvement. Increasing hospital robot-assisted radical prostatectomy volume was associated with improved perioperative outcomes up to approximately 100 surgeries per year, beyond which there appeared to be marginal improvement. A substantial proportion of these procedures is performed at low volume hospitals.

National Trends in Prostate Biopsy and Radical Prostatectomy Volumes Following the US Preventive Services Task Force Guidelines Against Prostate-Specific Antigen Screening

Studies demonstrate that use of prostate-specific antigen screening decreased significantly following the US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen screening in 2012. To determine downstream effects on practice patterns in prostate cancer diagnosis and treatment following the 2012 USPSTF recommendation. Procedural volumes of certifying and recertifying urologists from 2009 through 2016 were evaluated for variation in prostate biopsy and radical prostatectomy (RP) volume. Trends were confirmed using the New York Statewide Planning and Research Cooperative System and Nationwide Inpatient Sample. The study included a representative sample of urologists across practice settings and nationally representative sample of all RP discharges. We obtained operative case logs from the American Board of Urology and identified urologists performing at least 1 prostate biopsy (n = 5173) or RP (n = 3748), respectively. The 2012 USPSTF recommendation against routine population-wide prostate-specific antigen screening. Change in median biopsy and RP volume per urologist and national procedural volume. Following the USPSTF recommendation, median biopsy volume per urologist decreased from 29 to 21 (interquartile range [IQR}, 12-34; P < .001). After adjusting for physician and practice characteristics, biopsy volume decreased by 28.7% following 2012 (parameter estimate, -0.25; SE, 0.03; P < .001). Similarly, following the USPSTF recommendation, median RP volume per urologist decreased from 7 (IQR, 3-15) to 6 (IQR, 2-12) (P < .001), and in adjusted analyses, RP volume decreased 16.2% (parameter estimate, -0.15; SE, 0.05; P = .003). Following the 2012 USPSTF recommendation, prostate biopsy and RP volumes decreased significantly. A panoramic vantage point is needed to evaluate the long-term consequences of the 2012 USPSTF recommendation.

Surgeon Adoption of Minimally Invasive Radical Prostatectomy

IntroductionMinimally invasive radical prostatectomy has become the most common surgical treatment for prostate cancer. In this study we describe patterns of minimally invasive radical prostatectomy adoption among surgeons who performed open radical prostatectomy before their first minimally invasive radical prostatectomy and those who did not. MethodsWe performed a retrospective cohort study using the population based SEER (Surveillance, Epidemiology, and End Results)-Medicare data set. We identified all surgeons who performed minimally invasive radical prostatectomy in 2003 to 2010 in men with prostate cancer 66 years old or older. Surgeons were classified as “converters” if they performed open radical prostatectomy before their first minimally invasive radical prostatectomy or “de novos” if they had not. We estimated annual minimally invasive radical prostatectomy volume and the proportion of prostatectomies performed minimally invasively. We used logistic regression to identify predictors of minimally invasive radical prostatectomy discontinuation. ResultsA total of 11,511 minimally invasive radical prostatectomies were performed by 738 minimally invasive radical prostatectomy surgeons (converters 337 and de novos 401). Converters performed 55% of all minimally invasive radical prostatectomies and had higher median annual minimally invasive radical prostatectomy volume than de novos (4 vs 2). About 34% of converters and 54% of de novos discontinued minimally invasive radical prostatectomy after their first year. Second year discontinuation of minimally invasive radical prostatectomy was more likely among de novo surgeons (OR 1.9, 95% CI 1.3–2.7) and less likely among surgeons with higher minimally invasive radical prostatectomy volume in their first year (OR 0.5, 95% CI 0.5–0.6). ConclusionsDuring the years of the greatest growth in minimally invasive radical prostatectomy, surgeon adoption of this technique varied by surgeon type and volume. Many surgeons discontinued, and possibly abandoned, minimally invasive radical prostatectomy. Based on these observations, experienced and higher volume surgeons will be most successful adopting new surgical technology.

MP37-06 DELAYED TREATMENT OF HIGH-RISK PROSTATE CANCER PATIENTS: IMPACT OF SOCIOECONOMIC BARRIERS AND USE OF ADVANCED TECHNOLOGIES

INTRODUCTION AND OBJECTIVES: Though attention has been given to overtreatment of indolent prostate cancer, there has been less focus on potential undertreatment of men with high-risk tumors. To that end, we sought to characterize factors related to delayed or lack of treatment (DT) of high-risk prostate cancer patients, and to assess the impact on case volume and use of advanced technology on this outcome. METHODS: We identified patients with high-risk (i.e., Gleason 8+, PSA>20, cT3) localized (i.e., T1-3Nx-0Mx-0) prostate cancer in the National Cancer Database (2010-2012). Primary outcome was DT (i.e., no treatment within 6 months post-diagnosis). Exposures of interest were facility-level case volume (based on number of positive biopsies), robotic-assisted radical prostatectomy (RARP) volume, and intensitymodulated radiation therapy (IMRT) volume. Multivariable regression models, adjusted for clustering at the facility-level, estimated the association between facility volume factors (arranged in quartiles) and receipt of DT. The model adjusted for patient age, comorbidity, type of cancer center (academic vs comprehensive community vs community), and diagnosis year. Statistical tests were 2-sided and significant if p<0.05. RESULTS: Among 63439 prostate cancer patients with highrisk localized prostate tumors, 3690 (5.8%) received DT. Black patients (9.7% vs 4.9% White, OR 1.67, 95% CI 1.50-1.86), men with Medicaid or no insurance (12.6% vs 5% Private/HMO, OR 1.48, 95% CI 1.251.76), and those in the poorest census tracts (7.7% < $38,000 vs 5.2% $63,000+, OR 1.17, 95%CI: 1.02-1.34) were more likely to receive DT. Patients diagnosed at academic centers were more likely to receive DT (7.7% vs 5.7% community cancer centers, OR 1.48, 95% CI 1.06-2.08). Although facilities with the highest case volume had less delayed treatment (vs. lowest quartile, OR 0.35, 95% CI 0.23-0.52), centers with the highest RARP (OR 3.21, 95% CI 2.21-4.66) and IMRT volume (OR 1.45, 95% CI 1.15-1.83) had more frequent DT of high-risk prostate cancer patients. CONCLUSIONS: Black patients, underinsured men, and patients in the poorest census tracts were more likely to receive delayed treatment of high-risk prostate cancer, which may reflect impaired access to adequate cancer care. The unexpected finding of more delayed treatment at academic and high-volume RARP and IMRT centers may reflect barriers related to treatment capacity.

Utilization of the Robotic Surgical Platform for Radical Nephrectomy: A National Comparison of Trends for Open, Laparoscopic and Robotic Approaches

IntroductionThe robotic platform in surgery has been widely adopted as it facilitates complex surgical reconstructions such as renorrhaphy during partial nephrectomy. Although the robotic approach to radical nephrectomy has higher costs and a lack of perioperative and oncologic evidence, the use of robotic platforms for radical nephrectomy is increasing. We evaluated a national database to explain the increased use of robotic radical nephrectomy despite a lack of perioperative and oncologic evidence. MethodsThe current retrospective cohort study used NIS (Nationwide Inpatient Sample) to identify patients who underwent radical nephrectomy from the last quarter of 2008 through 2010. We investigated hospital and patient specific factors associated with the robotic approach to radical nephrectomy, including hospital volume of robotic partial nephrectomy and robot-assisted radical prostatectomy. ResultsOf the 124,462 radical nephrectomies 4.7% were performed robotically. The median cost of robotic radical nephrectomy was $1,324 to $2,759 higher than that of open and laparoscopic radical nephrectomy. No differences in complications, length of stay, blood transfusion rates or mortality were found between laparoscopic and robotic radical nephrectomy. However the rate of open and laparoscopic radical nephrectomy decreased during the study period while the use of robotic radical nephrectomy increased almost fourfold. At hospitals in the middle or highest tertile of robotic partial nephrectomy the procedure was more likely to be performed. Patients younger than 60 years were less likely to undergo the surgery than those older than 80 years (p <0.001). Robotic radical nephrectomy was less likely to be done at large and medium medical centers (p <0.05). The hospital volume of robot-assisted radical prostatectomy did not predict that of robotic radical nephrectomy. ConclusionsAlthough increased median costs and equivalent outcomes (perioperative and oncologic) question the benefit of robotic radical nephrectomy, its use is increasing. Robotic radical nephrectomy is more likely to be done at medium-high volume robotic centers for partial nephrectomy. This nationwide overtreatment and inefficiency may reflect the use of robotic radical nephrectomy as a training tool to facilitate the robotic learning curve and the proliferation of robotic partial nephrectomy.

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 ...

Association between provider-level factors and lymph node dissection outcomes during radical prostatectomy: A national cancer database analysis.

89 Background: Lymph node counts have been proposed as a quality metric for patients undergoing radical prostatectomy (RP) and pelvic lymph node dissection (PLND). It is unclear whether surgical approach and hospital characteristics independently determine the number of lymph nodes removed at PLND. Therefore, we assessed the variation in lymph node counts from a population-based cohort of patients undergoing surgery for intermediate and high-risk prostate cancer. Methods: Using the National Cancer Database, we identified all surgically treated patients diagnosed with pre-treatment intermediate or high-risk prostate cancer from 2010 to 2011. The primary outcome was the number of lymph nodes retrieved at the time of RP. Generalized estimating equations were used to assess for differences in the adjusted number of lymph nodes retrieved after accounting for patient and hospital characteristics and surgical approach. Results: Overall, 35,876 patients were diagnosed with intermediate (61.2%) and high-risk (38.8%) prostate cancer and underwent RP and PLND. On multivariable analysis, open radical prostatectomy (ORP) and high volume and academic hospitals were independently associated with greater lymph node counts compared to robotic-assisted radical prostatectomy (RARP) and medium/low and community hospitals, respectively (all p&lt;0.001). After adjusting for patient and hospital variables, higher adjusted lymph nodes counts were observed for ORP compared to RARP (7.1 vs. 6.1; p&lt;0.001). Adjusted counts were also higher for high volume compared to medium/low volume hospitals (7.8 vs. 5.9; p&lt;0.001), and academic compared to community hospitals (7.3 vs. 5.6; p&lt;0.001). Conclusions: Among patients with aggressive prostate cancer treated with RP and PLND, lymph node counts varied by surgical approach and hospital characteristics.

MP37-13 USE OF THE ROBOTIC SURGICAL PLATFORM FOR RADICAL NEPHRECTOMY: A NATIONAL COMPARISON OF UTILIZATION AND COMPLICATIONS FOR OPEN, LAPAROSCOPIC, AND ROBOTIC APPROACHES

You have accessJournal of UrologyTechnology & Instruments: Robotics - Benign & Malignant Disease1 Apr 2014MP37-13 USE OF THE ROBOTIC SURGICAL PLATFORM FOR RADICAL NEPHRECTOMY: A NATIONAL COMPARISON OF UTILIZATION AND COMPLICATIONS FOR OPEN, LAPAROSCOPIC, AND ROBOTIC APPROACHES Aaron Weinberg, Solomon Woldu, Tim Wen, Chris Deibert, and Ketan Badani Aaron WeinbergAaron Weinberg More articles by this author , Solomon WolduSolomon Woldu More articles by this author , Tim WenTim Wen More articles by this author , Chris DeibertChris Deibert More articles by this author , and Ketan BadaniKetan Badani More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1250AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The use of a robotic platform in urological surgery has been aggressively adopted and its use in partial nephrectomy (PN) and radical prostatectomy (RP) have rapidly increased. The inherent advantages of the da Vinci system allow for complex intracorporeal reconstruction and suturing during minimally invasive surgery. While this advantage does not necessarily apply to radical nephrectomy (RN), robotic RN utilization is increasing. We performed a population-based approach to assess the utilization and complications of robotic, laparoscopic, and open RN and factors which predict its use. METHODS Review of the Nationwide Inpatient Sample identified men undergoing RN from last quarter 2008-2010. Hospital specific factors and hospital volume of robotic PN or robotic RP were examined as predictors of robotic RN. Additionally, postoperative complications were compared between the surgical approaches. RESULTS 124,462 patients were identified who underwent RN, of which 80.6% were open (ORN), 14.7% laparoscopic (LRN) and 5.7% were robotic (RRN). The proportion of RRN increased from 2.0% to 8.0% over the study time period. Hospital factors predicted the use of robotic surgery; larger medical centers were less likely to perform RRN while those in the middle and higher tertile for robotic PN were more likely to perform robotic RN as compared to the lowest tertile (OR 4.69 for middle and 5.29 for high, p <0.001), which was not observed in volume of RP. Patient factors did not correlate to utilization of RRN versus other approaches to RN. Complications were identified in 35.3% of ORN, 27.4% LRN and 26.7% RRN; compared to ORN, RRN was no more protective of complications vs. LRN. CONCLUSIONS While robotic surgery provides a platform that allows urologists to perform complex reconstructive procedures, the benefit of its use in RN remains controversial. High volume robotic centers for PN are more likely to perform RRN despite its increased cost and equivalent complications to laparoscopic RN. Surgeon comfort level and hospital efficiency with robotic surgery may account for these findings. Additional studies are needed to better delineate the comparative and cost-effectiveness of RRN. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e397 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Aaron Weinberg More articles by this author Solomon Woldu More articles by this author Tim Wen More articles by this author Chris Deibert More articles by this author Ketan Badani More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...