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Bahlburg H, Rausch P, Tully KH, Berg S, Noldus J, Butea-Bocu MC, Beyer B, Müller G. Urinary continence outcomes, surgical margin status, and complications after radical prostatectomy in 2,141 German patients treated in one high-volume inpatient rehabilitation clinic in 2022. World J Urol 2024; 42:494. [PMID: 39172140 PMCID: PMC11341598 DOI: 10.1007/s00345-024-05200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/28/2024] [Indexed: 08/23/2024] Open
Abstract
PURPOSE To identify independent predictors of urinary continence and report early complications after radical prostatectomy (RP) in a large, contemporary German cohort. METHODS Urinary incontinence data of patients undergoing 3-week inpatient rehabilitation (IR) after RP were prospectively assessed by 24-hr pad test and uroflowmetry at the beginning and the end of IR, respectively. Lymphoceles were assessed prospectively by ultrasound. Tumor and patient characteristics, and information on urinary leakage on initial cystography were retrospectively extracted from discharge letters and surgical reports. Regression analyses were performed to identify predictors of urinary continence at the beginning of IR. RESULTS Overall, 2,141 patients were included in the final analyses. Anastomotic leakage on the initial cystography and lymphoceles were found in 11.4% and 30.8% of patients, respectively. Intervention for a symptomatic lymphocele was required in 4.2% of patients. At the end of IR, 54.2% of patients were continent, while the median urine loss decreased to 73 g (interquartile range 15-321). Multivariable logistic regression analysis identified age and diabetes mellitus as independent negative predictors, but nerve-sparing surgery as an independent positive predictor of urinary continence (each p < 0.001). Multivariable linear regression analysis showed that 24-hr urine loss increased by 7 g with each year of life (p < 0.001), was 79 g higher in patients with diabetes mellitus (p = 0.007), and 175 g lower in patients with NS (p < 0.001). CONCLUSION Age, diabetes mellitus, and NS are significantly associated with continence outcomes in the early period after RP. Our analyses may help clinicians to pre-operatively counsel patients on potential surgical outcomes.
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Affiliation(s)
- Henning Bahlburg
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany.
| | - Patricia Rausch
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Karl Heinrich Tully
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Sebastian Berg
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Joachim Noldus
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | | | - Burkhard Beyer
- Center for Urological Rehabilitation, Kliniken Hartenstein, Bad Wildungen, Germany
| | - Guido Müller
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
- Center for Urological Rehabilitation, Kliniken Hartenstein, Bad Wildungen, Germany
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Tesfai FM, Nagi J, Morrison I, Boal M, Olaitan A, Chandrasekaran D, Stoyanov D, Lanceley A, Francis N. Objective assessment tools in laparoscopic or robotic-assisted gynecological surgery: A systematic review. Acta Obstet Gynecol Scand 2024; 103:1480-1497. [PMID: 38610108 PMCID: PMC11266631 DOI: 10.1111/aogs.14840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/28/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION There is a growing emphasis on proficiency-based progression within surgical training. To enable this, clearly defined metrics for those newly acquired surgical skills are needed. These can be formulated in objective assessment tools. The aim of the present study was to systematically review the literature reporting on available tools for objective assessment of minimally invasive gynecological surgery (simulated) performance and evaluate their reliability and validity. MATERIAL AND METHODS A systematic search (1989-2022) was conducted in MEDLINE, Embase, PubMed, Web of Science in accordance with PRISMA. The trial was registered with the Prospective Register of Systematic Reviews (PROSPERO) ID: CRD42022376552. Randomized controlled trials, prospective comparative studies, prospective single-group (with pre- and post-training assessment) or consensus studies that reported on the development, validation or usage of assessment tools of surgical performance in minimally invasive gynecological surgery, were included. Three independent assessors assessed study setting and validity evidence according to a contemporary framework of validity, which was adapted from Messick's validity framework. Methodological quality of included studies was assessed using the modified medical education research study quality instrument (MERSQI) checklist. Heterogeneity in data reporting on types of tools, data collection, study design, definition of expertise (novice vs. experts) and statistical values prevented a meaningful meta-analysis. RESULTS A total of 19 746 titles and abstracts were screened of which 72 articles met the inclusion criteria. A total of 37 different assessment tools were identified of which 13 represented manual global assessment tools, 13 manual procedure-specific assessment tools and 11 automated performance metrices. Only two tools showed substantive evidence of validity. Reliability and validity per tool were provided. No assessment tools showed direct correlation between tool scores and patient related outcomes. CONCLUSIONS Existing objective assessment tools lack evidence on predicting patient outcomes and suffer from limitations in transferability outside of the research environment, particularly for automated performance metrics. Future research should prioritize filling these gaps while integrating advanced technologies like kinematic data and AI for robust, objective surgical skill assessment within gynecological advanced surgical training programs.
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Affiliation(s)
- Freweini Martha Tesfai
- The Griffin InstituteNorthwick Park & St Marks' HospitalLondonUK
- EGA Institute for Women's HealthUniversity College LondonLondonUK
- Wellcome/EPSRC Center for Interventional and Surgical Sciences (WEISS)University College LondonLondonUK
| | | | - Iona Morrison
- Yeovil District HospitalSomerset Foundation NHS TrustYeovilUK
| | - Matt Boal
- The Griffin InstituteNorthwick Park & St Marks' HospitalLondonUK
- EGA Institute for Women's HealthUniversity College LondonLondonUK
- Wellcome/EPSRC Center for Interventional and Surgical Sciences (WEISS)University College LondonLondonUK
| | | | - Dhivya Chandrasekaran
- EGA Institute for Women's HealthUniversity College LondonLondonUK
- Department of Gynecological OncologyUniversity College of London HospitalsLondonUK
| | - Danail Stoyanov
- EGA Institute for Women's HealthUniversity College LondonLondonUK
- Wellcome/EPSRC Center for Interventional and Surgical Sciences (WEISS)University College LondonLondonUK
| | - Anne Lanceley
- EGA Institute for Women's HealthUniversity College LondonLondonUK
| | - Nader Francis
- The Griffin InstituteNorthwick Park & St Marks' HospitalLondonUK
- EGA Institute for Women's HealthUniversity College LondonLondonUK
- Yeovil District HospitalSomerset Foundation NHS TrustYeovilUK
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Duwe G, Boehm K, Becker G, Ruckes C, Sparwasser P, Haack M, Dotzauer R, Thomas A, Mager R, Tsaur I, Neumann CCM, Feick G, Carl G, Brandt MP, Haferkamp A, Höfner T. Individualized center-based analysis of urinary and sexual functional outcome after radical prostatectomy based on the prostate cancer outcome study: a post hoc pathway to patient outcome measurement analysis for quality improvement. World J Urol 2024; 42:236. [PMID: 38619659 DOI: 10.1007/s00345-024-04950-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 02/08/2024] [Indexed: 04/16/2024] Open
Abstract
PURPOSE We evaluate differences of patient-reported outcome measurements (PROM) based urinary continence and sexual function 12 months after radical prostatectomy (RPE) based on perioperative, surgical, and patient-specific characteristics in a large European academic urology center. MATERIALS AND METHODS All men enrolled in the Prostate Cancer Outcome Study (PCO) study who were treated with RPE between 2017 and 2021 completed EPIC-26 information surveys before and 12 months after RPE. Survey data were linked to clinical data of our institution. Logistic regression analyses were performed to examine the correlation between individual surgeons, patient characteristics, patient clinical data, and their urinary continence and sexual function. RESULTS In total, data of 429 men were analyzed: unstratified mean (SD) EPIC-26 domain score for urinary function decreased from 93.3 (0.7) to 60.4 (1.5) one year after RPE, respectively for sexual function from 64.95 (1.6) to 23.24 (1.1). Patients with preoperative adequate urinary function (EPIC-26 score > 80) reported significantly different mean urinary function scores between 53.35 (28.88) and 66.25 (25.15), p= 0.001, stratified by surgeons experience. On binary logistic regression analyses, only nerve sparing techniques (OR: 1,83, 95% CI: 1.01;3.21; p = 0.045) and low body mass index (OR: 0.91, CI: 0.85;0.99, p= 0.032) predicted adequate postoperative urinary function. CONCLUSIONS The results show how using provider-specific data from a larger cohort study enables to develop institution-specific analysis for functional outcomes after RPE. These models can be used for internal quality improvement as well as enhanced and provider-specific patient communication and shared decision making.
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Affiliation(s)
- Gregor Duwe
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Katharina Boehm
- Department of Urology, University Hospital Carl Gustav-Carus, TU Dresden, 01307, Dresden, Germany
| | - Gerrit Becker
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Trials Mainz, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Peter Sparwasser
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Maximilian Haack
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Robert Dotzauer
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Anita Thomas
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Rene Mager
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Igor Tsaur
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Christopher C M Neumann
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, 10117, Berlin, Germany
| | - Günther Feick
- Federal Association of German Prostate Cancer Patient Support Groups, Thomas-Mann Strasse 40, 55311, Bonn, Germany
| | - Günter Carl
- Federal Association of German Prostate Cancer Patient Support Groups, Thomas-Mann Strasse 40, 55311, Bonn, Germany
| | - Maximilian Peter Brandt
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Axel Haferkamp
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Thomas Höfner
- Department of Urology and Pediatric Urology, University Medical Center Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- Department of Urology, Ordensklinikum Linz Elisabethinen, Fadingerstrasse 1, 4020, Linz, Austria
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Schepens MH, van Hooff ML, van der Galiën O, Ziedses des Plantes CM, Somford DM, van Leeuwen PJ, Busstra MB, Repping S, Wouters MW, van Limbeek J. Does Centralization of Radical Prostatectomy Reduce the Incidence of Postoperative Urinary Incontinence? EUR UROL SUPPL 2023; 58:47-54. [PMID: 38152486 PMCID: PMC10751543 DOI: 10.1016/j.euros.2023.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 12/29/2023] Open
Abstract
Background On 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. Objective To evaluate the impact of hospital RP volumes on the incidence and risk of UI after RP (RP-UI). Design setting and participants Patients 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 analysis The 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 limitations RP-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). Conclusions A 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 summary In 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.
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Affiliation(s)
- Maike H.J. Schepens
- Department of Biomedical Data Sciences, Leiden UMC, Leiden, The Netherlands
- Healthcare Strategy and Innovation, Cirka BV, Zeist, The Netherlands
| | - Miranda L. van Hooff
- Department of Orthopedic Surgery, Radboud UMC, Nijmegen, The Netherlands
- Department of Research, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Onno van der Galiën
- Department of Strategy and Innovation, Zilveren Kruis Health Insurance, Zeist, The Netherlands
| | | | - Diederik M. Somford
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Prosper Prostate Cancer Clinics, Nijmegen/Eindhoven, The Netherlands
| | - Pim J. van Leeuwen
- Department of Urology, Netherlands Cancer Institute, Netherlands Prostate Cancer Network, Amsterdam, The Netherlands
| | - Martijn B. Busstra
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sjoerd Repping
- Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Michel W.J.M. Wouters
- Department of Biomedical Data Sciences, Leiden UMC, Leiden, The Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Jacques van Limbeek
- Department of Medical Advice, Zilveren Kruis Health Insurance, Zeist, The Netherlands
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Tustumi F, Portilho AS, Teivelis MP, da Silva MFA, Szor DJ, Gerbasi LS, Pandini RV, Seid VE, Wolosker N, Araujo SEA. The impact of the institutional abdominoperineal resections volume on short-term outcomes and expenses: a nationwide study. Tech Coloproctol 2023; 27:647-653. [PMID: 36454374 DOI: 10.1007/s10151-022-02733-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the influence of the institutional volume of abdominoperineal resections (APR) on the short-term outcomes and costs in the Brazilian Public Health system. METHODS This population-based study evaluated the number of APRs by institutions performed in the Brazilian Public Health system from January/2010 to July/2022. Data were extracted from a public domain from the Brazilian Public Health system. RESULTS Four hundred and twelve hospitals performed APRs and were included. Only 23 performed at least 5 APRs per year on average and were considered high-volume institutions. The linear regression model showed that the number of hospital admissions for APRs was negatively associated with in-hospital mortality (Coef. = - 0.001; p = 0.013) and length of stay in the intensive care unit (Coef. = - 0.006; p = 0.01). The number of hospital admissions was not significantly associated with personnel, hospital, and total costs. The in-hospital mortality in high-volume institutions was significantly lower than in low-volume institutions (2.5 vs. 5.9%; p: < 0.001). The mean length of stay in the intensive care unit was shorter in high-volume institutions (1.23 vs. 1.79 days; p = 0.021). In high-volume institutions, the personnel (R$ 952.23 [US$ 186.64] vs. R$ 11,129.04 [US$ 221.29]; p = 0.305), hospital (R$ 4078.39 [US$ 799.36] vs. R$ 4987.39 [US$ 977.53]; p = 0.111), and total costs (R$ 5030.63 [US$ 986.00] vs. R$ 6116.71 [US$ 1198.88]; p = 0.226) were lower. CONCLUSIONS Higher institutional APR volume is associated with lower in-hospital mortality and less demand for intensive care. The findings of this nationwide study may affect how Public Health manages APR care.
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Affiliation(s)
- Francisco Tustumi
- Department of Health Sciences, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, SP, 05652-900, Brazil.
| | - Ana Sarah Portilho
- Department of Health Sciences, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, SP, 05652-900, Brazil
| | - Marcelo Passos Teivelis
- Department of Health Sciences, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, SP, 05652-900, Brazil
| | | | - Daniel José Szor
- Department of Health Sciences, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, SP, 05652-900, Brazil
| | - Lucas Soares Gerbasi
- Department of Health Sciences, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, SP, 05652-900, Brazil
| | - Rafael Vaz Pandini
- Department of Health Sciences, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, SP, 05652-900, Brazil
| | - Victor Edmond Seid
- Department of Health Sciences, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, SP, 05652-900, Brazil
| | - Nelson Wolosker
- Department of Health Sciences, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, SP, 05652-900, Brazil
| | - Sérgio Eduardo Alonso Araujo
- Department of Health Sciences, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, SP, 05652-900, Brazil
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Ma R, Ramaswamy A, Xu J, Trinh L, Kiyasseh D, Chu TN, Wong EY, Lee RS, Rodriguez I, DeMeo G, Desai A, Otiato MX, Roberts SI, Nguyen JH, Laca J, Liu Y, Urbanova K, Wagner C, Anandkumar A, Hu JC, Hung AJ. Surgical gestures as a method to quantify surgical performance and predict patient outcomes. NPJ Digit Med 2022; 5:187. [PMID: 36550203 PMCID: PMC9780308 DOI: 10.1038/s41746-022-00738-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
How well a surgery is performed impacts a patient's outcomes; however, objective quantification of performance remains an unsolved challenge. Deconstructing a procedure into discrete instrument-tissue "gestures" is a emerging way to understand surgery. To establish this paradigm in a procedure where performance is the most important factor for patient outcomes, we identify 34,323 individual gestures performed in 80 nerve-sparing robot-assisted radical prostatectomies from two international medical centers. Gestures are classified into nine distinct dissection gestures (e.g., hot cut) and four supporting gestures (e.g., retraction). Our primary outcome is to identify factors impacting a patient's 1-year erectile function (EF) recovery after radical prostatectomy. We find that less use of hot cut and more use of peel/push are statistically associated with better chance of 1-year EF recovery. Our results also show interactions between surgeon experience and gesture types-similar gesture selection resulted in different EF recovery rates dependent on surgeon experience. To further validate this framework, two teams independently constructe distinct machine learning models using gesture sequences vs. traditional clinical features to predict 1-year EF. In both models, gesture sequences are able to better predict 1-year EF (Team 1: AUC 0.77, 95% CI 0.73-0.81; Team 2: AUC 0.68, 95% CI 0.66-0.70) than traditional clinical features (Team 1: AUC 0.69, 95% CI 0.65-0.73; Team 2: AUC 0.65, 95% CI 0.62-0.68). Our results suggest that gestures provide a granular method to objectively indicate surgical performance and outcomes. Application of this methodology to other surgeries may lead to discoveries on methods to improve surgery.
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Affiliation(s)
- Runzhuo Ma
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Ashwin Ramaswamy
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | - Jiashu Xu
- Computer Science Department, Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - Loc Trinh
- Computer Science Department, Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - Dani Kiyasseh
- Department of Computing & Mathematical Sciences, California Institute of Technology, Pasadena, CA, USA
| | - Timothy N Chu
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Elyssa Y Wong
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Ryan S Lee
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Ivan Rodriguez
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Gina DeMeo
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | - Aditya Desai
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Maxwell X Otiato
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Sidney I Roberts
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Jessica H Nguyen
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Jasper Laca
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Yan Liu
- Computer Science Department, Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - Katarina Urbanova
- Department of Urology and Urologic Oncology, St. Antonius-Hospital, Gronau, Germany
| | - Christian Wagner
- Department of Urology and Urologic Oncology, St. Antonius-Hospital, Gronau, Germany
| | - Animashree Anandkumar
- Department of Computing & Mathematical Sciences, California Institute of Technology, Pasadena, CA, USA
| | - Jim C Hu
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | - Andrew J Hung
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA.
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The Impact of Facility Surgical Caseload Volumes on Survival Outcomes in Patients Undergoing Radical Cystectomy. Cancers (Basel) 2022; 14:cancers14235984. [PMID: 36497466 PMCID: PMC9735798 DOI: 10.3390/cancers14235984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/14/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
The role of surgical experience and its impact on the survival requires further investigation. A cohort of patients undergoing radical cystectomy or anterior pelvic exenteration for localized bladder cancer between 2006 and 2013 at 1143 facilities across the United States was identified using the National Cancer Database and analyzed. Using overall survival (OS) as the primary outcome, the relationship between facility annual caseload (FAC) and facility annual surgical caseload (FASC) for those undergoing curative surgery was examined. Four volume groups (VG) depending on caseload using both FAC and FASC were defined. These included VG1: below 50th percentile, VG2: 50th−74th percentile, VG3: 75th−89th percentile, and VG4: 90th and above. Between 2006 and 2013, 27,272 patients underwent surgery for localized bladder cancer. The median OS was 59.66 months (95% CI: 57.79−61.77). OS improved significantly as caseload increased. The unadjusted median OS difference between VG1 and VG4 was 15.35 months (64.3 vs. 48.95 months, HR 1.19 95% CI: 1.13−1.25, p < 0.001) for FAC. This figure was 19.84 months (66.89 vs. 47.05 months, HR 1.25 95% CI: 1.18−1.32, p < 0.0001) for FASC. This analysis revealed a significant and clinically important survival advantage for curative bladder cancer surgery at highly experienced centers.
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Janopaul-Naylor JR, Liu T, Zhou B, Yang X, McCall NS, Patel PR, Mehta A, Nour SG, Jani AB. Longitudinal Changes in U.S. Parameters of Neurovascular Bundles Suggest Mechanism for Radiation-Induced Erectile Dysfunction. Adv Radiat Oncol 2022; 7:100946. [PMID: 35514327 PMCID: PMC9065720 DOI: 10.1016/j.adro.2022.100946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/14/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- James R. Janopaul-Naylor
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Tian Liu
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Boran Zhou
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Xiaofeng Yang
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Neal S. McCall
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Pretesh R. Patel
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Akanksha Mehta
- Departments of Urology, Emory University School of Medicine, Atlanta, Georgia
| | - Sherif G. Nour
- Departments of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ashesh B. Jani
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
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9
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Sibert NT, Pfaff H, Breidenbach C, Wesselmann S, Roth R, Feick G, Carl G, Dieng S, Gaber AA, Blana A, Darr C, Distler F, Kunath F, Bedke J, Erdmann J, Minner J, Simon J, Kwiatkowski M, Burchardt M, Harz N, Conrad S, Höfner T, Knoll T, Beyer B, Hammerer P, Kowalski C. Variation across operating sites in urinary and sexual outcomes after radical prostatectomy in localized and locally advanced prostate cancer. World J Urol 2022; 40:1437-1446. [PMID: 35347412 DOI: 10.1007/s00345-022-03985-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/07/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The extent of variation in urinary and sexual functional outcomes after radical prostatectomy (RPE) between prostate cancer (PC) operating sites remains unknown. Therefore, this analysis aims to compare casemix-adjusted functional outcomes (EPIC-26 scores incontinence, irritative/obstructive function and sexual function) between operating sites 12 months after RPE. MATERIALS AND METHODS Analysis of a cohort of 7065 men treated with RPE at 88 operating sites (prostate cancer centers, "PCCs") between 2016 and 2019. Patients completed EPIC-26 and sociodemographic information surveys at baseline and 12 months after RPE. Survey data were linked to clinical data. EPIC-26 domain scores at 12 months after RPE were adjusted for relevant confounders (including baseline domain score, clinical and sociodemographic information) using regression analysis. Differences between sites were described using minimal important differences (MIDs) and interquartile ranges (IQR). The effects of casemix adjustment on the score results were described using Cohen's d and MIDs. RESULTS Adjusted domain scores at 12 months varied between sites, with IQRs of 66-78 (incontinence), 89-92 (irritative/obstructive function), and 20-29 (sexual function). Changes in domain scores after casemix adjustment for sites ≥ 1 MID were noted for the incontinence domain (six sites). Cohen's d ranged between - 0.07 (incontinence) and - 0.2 (sexual function), indicating a small to medium effect of casemix adjustment. CONCLUSIONS Variation between sites was greatest in the incontinence and sexual function domains for RPE patients. Future research will need to identify the factors contributing to this variation. TRIAL REGISTRY The study is registered at the German Clinical Trial Registry ( https://www.drks.de/drks_web/ ) with the following ID: DRKS00010774.
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Affiliation(s)
- Nora Tabea Sibert
- German Cancer Society, Kuno-Fischer-Straße 8, 14057, Berlin, Germany.
| | - Holger Pfaff
- Faculty of Human Sciences, Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research and Rehabilitation Science, University of Cologne, Eupener Str. 129, 50933, Cologne, Germany
| | - Clara Breidenbach
- German Cancer Society, Kuno-Fischer-Straße 8, 14057, Berlin, Germany
| | - Simone Wesselmann
- German Cancer Society, Kuno-Fischer-Straße 8, 14057, Berlin, Germany
| | - Rebecca Roth
- Faculty of Medicine and University Hospital Cologne, Institute of Medical Statistics and Computational Biology, University of Cologne, Robert-Koch-Str. 10, 50931, Cologne, Germany
| | - Günther Feick
- Federal Association of German Prostate Cancer Patient Support Groups, Bonn, Germany
| | - Günter Carl
- Federal Association of German Prostate Cancer Patient Support Groups, Bonn, Germany
| | | | - Amr A Gaber
- Urologische Klinik, Carl-Thiem-Klinikum Cottbus, Thiemstr. 111, 03048, Cottbus, Germany
| | - Andreas Blana
- Klinik für Urologie und Kinderurologie, Klinikum Fürth, Jakob-Henle-Strasse 1, 90766, Fürth, Germany
| | - Christopher Darr
- Klinik für Urologie, Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Florian Distler
- Klinik für Urologie, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Standort Klinikum Nürnberg, Prof.-Ernst-Nathan-Straße 1 (Haus 22), 90419, Nuremberg, Germany
| | - Frank Kunath
- Department of Urology and Pediatric Urology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Jens Bedke
- Klinik für Urologie, Universität Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Jörg Erdmann
- Prostatakarzinomzentrum Tauber-Franken, Uhlandstr. 7, 97980, Bad Mergentheim, Germany
| | - Jörg Minner
- Hegau-Bodensee-Klinikum GmbH, Virchowstraße 10, 78224, Singen, Germany
| | - Jörg Simon
- Klinik für Urologie und Kinderurologie, Ortenau Klinikum, Ebertplatz 12, 77654, Offenburg, Germany
| | - Maciej Kwiatkowski
- Kantonsspital Aarau AG, Onkologiezentrum Mittelland, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Martin Burchardt
- Klinik und Poliklinik für Urologie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Nino Harz
- Klinikum Dortmund, Münsterstraße 240, 44145, Dortmund, Germany
| | - Stefan Conrad
- DIAKOVERE Friederikenstift, Humboldtstraße 5, 30169, Hannover, Germany
| | - Thomas Höfner
- Klinik und Poliklinik für Urologie und Kinderurologie, UNIVERSITÄTSMEDIZIN der Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Thomas Knoll
- Kliniken Sindelfingen, Arthur-Gruber-Str. 70, 71065, Sindelfingen, Germany
| | - Burkhard Beyer
- Martini-Klinik Prostate Cancer Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany
| | - Peter Hammerer
- Städtisches Klinikum Braunschweig, Freisestraße 9/10, 38118, Braunschweig, Germany
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10
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Basourakos SP, Kowalczyk K, Moschovas MC, Dudley V, Hung AJ, Shoag JE, Patel V, Hu JC. Robot-Assisted Radical Prostatectomy Maneuvers to Attenuate Erectile Dysfunction: Technical Description and Video Compilation. J Endourol 2021; 35:1601-1609. [PMID: 34015959 PMCID: PMC8820193 DOI: 10.1089/end.2021.0081] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Erectile dysfunction (ED) remains a significant problem in up to 63% of men after robot-assisted radical prostatectomy (RARP). After the discovery of the neurovascular bundle (NVB), additional anatomic description and variation in nerve-sparing (NS) techniques have been described to improve post-RARP ED. However, it remains questionable whether ED rates have improved over time, and this is concerning as competing treatments are introduced that have better ED outcomes. In this review, we describe RARP NS technical modifications that improve erectile function recovery. We focused on reports that included detailed anatomical descriptions as well as video illustrations to disseminate technique. We found that the alternative RARP NS surgical techniques provide better outcomes compared with standard NS RARP. The use of validated quality of life questionnaires is necessary for the appropriate comparison of outcomes. However, the retrospective character and inherent weaknesses of the included studies do not allow one to conclude which is the best NS approach. Overall, there is significant variation in RARP NS techniques and outcomes, and the ideal technical maneuvers to optimize outcomes remains subject to debate. However, there is a consensus on the importance of anatomically dissecting the NVB, minimizing traction and thermal injury as well as preserving the periprostatic fascia. Well-designed randomized controlled trials with videos describing details of different surgical techniques for generalizability are needed to consistently and objectively evaluate sexual function outcomes after RARP to optimize postoperative potency.
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Affiliation(s)
- Spyridon P. Basourakos
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Keith Kowalczyk
- Department of Urology, MedStar Georgetown University Hospital, Lombardi Cancer Center, Washington, District of Columbia, USA
| | | | - Vanessa Dudley
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Andrew J Hung
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, University of Southern California Institute of Urology, Los Angeles, California, USA
| | - Jonathan E. Shoag
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA.,Department of Urology, Case Western University Hospital, Cleveland, Ohio, USA
| | - Vipul Patel
- AdventHealth Global Robotics Institute, Celebration, Florida, USA
| | - Jim C. Hu
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA.,Address correspondence to: Jim C. Hu, MD, Department of Urology, New York Presbyterian Hospital-Weill Cornell Medicine, 525 East 68th Street, Starr 900, New York, NY 10021, USA
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11
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Ju IE, Trieu D, Chang SB, Mungovan SF, Patel MI. Surgeon Experience and Erectile Function After Radical Prostatectomy: A Systematic Review. Sex Med Rev 2021; 9:650-658. [PMID: 34219004 DOI: 10.1016/j.sxmr.2020.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 08/30/2020] [Accepted: 09/06/2020] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Erectile dysfunction is a common consequence after radical prostatectomy (RP) affecting psychosocial well-being and quality of life. As the RP surgical technique is complex, it is reasonable to propose that the experience of the surgeon could influence the postoperative erectile function (EF) outcomes. OBJECTIVE To undertake a systematic review to investigate whether the surgeon's experience affects the patient's ability to regain EF after RP. METHODS A comprehensive literature search was performed in April 2020 using Medline, Embase, CINAHL, and psychINFO. All relevant English research studies investigating the topic area were included, with experience being defined as both cumulative RP and average RP annual surgical caseload. RESULTS The main outcome measure is EF after RP stratified by surgeon experience (annual case load or cumulative case volume). Ten case-control studies published between 2003 and 2020 met the inclusion criteria and were chosen for this systematic review. The included studies consisted of both single- and multiple-surgeon studies. Studies that compared annual RP caseload per surgeon demonstrated a difference between high- and low-volume surgeons, only when high volume was >25 RP cases/year. In the studies reporting cumulative case volume (learning curve), differences between high volume and low volume were only identified when the total case volume was approximately 1000 RP cases. Studies with low-volume cases (approximately 100) did not show any differences in EF outcomes. CONCLUSION The studies examined in our systematic review demonstrate that an annual surgeon caseload of >25 RP cases per year or total cumulative experience of >1000 RP cases results in better EF outcomes after RP. Ju IE, Trieu D, Chang SB, et al. Surgeon Experience and Erectile Function After Radical Prostatectomy: A Systematic Review. Sex Med Rev 2020;XX:XXX-XXX.
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Affiliation(s)
- Irene E Ju
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
| | - Danny Trieu
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Simon B Chang
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sean F Mungovan
- Westmead Private Physiotherapy Services, Westmead Private Hospital, Westmead, New South Wales, Australia; The Clinical Research Institute, Westmead, New South Wales, Australia; Department of Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, Victoria, Australia
| | - Manish I Patel
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Urology, Westmead Hospital, Westmead, New South Wales, Australia.
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12
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Mungovan SF, Carlsson SV, Gass GC, Graham PL, Sandhu JS, Akin O, Scardino PT, Eastham JA, Patel MI. Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy. Nat Rev Urol 2021; 18:259-281. [PMID: 33833445 PMCID: PMC8030653 DOI: 10.1038/s41585-021-00445-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 01/31/2023]
Abstract
Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.
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Affiliation(s)
- Sean F Mungovan
- Westmead Private Physiotherapy Services, Westmead Private Hospital, Westmead, New South Wales, Australia.
- The Clinical Research Institute, Westmead, New South Wales, Australia.
- Department of Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, Victoria, Australia.
| | - Sigrid V Carlsson
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Institute of Clinical Sciences, Department of Urology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Gregory C Gass
- The Clinical Research Institute, Westmead, New South Wales, Australia
- Physical Therapy Program, University of Jamestown, Fargo, ND, USA
| | - Petra L Graham
- Department of Mathematics and Statistics, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Jaspreet S Sandhu
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oguz Akin
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter T Scardino
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James A Eastham
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Manish I Patel
- Specialty of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Urology, Westmead Hospital, Westmead, New South Wales, Australia
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13
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Hoekstra RJ, Goossens WJH, Beulens A, van Herk H, Hoevenaars BM, de Baaij J, Somford DM, Sedelaar JPM, van Basten JPA, Vrijhof HJEJ. Reassessment of Prostate Biopsy Specimens for Patients Referred for Robot-assisted Radical Prostatectomy Rarely Influences Surgical Planning. EUR UROL SUPPL 2021; 28:36-42. [PMID: 34337523 PMCID: PMC8317876 DOI: 10.1016/j.euros.2021.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/23/2022] Open
Abstract
Background The minimum volume standard is 100 robot-assisted radical prostatectomy (RARP) procedures per hospital in the Netherlands, so patients have to be referred to high-volume surgical centers for RARP. During preoperative work-up, prostate biopsies taken elsewhere are reassessed, with upgrading or downgrading of the initial Gleason grade group a possible consequence. Objective To determine if prostate biopsy reassessment leads to adjustment of the surgical plan regarding a nerve-sparing approach and extended pelvic lymph node dissection (ePLND) during RARP. Design, setting, and participants For 125 men who were referred to the Prosper prostate center at Canisius Wilhelmina Hospital (CWH) in the Netherlands between 2013 and 2016, results for the initial assessment of prostate biopsy by a local uropathologist were compared to results for biopsy reassessment by dedicated uropathologists at CWH. Results and limitations The pathologists reached agreement in 80% of the cases. In cases for which there was disagreement (n = 25), biopsy revision involved upgrading of the initial grade group in 68% and downgrading in 32%. Biopsy reassessment led to a change in surgical plan in ten cases (8%). As a result of upgrading, ePLND was performed in three patients (2%). ePLND was omitted in one patient (1%) because of downgrading. For three patients (2%) a non–nerve-sparing procedure was planned after upgrading of the initial grade group. For four patients (3%), a unilateral nerve-sparing procedure was performed after downgrading. Conclusions This study shows that there is large interobserver agreement between uropathologists in the assessment of Gleason grade group in prostate biopsy specimens. Reassessment rarely leads to a change in surgical plan regarding the indication for a nerve-sparing approach and ePLND. Therefore, reassessment of prostate biopsy before radical prostatectomy can be omitted when the initial pathological assessment was performed by a dedicated uropathologist. Patient summary Reassessment of the initial prostate biopsy specimen for patients referred to a specialist center for robot-assisted removal of the prostate rarely influences surgical planning and can be omitted.
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Affiliation(s)
- Robert J Hoekstra
- Department of Urology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.,Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Prosper Prostate Clinic, Nijmegen, The Netherlands
| | - Ward J H Goossens
- Department of Urology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Alexander Beulens
- Department of Urology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Hilde van Herk
- Department of Pathology, PAMM Foundation Laboratory for Pathology and Medical Microbiology, Veldhoven, The Netherlands
| | - Brigiet M Hoevenaars
- Department of Pathology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Joost de Baaij
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Prosper Prostate Clinic, Nijmegen, The Netherlands
| | - Diederik M Somford
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Prosper Prostate Clinic, Nijmegen, The Netherlands
| | - J P Michiel Sedelaar
- Prosper Prostate Clinic, Nijmegen, The Netherlands.,Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jean-Paul A van Basten
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Prosper Prostate Clinic, Nijmegen, The Netherlands
| | - H J Eric J Vrijhof
- Department of Urology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.,Prosper Prostate Clinic, Nijmegen, The Netherlands
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14
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Yu N, Saadat H, Finelli A, Lee JY, Singal RK, Grantcharov TP, Goldenberg MG. Quantifying the "Assistant Effect" in Robotic-Assisted Radical Prostatectomy (RARP): Measures of Technical Performance. J Surg Res 2020; 260:307-314. [PMID: 33370599 DOI: 10.1016/j.jss.2020.11.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/12/2020] [Accepted: 11/01/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Surgeons are reliant on the bedside assistant during robotic surgeries. Using a modified global rating scale (GRS), we aim to assess the association between an assistant's technical skill on surgeon performance in Robotic-Assisted Radical Prostatectomy (RARP). METHODS Prospective, intraoperative video from RARP cases at three centers were collected. Baseline demographic and RARP-experience data were collected from participating surgeons and trainees. The dissection of the prostatic pedicle and neurovascular bundle step (NVB) was analyzed. Expert analysts scored the console surgeon performance using the Global Evaluative Assessment of Robotic Skills (GEARS), and the bedside assistant performance using a modified Objective Structured Assessment of Technical Skills (aOSATS). The primary outcome is the association between console surgeon performance, as measured by GEARS, and assistant skill, as measured by aOSATS. Spearman's rho correlations were used to test the relationship between assistant and surgeon technical performance, and a multivariable linear regression model was created to test this association while controlling for patient factors. RESULTS 92 RARP cases were available for the analysis, comprising 14 console surgeons and 22 different bedside assistants. In only 5 (5.4%) cases, the neurovascular bundle step was completed by a trainee, and in 13 (14.1%) of cases, a staff-level surgeon acted as the bedside assistant. aOSATS score was significantly associated with robotic console experience (P = 0.011), and prior laparoscopic experience (P < 0.001). Assistant aOSATS score showed a weak but significant correlation with surgeon GEARS score during the neurovascular bundle step (spearman's rho = 0.248, P = 0.028). On linear regression, aOSATS remained a significant predictor of console surgeon performance (P = 0.016), after controlling for patient age and BMI, prostate volume, tumor stage, and presence of nerve-sparing. CONCLUSIONS This is the first study to assess the association between assistant technical skill and surgeon performance in RARP. Additionally, we have provided validity evidence for a modified OSATS global rating scale for training and assessing bedside assistant performance.
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Affiliation(s)
- Nancy Yu
- Faculty of Medicine, McGill University, Montreal, Canada
| | - Hossein Saadat
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Antonio Finelli
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jason Y Lee
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Rajiv K Singal
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Teodor P Grantcharov
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; International Centre for Surgical Safety, St. Michael's Hospital, Toronto, Canada
| | - Mitchell G Goldenberg
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada; International Centre for Surgical Safety, St. Michael's Hospital, Toronto, Canada.
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15
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Trieu D, Ju IE, Chang SB, Mungovan SF, Patel MI. Surgeon case volume and continence recovery following radical prostatectomy: a systematic review. ANZ J Surg 2020; 91:521-529. [PMID: 33319438 DOI: 10.1111/ans.16491] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/16/2020] [Accepted: 11/29/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Urinary incontinence (UI) is a common complication following radical prostatectomy (RP). Prolonged UI has a substantial impact on quality of life and psychosocial well-being. As the RP technique is complex, it is reasonable to propose that surgeon experience could affect post-operative continence recovery outcomes. This study aimed to systematically evaluate evidence regarding a surgeon's experience and continence recovery after RP. METHODS A comprehensive search of the literature was performed in April 2020 using the Medline, Embase, CINAHL and psychINFO electronic databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. All English language studies investigating UI following RP, stratified by surgeon experience, were included. Surgeon experience was defined as average annual case load or volume. RESULTS Thirteen studies published between 2003 and 2020 met the inclusion criteria and were included in our systematic review. Three prospective and 10 retrospective cohort studies included a total of 47 316 patients undergoing RP via open, laparoscopic or robotic-assisted procedures. Heterogeneity in the definition of surgeon experience and UI did not allow a meta-analysis. The majority of studies reported that surgeons with higher surgical volumes achieved better continence recovery rates at the early (6-week), 3-month, 6-month and later (≥12-month) time points. Most studies where a high surgical volume was defined as >50 cases/year demonstrated a significant difference in continence outcomes. CONCLUSION Better urinary continence recovery results can be expected by patients who undergo RP performed by a surgeon with greater experience. An annual surgical case load of >50 cases/year results in improved continence recovery outcomes following RP.
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Affiliation(s)
- Danny Trieu
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Irene E Ju
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Simon B Chang
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sean F Mungovan
- Westmead Private Physiotherapy Services, Westmead Private Hospital, Sydney, New South Wales, Australia.,The Clinical Research Institute, Sydney, New South Wales, Australia.,Department of Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Manish I Patel
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Urology, Westmead Hospital, Sydney, New South Wales, Australia
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16
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Arenas-Gallo C, Shoag JE, Hu JC. Optimizing Surgical Techniques in Robot-Assisted Radical Prostatectomy. Urol Clin North Am 2020; 48:1-9. [PMID: 33218583 DOI: 10.1016/j.ucl.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Robot-assisted radical prostatectomy (RARP) is the most common surgical treatment of localized prostate cancer. The ideal procedure would achieve maximum oncological efficacy while minimizing associated side effects, such as erectile dysfunction and urinary incontinence. Surgeon experience and surgical technique affect RARP outcomes. Here, the authors review RARP technical modifications aimed at optimizing cancer control and postoperative urinary and sexual function.
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Affiliation(s)
- Camilo Arenas-Gallo
- School of Medicine, Universidad Industrial de Santander, Cra 21 No 158-80 Casa 83, Floridablanca, Santander 681004, Colombia
| | - Jonathan E Shoag
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Case Comprehensive Cancer Center, 11100 Euclid Ave, Cleveland, OH 44106, USA; Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, 24610 Sittingbourne Drive, Bechwood, NY 44122, USA.
| | - Jim C Hu
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, 413 East 69th Street, Starr 946, New York, NY 10021, USA
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17
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Checcucci E, Pecoraro A, DE Cillis S, Manfredi M, Amparore D, Aimar R, Piramide F, Granato S, Volpi G, Autorino R, Fiori C, Porpiglia F. The importance of anatomical reconstruction for continence recovery after robot assisted radical prostatectomy: a systematic review and pooled analysis from referral centers. Minerva Urol Nephrol 2020; 73:165-177. [PMID: 33200906 DOI: 10.23736/s2724-6051.20.04146-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Urinary incontinence is one of the most scared sequelae of robot assisted radical prostatectomy (RARP). Therefore, different surgical modifications, aimed to restore the original anatomy, were proposed to overcome this issue. The purpose of this study is to assess which is the best reconstruction technique (posterior only: PR; anterior only: AR; total: TR) compared to the standard approach for continence recovery after RARP in a tertiary care center. EVIDENCE ACQUISITION After establishing an a priori protocol, a systematic electronic literature search was conducted in May 2019. The article selection proceeded in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and was registered (PROSPERO registry number 131667). The risk of bias and the quality assessment of the included studies were performed. Simple pooled analysis was performed for continence rates according to the definition of continence (0 pad vs. 0-1 pad) and the different types of reconstruction at 1, 4, 12, 24, 52 weeks after RARP. Complication rate, operative and console time and estimated blood loss were pooled. Two-side test of proportion and T-test were used to compare rates and mean, respectively. EVIDENCE SYNTHESIS Six studies meeting the inclusion criteria were found and included in the analysis. All the included studies were of "poor" or "good" quality. A high or moderate risk of bias was recorded. TR showed higher continence recovery rates, compared to their anterior reconstruction counterpart at 1, 4, 12, 24, 52 weeks (P<0.001 at all time-points). At 12 weeks TR showed the highest continence rates (P<0.001), followed by AR and PR. No statistically significant differences were recorded regarding anastomosis-related complication rates (anastomosis stricture P=0.08; urine leakage P=0.1). CONCLUSIONS In patients undergoing RARP, TR facilitates a faster and higher continence recovery compared to standard approach or PR or AR only.
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Affiliation(s)
- Enrico Checcucci
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy -
| | - Angela Pecoraro
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Sabrina DE Cillis
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Matteo Manfredi
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Daniele Amparore
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Roberta Aimar
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Federico Piramide
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Stefano Granato
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Gabriele Volpi
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | | | - Cristian Fiori
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Francesco Porpiglia
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
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Nyberg M, Sjoberg DD, Carlsson SV, Wilderäng U, Carlsson S, Stranne J, Wiklund P, Steineck G, Haglind E, Hugosson J, Bjartell A. Surgeon heterogeneity significantly affects functional and oncological outcomes after radical prostatectomy in the Swedish LAPPRO trial. BJU Int 2020; 127:361-368. [PMID: 32916021 PMCID: PMC7984397 DOI: 10.1111/bju.15238] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objectives To evaluate how surgeon heterogeneity – the variation in outcomes between individual surgeons – influences functional and oncological outcomes after robot‐assisted laparoscopic prostatectomy (RALP) and retropubic radical prostatectomy (RRP), and to assess whether surgeon heterogeneity affects the comparison between RALP and RRP. Patients and Methods Laparoscopic Prostatectomy Robot Open (LAPPRO) is a prospective, controlled, non‐randomized trial performed at 14 Swedish centres with 68 operating surgeons. A total of 4003 men with localized prostate cancer were enrolled between 2008 and 2011. The endpoints were urinary incontinence, erectile dysfunction (ED) and recurrence at 24 months after surgery. Logistic regression models were built to evaluate surgeon heterogeneity and, secondarily, surgeon‐specific factors were added to the models to investigate their influence on heterogeneity and the comparison between RALP and RRP. Results Among surgeons who performed at least 20 surgeries during the study period (n=25), we observed statistically significant heterogeneity for incontinence (P = 0.001), ED (P < 0.001) and rate of recurrent disease (P < 0.001). The significant heterogeneity remained when analysing only experienced surgeons with a stated experience of at least 250 radical prostatectomies (n=12). Among all participating surgeons (n=68), differences in surgeon volume explained 42% of the observed heterogeneity for incontinence (P = 0.003), 11% for ED (P = 0.03) and 19% for recurrence (P = 0.01). Taking surgeon volume into account when comparing RALP and RRP had a significant impact on the results. The effect was greatest for functional outcomes, and the additional adjustments for the surgeons' previous experience changed whether the difference between techniques was statistically significant or not. The surgeons’ annual volume had the greatest effect on the recurrence rate. Conclusions There was a large degree of heterogeneity among surgeons regarding both functional and oncological outcomes and this had a significant impact on the results when comparing RALP and RRP. Some of the observed heterogeneity was explained by differences in surgeon volume. Efforts to decrease heterogeneity are warranted and variation among surgeons must be accounted for when conducting comparative analyses between surgical techniques.
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Affiliation(s)
- Martin Nyberg
- Department of Urology, Skåne University Hospital, Malmö, Sweden.,Division of Urological Cancers, Department of Translational Medicine, Faculty of Medicine, Lund University, Lund, Sweden
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sigrid V Carlsson
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Ulrica Wilderäng
- Department of Oncology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Stefan Carlsson
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - Johan Stranne
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Wiklund
- Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA.,Department of Molecular Medicine and Surgery Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - Gunnar Steineck
- Department of Oncology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, Scandinavian Surgical Outcomes Research Group, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Bjartell
- Department of Urology, Skåne University Hospital, Malmö, Sweden.,Division of Urological Cancers, Department of Translational Medicine, Faculty of Medicine, Lund University, Lund, Sweden
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19
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Capogrosso P, Pozzi EP, Celentano V, Sanchez-Salas R, Salonia A. Erectile Recovery After Radical Pelvic Surgery: Methodological Challenges and Recommendations for Data Reporting. J Sex Med 2020; 17:7-16. [DOI: 10.1016/j.jsxm.2019.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/16/2019] [Accepted: 09/19/2019] [Indexed: 01/16/2023]
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20
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Palagonia E, Mazzone E, De Naeyer G, D'Hondt F, Collins J, Wisz P, Van Leeuwen FWB, Van Der Poel H, Schatteman P, Mottrie A, Dell'Oglio P. The safety of urologic robotic surgery depends on the skills of the surgeon. World J Urol 2019; 38:1373-1383. [PMID: 31428847 DOI: 10.1007/s00345-019-02901-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/02/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To assess the available literature evidence that discusses the effect of surgical experience on patient outcomes in robotic setting. This information is used to help understand how we can develop a learning process that allows surgeons to maximally accommodate patient safety. METHODS A literature search of the MEDLINE/PubMed and Scopus database was performed. Original and review articles published in the English language were included after an interactive peer-review process of the panel. RESULTS Robotic surgical procedures require high level of experience to guarantee patient safety. This means that, for some procedures, the learning process might be longer than originally expected. In this context, structured training programs that assist surgeons to improve outcomes during their learning processes were extensively discussed. We identified few structured robotic curricula and demonstrated that for some procedures, curriculum trained surgeons can achieve outcomes rates during their initial learning phases that are at least comparable to those of experienced surgeons from high-volume centres. Finally, the importance of non-technical skills on patient safety and of their inclusion in robotic training programs was also assessed. CONCLUSION To guarantee safe robotic surgery and to optimize patient outcomes during the learning process, standardized and validated training programs are instrumental. To date, only few structured validated curricula exist for standardized training and further efforts are needed in this direction.
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Affiliation(s)
- Erika Palagonia
- ORSI Academy, Melle, Belgium.,Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - Elio Mazzone
- ORSI Academy, Melle, Belgium.,Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.,Division of Experimental Oncology and Department of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Geert De Naeyer
- ORSI Academy, Melle, Belgium.,Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - Frederiek D'Hondt
- ORSI Academy, Melle, Belgium.,Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | | | - Pawel Wisz
- ORSI Academy, Melle, Belgium.,Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - Fijs W B Van Leeuwen
- ORSI Academy, Melle, Belgium.,Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Urology, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk Van Der Poel
- Department of Urology, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Peter Schatteman
- ORSI Academy, Melle, Belgium.,Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - Alexandre Mottrie
- ORSI Academy, Melle, Belgium.,Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - Paolo Dell'Oglio
- ORSI Academy, Melle, Belgium. .,Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium. .,Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands.
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22
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Barzi A, Lara PN, Tsao-Wei D, Yang D, Gill IS, Daneshmand S, Klein EA, Pinski JK, Penson DF, Quinn DI, Sadeghi S. Influence of the facility caseload on the subsequent survival of men with localized prostate cancer undergoing radical prostatectomy. Cancer 2019; 125:3853-3863. [PMID: 31398279 DOI: 10.1002/cncr.32290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 04/05/2019] [Accepted: 05/08/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Several studies have investigated the relationship between experience measured by caseload and oncological outcomes, economics, and access to care for prostate cancer care. Oncological outcomes have been limited to biochemical failure after radical prostatectomy. Questions remain regarding the more definitive measures of outcomes and their relationship with caseload. METHODS The National Cancer Database was used to investigate the outcomes of radical prostatectomy in the United States. With overall survival (OS) as the primary outcome, the relationship between the facility annual caseload (FAC) for all prostate cancer encounters and the facility annual surgical caseload (FASC) for those requiring radical prostatectomy was examined with a Cox proportional hazards model. Four volume groups were defined by caseload: <50th percentile (volume group 1 [VG1]), 50th to 74th percentiles (volume group 2 [VG2]), 75th to 89th percentiles (volume group 3 [VG3]), and ≥90th percentile (volume group 4 [VG4]). By FAC/FASC, 11%/8%, 17%/18%, 25%/26%, and 47%/49% of patients were treated in VG1 through VG4, respectively. RESULTS Between 2004 and 2014, 488,389 patients underwent radical prostatectomy. At a median follow-up of 60.75 months, the median OS was not reached. There was a significant OS benefit as the caseload increased. For FAC, the adjusted OS difference between VG1 and VG4 at 90th percentile survivorship reached 13.2 months (hazard ratio [HR], 1.30; 95% CI, 1.23-1.36; P < .0001). For FASC, this was 11.3 months (HR, 1.25; 95% CI, 1.192-1.321; P < .0001). CONCLUSIONS There is a statistically significant OS advantage from performing radical prostatectomy at a facility with a high annual caseload. Caseload measured by all prostate cancer encounters is a better predictor of favorable outcomes than the number of surgeries performed at a facility. LAY SUMMARY An in-depth analysis of 488,389 cases of radical prostatectomy performed in more than 1000 facilities over a 10-year period showed better survival when surgery was performed in facilities with more experience and greater caseload. A survival difference of up to 13 months was observed when comparing patients treated at less experienced versus more experienced centers. Experience across all stages of prostate cancer was a stronger predictor of survival outcome than just the number of surgeries performed.
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Affiliation(s)
- Afsaneh Barzi
- Division of Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California
| | - Primo N Lara
- Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, California
| | - Denice Tsao-Wei
- Department of Preventive Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California
| | - Dongyun Yang
- Department of Computational and Quantitative Medicine, City of Hope National Medical Center, Duarte, California
| | - Inderbir S Gill
- Institute of Urology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California
| | - Siamak Daneshmand
- Institute of Urology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California
| | - Eric A Klein
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jacek K Pinski
- Division of Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David I Quinn
- Division of Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California
| | - Sarmad Sadeghi
- Division of Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California
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Cao L, Yang Z, Qi L, Chen M. Robot-assisted and laparoscopic vs open radical prostatectomy in clinically localized prostate cancer: perioperative, functional, and oncological outcomes: A Systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15770. [PMID: 31145297 PMCID: PMC6709105 DOI: 10.1097/md.0000000000015770] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To perform a systematic review and meta-analysis evaluating the perioperative, functional, and oncological outcomes and cost of robot-assisted radical prostatectomy (RARP), or laparoscopic radical prostatectomy (LRP) comparing with open radical prostatectomy (ORP) in men with clinically localized prostate cancer through all prospective comparative studies. METHODS A comprehensive literature search was performed in August 2018 using the Pubmed, Medline, Embase, and Cochrane databases. Only randomized controlled trials (RCTs) and prospective studies including patients with clinically localized prostate cancer were eligible for study inclusion. Cumulative analysis was conducted using Review Manager v. 5.3 software. RESULTS Two RCTs and 9 prospective studies were included in this systematic review. There were no significant differences between RARP/LRP and ORP in overall complication rate, major complication rate, overall positive surgical margin (PSM) rate, ≤pT2 tumor PSM rate, ≥pT3 tumor PSM rate. Moreover, RARP/LRP and ORP showed similarity in biochemical recurrence (BCR) rate at 3, 12, 24 months postoperatively. Urinary continence and erectile function at 12 months postoperatively between RARP and ORP are also comparable. RARP/LRP were associated with significantly lower estimated blood loss [mean difference (MD) -749.67, 95% CI -1038.52 to -460.82, P = .001], lower transfusion rate (OR 0.17, 95% CI 0.10 to 0.30, P < .001) and less hospitalization duration (MD -1.18, 95% CI -2.18 to -0.19, P = .02). And RARP/LRP required more operative time (MD 50.02, 95% CI 6.50 to 93.55, P = .02) and cost. CONCLUSION RARP/LRP is associated with lower blood loss, transfusion rate and less hospitalization duration. The available data were insufficient to prove the superiority of any surgical approach in terms of postoperative complications, functional and oncologic outcomes.
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Affiliation(s)
| | - Zhenyu Yang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lin Qi
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Minfeng Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, China
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Bautista Vidal J, García Galisteo E, Barón López J, Sánchez Martínez N, Hernández Alcaraz D, Morales Jiménez P, Vozmediano Chicharro R. Objective assessment of early urinary continence by analysis and visualisation of intraoperative variables of radical robotic prostatectomies with a video editor. Actas Urol Esp 2019; 43:99-105. [PMID: 30287138 DOI: 10.1016/j.acuro.2018.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION UI after RP is a factor that has a major impact on patients' quality of life and the associated healthcare costs. The definition of UI is very variable in the literature. Similarly, a great many predictors have been studied that affect recovery of continence after surgery, the most important of which are intraoperative. MATERIAL AND METHODS a retrospective and observational study performed between September 2008 and March 2015. We studied intraoperative factors through visualisation using a video editor of 148 patients who underwent robot-assisted radical prostatectomy, together with other perioperative factors associated with continence, and described in the literature. We assessed continence through ICQ questionnaires, urinary loss calculated by pad count, and clinical interview in the first, third, sixth month and at one year after surgery. We defined continence as not having to use a pad or using a pad for protection socially, or an ICQ ≤ 7. We used binary and lineal logistic regression analysis to study the relationship between the intraoperative and perioperative variables on urinary continence measured at the first, third, sixth month and one year after the operation, and on continence stability. RESULTS In our study, 72.9% of the patients were continent at one year after surgery with a mean continence stabilisation time at 4.3 months. In our lineal logistic regression analyses we found no significant relationship with the continence variable analysed during the first year. In the lineal logistic regression analysis we found that tension-free sutures had a direct positive effect (P≤.05) on the stability time of continence, as well as the urinary losses measured in the first month after surgery. CONCLUSION In conclusion, we found in our study that the tension-free sutures were able to help towards early stability of continence. We found no other intraoperative predictors that influenced urinary continence. The urinary losses measured in the first month related to early recovery of continence.
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25
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Linking surgical skills to postoperative outcomes: a Delphi study on the robot-assisted radical prostatectomy. J Robot Surg 2019; 13:675-687. [PMID: 30610535 DOI: 10.1007/s11701-018-00916-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To develop an assessment instrument for the evaluation of surgical videos to elucidate the association between surgical skills and postoperative outcomes after a robot-assisted radical prostatectomy (RARP). DESIGN A Delphi study consisting of two consecutive online surveys and a consensus group meeting. SETTING Urology departments of general, teaching and university hospitals in the Netherlands. PARTICIPANTS All Dutch urologists with a specialization in RARP. RESULTS Of 18 invited experts, 12 (67%) participated in the first online survey. In the second round, 9 of the 18 invited experts participated (50%). The Delphi meeting was attended by 5 of the 18 (27%) invited experts. The panel identified seven surgical steps with a possible association to postoperative outcomes. The experts also expected an association between adverse postoperative outcomes and the frequency of camera removals, the number of stitches placed, the amount of bleeding, and the extent of coagulation. These factors were incorporated into an assessment instrument. CONCLUSIONS Experts in the field of RARP achieved consensus on 7 surgical steps and 4 aspects of the RARP procedure that may be related to adverse postoperative outcomes. The resulting assessment instrument will be tested in future research to determine its validity.
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Gokce A, Gul D. Re: Mark Douglas Tyson II, Tatsuki Koyama, Dan Lee, et al. Effect of Prostate Cancer Severity on Functional Outcomes After Localized Treatment: Comparative Effectiveness Analysis of Surgery and Radiation Study Results. Eur Urol 2018;74:26-33. Eur Urol 2018; 75:e157. [PMID: 30558898 DOI: 10.1016/j.eururo.2018.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Ahmet Gokce
- Sakarya University School of Medicine, Department of Urology, Sakarya, Turkey.
| | - Deniz Gul
- Sakarya University School of Medicine, Department of Urology, Sakarya, Turkey
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Khan H, Kozlowski JD, Hussein AA, Sharif M, Ahmed Y, May P, Hammond Y, Stone K, Ahmad B, Cole A, Hasasneh A, Raheem S, Guru KA. Use of Robotic Anastomosis Competency Evaluation (RACE) for assessment of surgical competency during urethrovesical anastomosis. Can Urol Assoc J 2018; 13:E10-E16. [PMID: 30059282 DOI: 10.5489/cuaj.5348] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION We sought to evaluate the Robotic Anastomosis Competency Evaluation (RACE), a validated tool that objectively quantifies surgical skills specifically for urethrovesical anastomosis (UVA), as a tool to track progress of trainees, and to determine the predictive value of RACE. METHODS UVAs performed by trainees at our institution were evaluated using RACE over a period of two years. Trainees were supervised by an experienced robotic surgeon. Outcomes included trainee-related variables (RACE score, proportion of UVA performed by trainee, and suturing speed), and clinical outcomes (total UVA duration, postoperative urinary continence, and UVA-related complications). Significance was determined using linear regression analysis. RESULTS A total of 51 UVAs performed by six trainees were evaluated. Trainee RACE scores (19.8 to 22.3; p=0.01) and trainee proportion of UVA (67% to 80%; p=0.003) improved significantly over time. Trainee suture speed was significantly associated with RACE score (mean speed range 0.54-0.74 sutures/minute; p=0.03). Neither urinary continence at six weeks nor six months was significantly associated with RACE score (p=0.17 and p=0.15, respectively), and only one UVA-related postoperative complication was reported. CONCLUSIONS Trainee RACE scores improved and proportion of UVA performed by trainees increased over time. RACE can be used as an objective measure of surgical performance during training. Strict mentor supervision allowed safe training without compromising patient outcomes.
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Affiliation(s)
- Hijab Khan
- Roswell Park Cancer Institute, Buffalo, NY, United States
| | | | - Ahmed A Hussein
- Roswell Park Cancer Institute, Buffalo, NY, United States.,Cairo University, Egypt
| | - Mohamed Sharif
- Roswell Park Cancer Institute, Buffalo, NY, United States
| | - Youssef Ahmed
- Roswell Park Cancer Institute, Buffalo, NY, United States
| | - Paul May
- Roswell Park Cancer Institute, Buffalo, NY, United States
| | - Yana Hammond
- Roswell Park Cancer Institute, Buffalo, NY, United States
| | - Kevin Stone
- Roswell Park Cancer Institute, Buffalo, NY, United States
| | - Basim Ahmad
- Roswell Park Cancer Institute, Buffalo, NY, United States
| | - Adam Cole
- Roswell Park Cancer Institute, Buffalo, NY, United States
| | - Adam Hasasneh
- Roswell Park Cancer Institute, Buffalo, NY, United States
| | - Sana Raheem
- Roswell Park Cancer Institute, Buffalo, NY, United States
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Sharma V, Karnes RJ. Much ado about robotic versus open radical prostatectomy. Lancet Oncol 2018; 19:1003-1004. [PMID: 30017350 DOI: 10.1016/s1470-2045(18)30417-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 05/25/2018] [Indexed: 10/28/2022]
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Nyberg M, Hugosson J, Wiklund P, Sjoberg D, Wilderäng U, Carlsson SV, Carlsson S, Stranne J, Steineck G, Haglind E, Bjartell A. Functional and Oncologic Outcomes Between Open and Robotic Radical Prostatectomy at 24-month Follow-up in the Swedish LAPPRO Trial. Eur Urol Oncol 2018; 1:353-360. [PMID: 31158073 DOI: 10.1016/j.euo.2018.04.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/06/2018] [Accepted: 04/16/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The adoption of robot-assisted laparoscopic radical prostatectomy (RALP) has increased rapidly, despite lack of conclusive evidence of its superiority regarding long-term outcomes over open retropubic RP (RRP). In 2015, we reported on 12-mo follow-up from the LAPPRO trial showing a moderate advantage of RALP regarding erectile dysfunction. No significant differences were seen for urinary incontinence or surgical margin status. OBJECTIVE To present patient-reported functional outcomes and recurrent and residual disease at 24-mo follow-up from the prospective multicenter LAPPRO trial. DESIGN, SETTING, AND PARTICIPANTS A total of 4003 patients with clinically localized prostate cancer were recruited from 14 Swedish centers, seven performing RALP and seven RRP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Data were only analyzed for patients operated on by surgeons with >100 prior RPs. Adjusted odds ratios (AORs) were calculated using logistic regression, with adjustment for differences in patient mix. RESULTS AND LIMITATIONS At 24 mo, there was a significant difference in erectile dysfunction in favor of RALP (68% vs 74%; AOR 0.72, 95% confidence interval [CI] 0.57-0.91; p=0.006). No significant difference was observed for incontinence (19% vs 16%; AOR 1.29, 95% CI 1.00-1.67; p=0.053) or recurrent or residual disease (13% vs 13%; AOR 0.79, 95% CI 0.59-1.07; p=0.13). We did not adjust for individual surgeon volume and experience, which is a potential limitation. CONCLUSIONS Extended follow-up corroborated our previous report at 12 mo of a persistent RALP benefit regarding potency. PATIENT SUMMARY LAPPRO is a Swedish trial comparing two different prostate cancer surgical techniques (robotic compared to open). At 24-mo follow-up after surgery there was a moderate advantage for the robotic technique regarding erectile dysfunction (potency), while there was a small but not significant difference in urinary leakage in favor of open surgery. We did not find any difference regarding cancer relapse.
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Affiliation(s)
- Martin Nyberg
- Department of Urology, Skåne University Hospital, Malmö, Sweden; Department of Translational Medicine, Division of Urological Cancers, Faculty of Medicine, Lund University, Sweden
| | - Jonas Hugosson
- Institute of Clinical Sciences, Department of Urology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - Daniel Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ulrica Wilderäng
- Department of Oncology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Sigrid V Carlsson
- Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stefan Carlsson
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - Johan Stranne
- Institute of Clinical Sciences, Department of Urology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gunnar Steineck
- Department of Oncology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Division of Clinical Cancer Epidemiology, Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, Scandinavian Surgical Outcomes Research Group, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Anders Bjartell
- Department of Urology, Skåne University Hospital, Malmö, Sweden; Department of Translational Medicine, Division of Urological Cancers, Faculty of Medicine, Lund University, Sweden.
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Re: The Risks and Benefits of Cavernous Neurovascular Bundle Sparing during Radical Prostatectomy: A Systematic Review and Meta-Analysis. J Urol 2018; 199:1070-1072. [DOI: 10.1016/j.juro.2017.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 11/23/2022]
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Williams SB, Morales BE, Huynh LM, Osann K, Skarecky DW, Ahlering TE. Analysis of Accessory Pudendal Artery Transection on Erections During Robot-Assisted Radical Prostatectomy. J Endourol 2017; 31:1170-1175. [PMID: 28859491 DOI: 10.1089/end.2017.0542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To compare the recovery of erections and potency following the transection of accessory pudendal arteries (APAs) in men undergoing robot-assisted radical prostatectomy (RARP) compared with men with normal vascular anatomy. MATERIALS AND METHODS A total of 880 consecutive patients who underwent RARP from January 1, 2007 to December 31, 2014 were included with prospectively collected data in cross-sectional analysis. Erectile function (EF) was assessed preoperatively and postoperatively at 3, 6, 12, and 24 months using the International Index of Erectile Function (IIEF)-5, a percent erection fullness compared to preoperative status, and two Expanded Prostate Cancer Index (EPIC) questions: (1) are erections firm enough for penetration and (2) are they satisfactory? RESULTS Two hundred thirty-one (33.1%) men had APAs transected. There were no significant differences in baseline demographics or clinical characteristics in men with or without APAs transected. Multivariate analyses demonstrated that age (confidence interval [95% CI]: 0.94, 0.99) and baseline IIEF-5 (95% CI: 1.15, 1.26) strongly correlated with recovery of erections and potency. Transection of APAs was not a significant predictor of erectile dysfunction (ED). CONCLUSION Good surgical technique dictates the preservation of APAs. However, when preservation is questioned, we found that APA transection had no measurable effect on recovery of erections or potency regardless of age, preoperative ED, or number of APAs transected.
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Affiliation(s)
- Stephen B Williams
- 1 Division of Urology, The University of Texas Medical Branch , Galveston, Texas
| | - Blanca E Morales
- 2 Department of Urology, University of California Irvine Health , Orange, California
| | - Linda M Huynh
- 2 Department of Urology, University of California Irvine Health , Orange, California
| | - Kathryn Osann
- 3 Department of Medicine, University of California Irvine , Irvine, California
| | - Douglas W Skarecky
- 2 Department of Urology, University of California Irvine Health , Orange, California
| | - Thomas E Ahlering
- 2 Department of Urology, University of California Irvine Health , Orange, California
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Gilbert SM, Dunn RL, Miller DC, Montgomery JS, Skolarus TA, Weizer AZ, Wood DP, Hollenbeck BK. Functional Outcomes Following Nerve Sparing Prostatectomy Augmented with Seminal Vesicle Sparing Compared to Standard Nerve Sparing Prostatectomy: Results from a Randomized Controlled Trial. J Urol 2017; 198:600-607. [DOI: 10.1016/j.juro.2017.03.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Scott M. Gilbert
- Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
- Health Outcomes and Behavior Programs, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rodney L. Dunn
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David C. Miller
- Veterans Affairs Health Services Research and Development Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jeffrey S. Montgomery
- Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Ted A. Skolarus
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
- Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Alon Z. Weizer
- Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Brent K. Hollenbeck
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
- Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
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Henríquez I, Rodríguez-Antolín A, Cassinello J, Gonzalez San Segundo C, Unda M, Gallardo E, López-Torrecilla J, Juarez A, Arranz J. Consensus statement on definition, diagnosis, and management of high-risk prostate cancer patients on behalf of the Spanish Groups of Uro-Oncology Societies URONCOR, GUO, and SOGUG. Clin Transl Oncol 2017; 20:392-401. [PMID: 28785912 DOI: 10.1007/s12094-017-1726-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 07/26/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Prostate cancer (PCa) is the most prevalent malignancy in men and the second cause of mortality in industrialized countries. METHODS Based on Spanish Register of PCa, the incidence of high-risk PCa is 29%, approximately. In spite of the evidence-based beneficial effect of radiotherapy and androgen deprivation therapy in high-risk PCa, these patients (pts) are still a therapeutic challenge for all specialists involved, in part due to the absence of comparative studies to establish which of the present disposable treatments offer better results. RESULTS Nowadays, high-risk PCa definition is not well consensual through the published oncology guides. Clinical stage, tumour grade, and number of risk factors are relevant to be considered on PCa prognosis. However, these factors are susceptible to change depending on when surgical or radiation therapy is considered to be the treatment of choice. Other factors, such as reference pathologist, different diagnosis biopsy schedules, surgical or radiotherapy techniques, adjuvant treatments, biochemical failures, and follow-up, make it difficult to compare the results between different therapeutic options. CONCLUSIONS This article reviews important issues concerning high-risk PCa. URONCOR, GUO, and SOGUG on behalf of the Spanish Groups of Uro-Oncology Societies have reached a consensus addressing a practical recommendation on definition, diagnosis, and management of high-risk PCa.
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Affiliation(s)
- I Henríquez
- Radiation Oncology Department, Hospital Universitario of Sant Joan, Institute d'Investigació Sanitaria Pere Virgili (IISPV), Josep Laporte 2, 43204, Reus, Spain.
| | | | - J Cassinello
- Medical Oncology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | | | - M Unda
- Urology Department, Hospital Barakaldo, Bilbao, Spain
| | - E Gallardo
- Medical Oncology Department, Hospital Parc Taulí, Sabadell, Spain
| | | | - A Juarez
- Urology Department, Hospital Cádiz, Andalucía, Spain
| | - J Arranz
- Medical Oncology Department, Hospital Gregorio Marañón, Madrid, Spain
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Hung AJ, Chen J, Jarc A, Hatcher D, Djaladat H, Gill IS. Development and Validation of Objective Performance Metrics for Robot-Assisted Radical Prostatectomy: A Pilot Study. J Urol 2017; 199:296-304. [PMID: 28765067 DOI: 10.1016/j.juro.2017.07.081] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE We explore and validate objective surgeon performance metrics using a novel recorder ("dVLogger") to directly capture surgeon manipulations on the da Vinci® Surgical System. We present the initial construct and concurrent validation study of objective metrics during preselected steps of robot-assisted radical prostatectomy. MATERIALS AND METHODS Kinematic and events data were recorded for expert (100 or more cases) and novice (less than 100 cases) surgeons performing bladder mobilization, seminal vesicle dissection, anterior vesicourethral anastomosis and right pelvic lymphadenectomy. Expert/novice metrics were compared using mixed effect statistical modeling (construct validation). Expert reviewers blindly rated seminal vesicle dissection and anterior vesicourethral anastomosis using GEARS (Global Evaluative Assessment of Robotic Skills). Intraclass correlation measured inter-rater variability. Objective metrics were correlated to corresponding GEARS metrics using Spearman's test (concurrent validation). RESULTS The performance of 10 experts (mean 810 cases, range 100 to 2,000) and 10 novices (mean 35 cases, range 5 to 80) was evaluated in 100 robot-assisted radical prostatectomy cases. For construct validation the experts completed operative steps faster (p <0.001) with less instrument travel distance (p <0.01), less aggregate instrument idle time (p <0.001), shorter camera path length (p <0.001) and more frequent camera movements (p <0.03). Experts had a greater ratio of dominant-to-nondominant instrument path distance for all steps (p <0.04) except anterior vesicourethral anastomosis. For concurrent validation the median experience of 3 expert reviewers was 300 cases (range 200 to 500). Intraclass correlation among reviewers was 0.6-0.7. For anterior vesicourethral anastomosis and seminal vesicle dissection, kinematic metrics had low associations with GEARS metrics. CONCLUSIONS Objective metrics revealed experts to be more efficient and directed during preselected steps of robot-assisted radical prostatectomy. Objective metrics had limited associations to GEARS. These findings lay the foundation for developing standardized metrics for surgeon training and assessment.
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Affiliation(s)
- Andrew J Hung
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, University of Southern California Institute of Urology, Los Angeles, California.
| | - Jian Chen
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, University of Southern California Institute of Urology, Los Angeles, California
| | - Anthony Jarc
- Medical Research, Intuitive Surgical, Inc., Norcross, Georgia
| | - David Hatcher
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, University of Southern California Institute of Urology, Los Angeles, California
| | - Hooman Djaladat
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, University of Southern California Institute of Urology, Los Angeles, California
| | - Inderbir S Gill
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, University of Southern California Institute of Urology, Los Angeles, California
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Gershman B, Meier SK, Jeffery MM, Moreira DM, Tollefson MK, Kim SP, Karnes RJ, Shah ND. Redefining and Contextualizing the Hospital Volume-Outcome Relationship for Robot-Assisted Radical Prostatectomy: Implications for Centralization of Care. J Urol 2017; 198:92-99. [DOI: 10.1016/j.juro.2017.01.067] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Boris Gershman
- Division of Urology, Rhode Island Hospital and Miriam Hospital, Providence, Rhode Island
| | - Sarah K. Meier
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Molly M. Jeffery
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Daniel M. Moreira
- Department of Urology, University of Illinois at Chicago, Chicago, Illinois
| | | | - Simon P. Kim
- Department of Urology, Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Nilay D. Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- OptumLabs, Cambridge, Massachusetts
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Goldenberg MG, Goldenberg L, Grantcharov TP. Surgeon Performance Predicts Early Continence After Robot-Assisted Radical Prostatectomy. J Endourol 2017; 31:858-863. [PMID: 28557582 DOI: 10.1089/end.2017.0284] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION There is limited, yet compelling evidence supporting the role of surgeon technical performance in influencing patient outcomes. To date, this concept has been underexplored in endourologic procedures. We hypothesized that a surgeon's technical performance plays a role in predicting an early return to continence after robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS We conducted a retrospective, matched case-control analysis of prospectively collected unedited RARP endoscopic videos performed by a single surgeon. A blinded observer with expertise in intraoperative video analysis evaluated clinically relevant steps of RARP using the global evaluative assessment of robotic skill (GEARS) and the generic error rating tool (GERT). The primary outcome was continence status at 3 months postoperatively, defined as patient use of less than or equal to a single precautionary pad. Mann-Whitney U tests examined differences in predictor variables between cases and controls, and multivariate analysis was conducted using binary logistic regression models. RESULTS Twenty-four incontinent patients were matched for age, body mass index, preoperative International Prostate Symptoms Score, use of posterior/anterior hitch, prostate weight, and learning curve position. No statistically significant difference in errors between groups was observed using the GERT. On multivariate analysis, overall case GEARS score was independently predictive of 3-month continence status (odds ratios [OR] = 0.55, 95% confidence interval [CI] 0.33-0.91), as were urethrovesical anastomosis (OR = 0.70, 95% CI 0.50-0.97) and bladder neck GEARS scores (OR = 0.69, 95% CI 0.51-0.94). CONCLUSIONS Our study generates the hypothesis that there may be a link between surgeon technical performance and functional outcomes in RARP. This relationship may have implications for the accreditation and training of future urologists and warrants further investigation.
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Affiliation(s)
- Mitchell G Goldenberg
- 1 Division of Urology, University of Toronto , Toronto, Canada .,2 Department of Urologic Sciences, University of British Columbia , Vancouver, Canada
| | - Larry Goldenberg
- 3 Department of Surgery, University of Toronto , Toronto, Canada
| | - Teodor P Grantcharov
- 2 Department of Urologic Sciences, University of British Columbia , Vancouver, Canada
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Hussein AA, Ghani KR, Peabody J, Sarle R, Abaza R, Eun D, Hu J, Fumo M, Lane B, Montgomery JS, Hinata N, Rooney D, Comstock B, Chan HK, Mane SS, Mohler JL, Wilding G, Miller D, Guru KA. Development and Validation of an Objective Scoring Tool for Robot-Assisted Radical Prostatectomy: Prostatectomy Assessment and Competency Evaluation. J Urol 2017; 197:1237-1244. [DOI: 10.1016/j.juro.2016.11.100] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Ahmed A. Hussein
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
- Department of Urology, Cairo University, Cairo, Egypt
| | | | | | | | | | - Daniel Eun
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Jim Hu
- Weil Cornell Medicine, New York, New York
| | | | - Brian Lane
- Spectrum Health Medical, Grand Rapids, Michigan
| | | | | | - Deborah Rooney
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
| | | | - Hei Kit Chan
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
| | - Sridhar S. Mane
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
| | - James L. Mohler
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
| | - Gregory Wilding
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
| | - David Miller
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Khurshid A. Guru
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
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Access to high-volume surgeons and the opportunity cost of performing radical prostatectomy by low-volume providers. Urol Oncol 2017; 35:459.e15-459.e24. [PMID: 28284890 DOI: 10.1016/j.urolonc.2017.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/15/2017] [Accepted: 01/30/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evidence 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. METHODS Medicare 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. RESULTS A 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. CONCLUSIONS About 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.
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Carlsson SV, de Carvalho TM, Roobol MJ, Hugosson J, Auvinen A, Kwiatkowski M, Villers A, Zappa M, Nelen V, Páez A, Eastham JA, Lilja H, de Koning HJ, Vickers AJ, Heijnsdijk EAM. Estimating the harms and benefits of prostate cancer screening as used in common practice versus recommended good practice: A microsimulation screening analysis. Cancer 2016; 122:3386-3393. [PMID: 27459245 PMCID: PMC5073010 DOI: 10.1002/cncr.30192] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/07/2016] [Accepted: 06/07/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Prostate-specific antigen (PSA) screening and concomitant treatment can be implemented in several ways. The authors investigated how the net benefit of PSA screening varies between common practice versus "good practice." METHODS Microsimulation screening analysis (MISCAN) was used to evaluate the effect on quality-adjusted life-years (QALYs) if 4 recommendations were followed: limited screening in older men, selective biopsy in men with elevated PSA, active surveillance for low-risk tumors, and treatment preferentially delivered at high-volume centers. Outcomes were compared with a base model in which annual screening started at ages 55 to 69 years and were simulated using data from the European Randomized Study of Screening for Prostate Cancer. RESULTS In terms of QALYs gained compared with no screening, for 1000 screened men who were followed over their lifetime, recommended good practice led to 73 life-years (LYs) and 74 QALYs gained compared with 73 LYs and 56 QALYs for the base model. In contrast, common practice led to 78 LYs gained but only 19 QALYs gained, for a greater than 75% relative reduction in QALYs gained from unadjusted LYs gained. The poor outcomes for common practice were influenced predominantly by the use of aggressive treatment for men with low-risk disease, and PSA testing in older men also strongly reduced potential QALY gains. CONCLUSIONS Commonly used PSA screening and treatment practices are associated with little net benefit. Following a few straightforward clinical recommendations, particularly greater use of active surveillance for low-risk disease and reducing screening in older men, would lead to an almost 4-fold increase in the net benefit of prostate cancer screening. Cancer 2016;122:3386-3393. © 2016 American Cancer Society.
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Affiliation(s)
- Sigrid V Carlsson
- Deptartment of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
- Department of Urology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
| | - Tiago M de Carvalho
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Monique J Roobol
- Department of Urology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jonas Hugosson
- Department of Urology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Anssi Auvinen
- School of Health Sciences, Tampere University, Tampere, Finland
| | - Maciej Kwiatkowski
- Department of Urology, Cantonal Hospital Aarau, Aarau, Switzerland
- Department of Urology, Academic Hospital Braunschweig, Brunswick, Germany
| | - Arnauld Villers
- Department of Urology, Lille University Hospital, University of Lille Nord de France, Lille, France
| | - Marco Zappa
- Unit of Clinical and Descriptive Epidemiology, Institute for Cancer Research and Prevention-ISPO, Florence, Italy
| | - Vera Nelen
- Provincial Institute for Hygiene, Antwerp, Belgium
| | - Alvaro Páez
- Department of Urology, Fuenlabrada University Hospital, Madrid, Spain
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hans Lilja
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- Department of Translational Medicine, Lund University, Malmo, Sweden
| | - Harry J de Koning
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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Re: Robot-assisted Laparoscopic Prostatectomy (RALP) Versus Open Radical Retropubic Prostatectomy (RRP): Early Outcomes from a Randomised Controlled Phase 3 Trial. Eur Urol 2016; 71:493-494. [PMID: 27838172 DOI: 10.1016/j.eururo.2016.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/19/2016] [Indexed: 11/20/2022]
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Tilki D. Editorial Comment. J Urol 2016; 197:375. [PMID: 27821259 DOI: 10.1016/j.juro.2016.08.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Derya Tilki
- Department of Urology, Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Onyeji IC, Sui W, Pagano MJ, Weinberg AC, James MB, Theofanides MC, Stember DS, Anderson CB, Stahl PJ. Impact of Surgeon Case Volume on Reoperation Rates after Inflatable Penile Prosthesis Surgery. J Urol 2016; 197:223-229. [PMID: 27545573 DOI: 10.1016/j.juro.2016.08.083] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2016] [Indexed: 01/11/2023]
Abstract
PURPOSE We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery. MATERIALS AND METHODS The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications. RESULTS A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p <0.001), 2.4 (p <0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively. CONCLUSIONS Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.
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Affiliation(s)
- Ifeanyi C Onyeji
- Department of Urology, Columbia University Medical Center, New York, New York.
| | - Wilson Sui
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Mathew J Pagano
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Aaron C Weinberg
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Maxwell B James
- Department of Urology, Columbia University Medical Center, New York, New York
| | | | | | | | - Peter J Stahl
- Department of Urology, Columbia University Medical Center, New York, New York
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Wirth MP, Huber J. Auch die fokale Therapie ist kein Kamillentee. Urologe A 2016; 55:593. [DOI: 10.1007/s00120-016-0108-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Barzi A, Klein EA, Dorff TB, Quinn DI, Sadeghi S. Prostatectomy at high-volume centers improves outcomes and lowers the costs of care for prostate cancer. Prostate Cancer Prostatic Dis 2016; 19:84-91. [PMID: 26666409 PMCID: PMC8942441 DOI: 10.1038/pcan.2015.56] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 09/14/2015] [Accepted: 10/11/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND High-volume surgeons with ⩾250 radical prostatectomies provide superior oncological outcomes as evidenced by a lower rate of PSA recurrence (PSAR). The financial benefits of performing prostatectomies at high-volume centers (HVC) are unexplored. METHODS A base case--referent scenario--where the share of prostatectomies at high- and low-volume centers were evenly divided at 50% was defined. Additional scenarios with increasing shares of prostatectomies at HVC with 10% increments were also modeled. Using a lower probability of PSAR as the only advantage of more experienced surgeons, the savings that would result from fewer recurrences, avoidance of salvage radiation therapy (SRT) and management of fewer men with metastatic cancer were calculated. RESULTS The savings associated with performing 80% of radical prostatectomy at HVC were $177, $357 and $559 per prostatectomy at 5, 10 and 20 years, respectively. These savings would offset referral costs of up to $1833 per prostatectomy referral at no additional total societal costs. Given the longer average biochemical failure-free survival with prostatectomies at HVC, referral costs of more than $1833 may be cost effective. CONCLUSIONS Under the conservative assumption of accounting for lower rates of PSAR as the only benefit of surgery in an HVC, performing prostatectomies at an HVC was associated with savings that may offset part of the initial referral costs.
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Affiliation(s)
- A Barzi
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - EA Klein
- Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - TB Dorff
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - DI Quinn
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - S Sadeghi
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
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Leow JJ, Chang SL, Meyer CP, Wang Y, Hanske J, Sammon JD, Cole AP, Preston MA, Dasgupta P, Menon M, Chung BI, Trinh QD. Robot-assisted Versus Open Radical Prostatectomy: A Contemporary Analysis of an All-payer Discharge Database. Eur Urol 2016; 70:837-845. [PMID: 26874806 DOI: 10.1016/j.eururo.2016.01.044] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 01/22/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND More than a decade since its inception, the benefits and cost efficiency of robot-assisted radical prostatectomy (RARP) continue to elicit controversy. OBJECTIVE To compare outcomes and costs between RARP and open RP (ORP). DESIGN, SETTING, AND PARTICIPANTS A cohort study of 629 593 men who underwent RP for localized prostate cancer at 449 hospitals in the USA from 2003 to 2013, using the Premier Hospital Database. INTERVENTION RARP was ascertained through a review of the hospital charge description master for robotic supplies. OUTCOME MEASURES AND STATISTICAL ANALYSIS Outcomes were 90-d postoperative complications (Clavien), blood product transfusions, operating room time (ORT), length of stay (LOS), and direct hospital costs. Propensity-weighted regression analyses accounting for clustering by hospitals and survey weighting ensured nationally representative estimates. RESULTS AND LIMITATIONS RARP utilization rapidly increased from 1.8% in 2003 to 85% in 2013 (p<0.001). RARP patients (n=311 135) were less likely to experience any complications (odds ratio [OR] 0.68, p<0.001) or prolonged LOS (OR 0.28, p<0.001), or to receive blood products (OR 0.33, p=0.002) compared to ORP patients (n=318 458). The adjusted mean ORT was 131min longer for RARP (p=0.002). The 90-d direct hospital costs were higher for RARP (+$4528, p<0.001), primarily attributed to operating room and supplies costs. Costs were no longer signficantly different between ORP and RARP among the highest-volume surgeons (≥104 cases/yr; +$1990, p=0.40) and highest-volume hospitals (≥318 cases/yr; +$1225, p=0.39). Limitations include the lack of oncologic characteristics and the retrospective nature of the study. CONCLUSIONS Our contemporary analysis reveals that RARP confers a perioperative morbidity advantage at higher cost. In the absence of large randomized trials because of the widespread adoption of RARP, this retrospective study represents the best available evidence for the morbidity and cost profile of RARP versus ORP. PATIENT SUMMARY In this large study of men with prostate cancer who underwent either open or robotic radical prostatectomy, we found that robotic surgery has a better morbidity profile but costs more.
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Affiliation(s)
- Jeffrey J Leow
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Steven L Chang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian P Meyer
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Ye Wang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Julian Hanske
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Jesse D Sammon
- VUI Center for Outcomes Research Analytics and Evaluation (VCORE), Henry Ford Health System, Detroit, MI, USA
| | - Alexander P Cole
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark A Preston
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Prokar Dasgupta
- Department of Urology, King's College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, Guy's Hospital, London, UK
| | - Mani Menon
- VUI Center for Outcomes Research Analytics and Evaluation (VCORE), Henry Ford Health System, Detroit, MI, USA
| | - Benjamin I Chung
- Department of Urology, Stanford University Medical Center, Stanford, CA, USA
| | - Quoc-Dien Trinh
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Lopez A, Zlatev DV, Mach KE, Bui D, Liu JJ, Rouse RV, Harris T, Leppert JT, Liao JC. Intraoperative Optical Biopsy during Robotic Assisted Radical Prostatectomy Using Confocal Endomicroscopy. J Urol 2015; 195:1110-1117. [PMID: 26626214 DOI: 10.1016/j.juro.2015.10.182] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2015] [Indexed: 01/16/2023]
Abstract
PURPOSE Intraoperative optical biopsy technologies may aid in the identification of important anatomical landmarks and improve surgical outcomes of robotic assisted radical prostatectomy. We evaluate the feasibility of confocal laser endomicroscopy during robotic assisted radical prostatectomy. MATERIALS AND METHODS A total of 21 patients with biopsy proven prostate cancer scheduled for robotic assisted radical prostatectomy were recruited. After intravenous administration of fluorescein 15 patients underwent in vivo intraoperative confocal laser endomicroscopy of prostatic and periprostatic structures using a 2.6 or 0.85 mm imaging probe. Standard robotic instruments were used to grasp and maneuver the confocal laser endomicroscopy probes for image acquisition. Confocal laser endomicroscopy imaging was performed ex vivo on fresh prostate specimens from 20 patients. Confocal video sequences acquired in vivo and ex vivo were reviewed and analyzed, with additional image processing using a mosaicing algorithm. Processed confocal images were compared with standard hematoxylin and eosin analysis of imaged regions. RESULTS Confocal laser endomicroscopy was successfully integrated with robotic surgery, including co-registration of confocal video sequences with white light and probe handling with standard robotic instrumentation. Intraoperative confocal laser endomicroscopy imaging of the neurovascular bundle before and after nerve sparing dissection revealed characteristic features including dynamic vascular flow and intact axon fibers. Ex vivo confocal imaging of the prostatic parenchyma demonstrated normal prostate glands, stroma and prostatic carcinoma. CONCLUSIONS We report the initial feasibility of optical biopsy of prostatic and periprostatic tissue during robotic assisted radical prostatectomy. Image guidance and tissue interrogation using confocal laser endomicroscopy offer a new intraoperative imaging method that has the potential to improve the functional and oncologic outcomes of prostate cancer surgery.
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Affiliation(s)
- Aristeo Lopez
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5118.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304
| | - Dimitar V Zlatev
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5118.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304
| | - Kathleen E Mach
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5118.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304
| | - Daniel Bui
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5118.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304
| | - Jen-Jane Liu
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5118.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304
| | - Robert V Rouse
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304.,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305
| | - Theodore Harris
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304
| | - John T Leppert
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5118.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304
| | - Joseph C Liao
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5118.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304
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47
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Soulié M, Salomon L. [Oncological outcomes of prostate cancer surgery]. Prog Urol 2015; 25:1010-27. [PMID: 26519965 DOI: 10.1016/j.purol.2015.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 07/30/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Review of the oncological results of the radical prostatectomy as initial treatment of prostate cancer, according to the surgical approach and the risk stratification using D'Amico risk groups. MATERIALS AND METHODS Review of literature using Medline databases and MedScience based on scientific relevance. Research focused on the oncological results of the radical prostatectomy in series and meta-analysis published since 10 years, taking into consideration the surgical approach if mentioned. RESULTS The characteristics of the operated tumor highly impact the local control authenticated by the pathologic stage and the rates of positive surgical margins (PSM), in addition to the survival and the biochemical recurrence. Surgical technique adapted according to the tumor treated, was a constant challenge to the urologist, who counter balance between the oncological control and the conservation of urinary and sexual function by conditioning the type of radical prostatectomy. Results of radical prostatectomy acceptable in terms of PSM and survival are not influenced by the surgical approach but by the degree of surgical experience. CONCLUSION Results of radical prostatectomy show the efficient local control of prostate cancer, taking into consideration the oncological rules and indications validated by multidisciplinary meetings, based on the national (CCAFU) and European oncological guidelines. Tendency is going toward considering radical prostatectomy indicated for patients with higher risk of disease progression, so integrating surgery in a multidisciplinary personalized approach.
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Affiliation(s)
- M Soulié
- Département d'urologie-andrologie-transplantation rénale, CHU Rangueil, 1, avenue Jean-Poulhès, 31059 Toulouse cedex 9, France.
| | - L Salomon
- Service d'urologie et de transplantation rénale et pancréatique, CHU Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
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Gershman B, Psutka SP, McGovern FJ, Dahl DM, Tabatabaei S, Gettman MT, Frank I, Carlson RE, Rangel LJ, Barry MJ, Blute ML, Karnes RJ. Patient-reported Functional Outcomes Following Open, Laparoscopic, and Robotic Assisted Radical Prostatectomy Performed by High-volume Surgeons at High-volume Hospitals. Eur Urol Focus 2015; 2:172-179. [PMID: 28723533 DOI: 10.1016/j.euf.2015.06.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/30/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Functional outcomes following radical prostatectomy (RP) have received increased focus with dissemination of minimally invasive approaches. OBJECTIVE To examine contemporary patient-reported functional outcomes following open RP. (ORP), laparoscopic RP, (LRP), and robotic assisted RP (RARP) performed by high-volume surgeons at high-volume hospitals. DESIGN, SETTINGS, AND PARTICIPANTS This was a retrospective cohort study of 1686 men with cT1-cT2 prostate cancer treated with ORP (n=441), LRP (n=156), or RARP (n=1089) by high-volume surgeons (annual volume ≥25 cases) at two academic centers from 2009 to 2012. Surveys containing the Expanded Prostate Cancer Index Composite urinary and sexual domains were administered at a median of 30.5 mo postoperatively. INTERVENTIONS ORP, LRP, and RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Bother with overall urinary and sexual function was examined and stratified by surgical technique. Logistic regression models evaluated the associations of clinicopathologic features with survey responses. RESULTS AND LIMITATIONS In total, 6.4% of men reported a moderate or big problem with overall urinary function (ORP 5.8%, LRP 5.1%, RARP 6.8%; p=0.62), whereas 37.3% reported a moderate or big problem with overall sexual function (ORP 37.2%, LRP 36.1%, RARP 37.5%; p=0.95). On multivariable analysis, older age at surgery (odds ratio [OR]: 1.08; p<0.0001) was associated with overall urinary bother, whereas older age at surgery (OR: 1.03; p=0.005), preoperative erectile dysfunction treatment (OR: 2.22; p<0.0001), greater prostate volume (OR: 1.01; p=0.02), and RP Gleason score (7 vs 6: OR: 0.96; p=0.004; 8-10 vs 6: OR: 2.25; p=0.0006) were associated with overall sexual bother. Surgical technique was not associated with either functional outcome. Limitations included selection bias and a retrospective design. CONCLUSIONS In this study of high-volume surgeons at high-volume hospitals, patients reported excellent functional outcomes independent of surgical technique. These results have implications for patient counseling. PATIENT SUMMARY In this study of high-volume surgeons at high-volume hospitals, patients reported excellent outcomes for urinary and sexual function following radical prostatectomy regardless of surgical technique.
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Affiliation(s)
| | | | | | - Douglas M Dahl
- Department of Urology, Massachusetts General Hospital, Boston, MA, USA
| | - Shahin Tabatabaei
- Department of Urology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Igor Frank
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Rachel E Carlson
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Laureano J Rangel
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Michael J Barry
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michael L Blute
- Department of Urology, Massachusetts General Hospital, Boston, MA, USA
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50
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Matsushita K, Kent MT, Vickers AJ, von Bodman C, Bernstein M, Touijer KA, Coleman JA, Laudone VT, Scardino PT, Eastham JA, Akin O, Sandhu JS. Preoperative predictive model of recovery of urinary continence after radical prostatectomy. BJU Int 2015; 116:577-83. [PMID: 25682782 DOI: 10.1111/bju.13087] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To build a predictive model of urinary continence recovery after radical prostatectomy (RP) that incorporates magnetic resonance imaging (MRI) parameters and clinical data. PATIENTS AND METHODS We conducted a retrospective review of data from 2,849 patients who underwent pelvic staging MRI before RP from November 2001 to June 2010. We used logistic regression to evaluate the association between each MRI variable and continence at 6 or 12 months, adjusting for age, body mass index (BMI) and American Society of Anesthesiologists (ASA) score, and then used multivariable logistic regression to create our model. A nomogram was constructed using the multivariable logistic regression models. RESULTS In all, 68% (1,742/2,559) and 82% (2,205/2,689) regained function at 6 and 12 months, respectively. In the base model, age, BMI and ASA score were significant predictors of continence at 6 or 12 months on univariate analysis (P < 0.005). Among the preoperative MRI measurements, membranous urethral length, which showed great significance, was incorporated into the base model to create the full model. For continence recovery at 6 months, the addition of membranous urethral length increased the area under the curve (AUC) to 0.664 for the validation set, an increase of 0.064 over the base model. For continence recovery at 12 months, the AUC was 0.674, an increase of 0.085 over the base model. CONCLUSION Using our model, the likelihood of continence recovery increases with membranous urethral length and decreases with age, BMI and ASA score. This model could be used for patient counselling and for the identification of patients at high risk for urinary incontinence in whom to study changes in operative technique that improve urinary function after RP.
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Affiliation(s)
- Kazuhito Matsushita
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Urology, Juntendo University, Graduate School of Medicine, Tokyo, Japan.,Department of Urology, St. Luke's International Hospital, Tokyo, Japan
| | - Matthew T Kent
- Department of Epidemiology and Biostatistics, Memorial Sloan-Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan-Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian von Bodman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melanie Bernstein
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karim A Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent T Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter T Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oguz Akin
- Department of Radiology, Memorial Sloan-Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jaspreet S Sandhu
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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