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Patterns and characteristics of patients' selection of cancer surgeons. Am J Surg 2020; 221:1033-1041. [PMID: 33969822 DOI: 10.1016/j.amjsurg.2020.09.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/10/2020] [Accepted: 09/30/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Despite evidence of volume-outcome relationships for cancer surgery, treatment at low-volume hospitals remains common. Our objective was to evaluate whether individuals actively involved in selecting their cancer surgeon were more likely to go to hospitals recognized for quality cancer care. METHODS Individuals diagnosed with breast, prostate and colorectal cancer in 2015 completed online surveys in 2017-2018. Participants were categorized as "directed" to a surgeon (relied on referral) or "active" (sought additional information), and hospitals were categorized by NCI-designation, CoC accreditation, and academic affiliation. RESULTS Of 299 participants, 42% were active. Individuals with breast cancer were more active (aOR = 2.46,95%CI:1.32-4.59). Active participants had nonsignificantly higher odds of surgery at NCI-designated facilities (aOR = 2.04,95%CI:0.95-4.38), or academic centers (aOR = 1.51,95%CI:0.86-2.64). CONCLUSIONS While most participants were directed to their cancer surgeon, active participants tended to select NCI-designated/academic hospitals. Although centralization of cancer care would require altering referral patterns, decision-support resources may help patients make informed choices.
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Forsmark A, Gehrman J, Angenete E, Bjartell A, Björholt I, Carlsson S, Hugosson J, Marlow T, Stinesen-Kollberg K, Stranne J, Wallerstedt A, Wiklund P, Wilderäng U, Haglind E. Health Economic Analysis of Open and Robot-assisted Laparoscopic Surgery for Prostate Cancer Within the Prospective Multicentre LAPPRO Trial. Eur Urol 2018; 74:816-824. [DOI: 10.1016/j.eururo.2018.07.038] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
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Leow JJ, Leong EK, Serrell EC, Chang SL, Gruen RL, Png KS, Beaule LT, Trinh QD, Menon MM, Sammon JD. Systematic Review of the Volume-Outcome Relationship for Radical Prostatectomy. Eur Urol Focus 2017; 4:775-789. [PMID: 28753874 DOI: 10.1016/j.euf.2017.03.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Radical prostatectomy (RP) is one of the most complex urological procedures performed. Higher surgical volume has been found previously to be associated with better patient outcomes and reduced costs to the health care system. This has resulted in some regionalization of care toward high-volume facilities and providers; however, the preponderance of RPs is still performed at low-volume institutions. OBJECTIVE To provide an updated systematic review of the association of hospital and surgeon volume on patient and system outcomes after RP, including robot-assisted RP. EVIDENCE ACQUISITION A systematic review of literature was undertaken, searching PubMed (1959-2016) for original articles. Selection criteria included RP, hospital and/or surgeon volumes as predictor variables, categorization of hospital and/or surgeon volumes, and measurable end points. EVIDENCE SYNTHESIS Overall 49 publications fulfilled the inclusion criteria. Most of the studies demonstrated that higher-volume surgeries are associated with better outcomes including reduced mortality, morbidity, postoperative complications, length of stay, readmission, and cost-associated factors. The volume-outcome relationship is maintained in robotic surgery. Eleven studies assessed hospital and surgeon volume simultaneously, and findings reflect that neither is an independent predictor variable affecting outcomes. The studies varied in how volume cutoffs were categorized as well as how the volume-outcome relationship was methodologically evaluated. CONCLUSIONS Contemporary evidence continues to support the relationship between high-volume surgeries with improved RP outcomes. Recent studies demonstrate that the volume-outcome relationship applies to robot-assisted RP and may be applied for potential cost savings in health care. An increase in the number of international studies suggests reproducibility of the association. Although regionalization of surgical care remains a contentious issue, there is an increasing body of evidence that short-term outcomes are improved at high-volume centers for RP. PATIENT SUMMARY This systematic review of the latest literature found that higher surgical volume was associated with improved outcomes for radical prostatectomy.
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Affiliation(s)
- Jeffrey J Leow
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Eugene K Leong
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore-Imperial College London, Singapore
| | | | - Steven L Chang
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Russell L Gruen
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore-Imperial College London, Singapore
| | - Keng Siang Png
- Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Lisa T Beaule
- Tufts University School of Medicine, Boston, MA, USA; Division of Urology, Maine Medical Center, Portland, ME, USA; Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mani M Menon
- VUI Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Jesse D Sammon
- Tufts University School of Medicine, Boston, MA, USA; Division of Urology, Maine Medical Center, Portland, ME, USA; Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA.
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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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Gandaglia G, Bray F, Cooperberg MR, Karnes RJ, Leveridge MJ, Moretti K, Murphy DG, Penson DF, Miller DC. Prostate Cancer Registries: Current Status and Future Directions. Eur Urol 2016; 69:998-1012. [PMID: 26056070 DOI: 10.1016/j.eururo.2015.05.046] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 05/26/2015] [Indexed: 01/08/2023]
Abstract
CONTEXT Disease-specific registries that enroll a considerable number of patients play a major role in prostate cancer (PCa) research. OBJECTIVE To evaluate available registries, describe their strengths and limitations, and discuss the potential future role of PCa registries in outcomes research. EVIDENCE ACQUISITION We performed a literature review of the Medline, Embase, and Web of Science databases. The search strategy included the terms prostate cancer, outcomes, statistical approaches, population-based cohorts, registries of outcomes, and epidemiological studies, alone or in combination. We limited our search to studies published between January 2005 and January 2015. EVIDENCE SYNTHESIS Several population-based and prospective disease-specific registries are currently available for prostate cancer. Studies performed using these data sources provide important information on incidence and mortality, disease characteristics at presentation, risk factors, trends in utilization of health care services, disparities in access to treatment, quality of care, long-term oncologic and health-related quality of life outcomes, and costs associated with management of the disease. Although data from these registries have some limitations, statistical methods are available that can address certain biases and increase the internal and external validity of such analyses. In the future, improvements in data quality, collection of tissue samples, and the availability of data feedback to health care providers will increase the relevance of studies built on population-based and disease-specific registries. CONCLUSIONS The strengths and limitations of PCa registries should be carefully considered when planning studies using these databases. Although randomized controlled trials still provide the highest level of evidence, large registries play an important and growing role in advancing PCa research and care. PATIENT SUMMARY Several population-based and prospective disease-specific registries for prostate cancer are currently available. Analyses of data from these registries yield information that is clinically relevant for the management of patients with prostate cancer.
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Affiliation(s)
- Giorgio Gandaglia
- Unit of Urology/Department of Oncology, San Raffaele Hospital, Milan, Italy.
| | - Freddie Bray
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Matthew R Cooperberg
- Departments of Urology and Epidemiology & Biostatistics, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | | | | | - Kim Moretti
- South Australian Prostate Cancer Clinical Outcomes Collaborative, Repatriation General Hospital, Daw Park, and the University of South Australia and the University of Adelaide, South Australia, Australia
| | - Declan G Murphy
- Division of Cancer Surgery, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University, and the VA Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - David C Miller
- Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Almatar A, Wallis CJD, Herschorn S, Saskin R, Kulkarni GS, Kodama RT, Nam RK. Effect of radical prostatectomy surgeon volume on complication rates from a large population-based cohort. Can Urol Assoc J 2016; 10:45-9. [PMID: 26977206 DOI: 10.5489/cuaj.3214] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Surgical volume can affect several outcomes following radical prostatectomy (RP). We examined if surgical volume was associated with novel categories of treatment-related complications following RP. METHODS We examined a population-based cohort of men treated with RP in Ontario, Canada between 2002 and 2009. We used Cox proportional hazard modeling to examine the effect of physician, hospital and patient demographic factors on rates of treatment-related hospital admissions, urologic procedures, and open surgeries. RESULTS Over the study interval, 15 870 men were treated with RP. A total of 196 surgeons performed a median of 15 cases per year (range: 1-131). Patients treated by surgeons in the highest quartile of annual case volume (>39/year) had a lower risk of hospital admission (hazard ratio [HR]=0.54, 95% CI 0.47-0.61) and urologic procedures (HR=0.69, 95% CI 0.64-0.75), but not open surgeries (HR=0.83, 95% CI 0.47-1.45) than patients treated by surgeons in the lowest quartile (<15/year). Treatment at an academic hospital was associated with a decreased risk of hospitalization (HR=0.75, 95% CI 0.67-0.83), but not of urologic procedures (HR=0.94, 95% CI 0.88-1.01) or open surgeries (HR=0.87, 95% CI 0.54-1.39). There was no significant trend in any of the outcomes by population density. CONCLUSIONS The annual case volume of the treating surgeon significantly affects a patient's risk of requiring hospitalization or urologic procedures (excluding open surgeries) to manage treatment-related complications.
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Affiliation(s)
- Ashraf Almatar
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, ON, Canada
| | - Christopher J D Wallis
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, ON, Canada
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, ON, Canada
| | - Refik Saskin
- Institute of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, ON, Canada
| | - Girish S Kulkarni
- Division of Urology, University Health Network, University of Toronto, ON, Canada
| | - Ronald T Kodama
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, ON, Canada
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, ON, Canada
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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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Koerber F, Waidelich R, Stollenwerk B, Rogowski W. The cost-utility of open prostatectomy compared with active surveillance in early localised prostate cancer. BMC Health Serv Res 2014; 14:163. [PMID: 24721557 PMCID: PMC4022451 DOI: 10.1186/1472-6963-14-163] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 03/25/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is an on-going debate about whether to perform surgery on early stage localised prostate cancer and risk the common long term side effects such as urinary incontinence and erectile dysfunction. Alternatively these patients could be closely monitored and treated only in case of disease progression (active surveillance). The aim of this paper is to develop a decision-analytic model comparing the cost-utility of active surveillance (AS) and radical prostatectomy (PE) for a cohort of 65 year old men with newly diagnosed low risk prostate cancer. METHODS A Markov model comparing PE and AS over a lifetime horizon was programmed in TreeAge from a German societal perspective. Comparative disease specific mortality was obtained from the Scandinavian Prostate Cancer Group trial. Direct costs were identified via national treatment guidelines and expert interviews covering in-patient, out-patient, medication, aids and remedies as well as out of pocket payments. Utility values were used as factor weights for age specific quality of life values of the German population. Uncertainty was assessed deterministically and probabilistically. RESULTS With quality adjustment, AS was the dominant strategy compared with initial treatment. In the base case, it was associated with an additional 0.04 quality adjusted life years (7.60 QALYs vs. 7.56 QALYs) and a cost reduction of €6,883 per patient (2011 prices). Considering only life-years gained, PE was more effective with an incremental cost-effectiveness ratio of €96,420/life year gained. Sensitivity analysis showed that the probability of developing metastases under AS and utility weights under AS are a major sources of uncertainty. A Monte Carlo simulation revealed that AS was more likely to be cost-effective even under very high willingness to pay thresholds. CONCLUSION AS is likely to be a cost-saving treatment strategy for some patients with early stage localised prostate cancer. However, cost-effectiveness is dependent on patients' valuation of health states. Better predictability of tumour progression and modified reimbursement practice would support widespread use of AS in the context of the German health care system. More research is necessary in order to reliably quantify the health benefits compared with initial treatment and account for patient preferences.
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Affiliation(s)
- Florian Koerber
- Institute for Health Economics and Health Care Management, Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Ingolstädter Landstrasse 1, 85764 Neuherberg, Germany
| | - Raphaela Waidelich
- Department of Urology, University of Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Björn Stollenwerk
- Institute for Health Economics and Health Care Management, Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Ingolstädter Landstrasse 1, 85764 Neuherberg, Germany
| | - Wolf Rogowski
- Institute for Health Economics and Health Care Management, Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Ingolstädter Landstrasse 1, 85764 Neuherberg, Germany
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany
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Huang KH, Carter SC, Hu JC. Does robotic prostatectomy meet its promise in the management of prostate cancer? Curr Urol Rep 2014; 14:184-91. [PMID: 23564268 DOI: 10.1007/s11934-013-0327-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Following Walsh's advances in pelvic anatomy and surgical technique to minimize intraoperative peri-prostatic trauma more than 30 years ago, open retropubic radical prostatectomy (RRP) evolved to become the gold standard treatment of localized prostate cancer, with excellent long-term survival outcomes [1•]. However, RRP is performed with great heterogeneity, even among high volume surgeons, and subtle differences in surgical technique result in clinically significant differences in recovery of urinary and sexual function. Since the initial description of robotic-assisted radical prostatectomy (RARP) in 2000 [2], and U.S. Food and Drug Administration approval shortly thereafter, RARP has been rapidly adopted and has overtaken RRP as the most popular surgical approach in the management of prostate cancer in the United States [3]. However, the surgical management of prostate cancer remains controversial. This is confounded by the idolatry of new technologies and aggressive marketing versus conservatism in embracing tradition. Herein, we review the literature to compare RRP to RARP in terms of perioperative, oncologic, and quality-of-life outcomes as well as healthcare costs. This is a particularly relevant, given the absence of randomized trials and long-term (more than 10-year) follow-up for RARP biochemical recurrence-free survival.
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Affiliation(s)
- Kuo-How Huang
- Institute of Urologic Oncology, Department of Urology, David Geffen School of Medicine, University of California Los Angeles, 924 Westwood Blvd, Suite 1000, Los Angeles, CA 90024, USA
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10
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Trinh QD, Bjartell A, Freedland SJ, Hollenbeck BK, Hu JC, Shariat SF, Sun M, Vickers AJ. A systematic review of the volume-outcome relationship for radical prostatectomy. Eur Urol 2013; 64:786-98. [PMID: 23664423 PMCID: PMC4109273 DOI: 10.1016/j.eururo.2013.04.012] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Accepted: 04/09/2013] [Indexed: 01/09/2023]
Abstract
CONTEXT Due to the complexity and challenging nature of radical prostatectomy (RP), it is likely that both short- and long-term outcomes strongly depend on the cumulative number of cases performed by the surgeon as well as by the hospital. OBJECTIVE To review systematically the association between hospital and surgeon volume and perioperative, oncologic, and functional outcomes after RP. EVIDENCE ACQUISITION A systematic review of the literature was performed, searching PubMed, Embase, and Scopus databases for original and review articles between January 1, 1995, and December 31, 2011. Inclusion and exclusion criteria comprised RP, hospital and/or surgeon volume reported as a predictor variable, a measurable end point, and a description of multiple hospitals or surgeons. EVIDENCE SYNTHESIS Overall 45 publications fulfilled the inclusion criteria, where most data originated from retrospective institutional or population-based cohorts. Studies generally focused on hospital or surgeon volume separately. Although most of these analyses corroborated the impact of increasing volume with better outcomes, some failed to find any significant effect. Studies also differed with respect to the proposed volume cut-off for improved outcomes, as well as the statistical means of evaluating the volume-outcome relationship. Five studies simultaneously compared hospital and surgeon volume, where results suggest that the importance of either hospital or surgeon volume largely depends on the end point of interest. CONCLUSIONS Undeniable evidence suggests that increasing volume improves outcomes. Although it would seem reasonable to refer RP patients to high-volume centers, such regionalization may not be entirely practical. As such, the implications of such a shift in practice have yet to be fully determined and warrant further exploration.
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Affiliation(s)
- Quoc-Dien Trinh
- CRCHUM, Centre Hospitalier de l'Université de Montréal, Montreal, Canada; Cancer Prognostics and Health Outcomes Unit, Centre Hospitalier de l'Université de Montréal, Montreal, Canada; Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA.
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Pierorazio PM, Mullins JK, Ross AE, Hyams ES, Partin AW, Han M, Walsh PC, Schaeffer EM, Pavlovich CP, Allaf ME, Bivalacqua TJ. Trends in immediate perioperative morbidity and delay in discharge after open and minimally invasive radical prostatectomy (RP): a 20-year institutional experience. BJU Int 2013; 112:45-53. [PMID: 23759008 DOI: 10.1111/j.1464-410x.2012.11767.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Standard clinical care pathways to discharge have been established for a number of operations including radical prostatectomy (RP). The pathway after RP has changed dramatically over the past two decades due to improvements in surgical technique, anaesthesia and most recently, the introduction of minimally invasive RP (MIRP). This study adds evidence that the emergence of MIRP is associated with a decrease in LOS for all patients undergoing RP. In addition, it catalogues the development of the clinical care pathway over 20 years at a large, tertiary care hospital with extensive experience in RP. Finally, it defines the common reasons patients fall 'off-pathway' (ileus, urine leak, anaemia and re-exploration for bleeding) and defines the immediate perioperative morbidity profile of RP. Specifically, it addresses approach-specific morbidities and indicates that MIRP is associated with higher rates of 'off-pathway' discharge, most often due to ileus. OBJECTIVE To investigate the development of the clinical care pathway to discharge after radical prostatectomy (RP) at a large, academic medical centre over the past 20 years, focusing on the rates and reasons for deviation. PATIENTS AND METHODS In all, 18 049 men were identified from the Johns Hopkins RP database who had undergone surgery since 1991. Patients in whom the length of stay (LOS) was ≤95th percentile, defined the clinical care pathway to discharge and those in whom LOS was ≥98th percentile were termed 'off-pathway'. RESULTS The mean LOS decreased from 7.7 days in 1991 to 1.6 days in 2010. Of 7126 patients undergoing RP since 2005, 1803(25.3%), 4881(68.5%) and 312 (4.4%) were discharged on postoperative day (POD) 1, 2 and 3, respectively; 126 (1.8%) patients, discharged on POD4-21 were 'off-pathway'. The most common reasons for delay of discharge were ileus (44, 0.615%), urine leak (12, 0.17%), anaemia requiring blood transfusion (nine, 0.126%) and bleeding requiring re-exploration (six, 0.08%). The proportion of patients 'off-pathway' was 1.20%, 1.06% and 4.01% for retropubic RP (RRP), laparoscopic RP (LRP) and robot-assisted laparoscopic RP (RALRP), respectively (P < 0.001). Ileus delayed discharge in 0.28%, 0.37% and 1.9% of patients undergoing RRP, LRP and RALRP, respectively (P < 0.001). CONCLUSIONS The clinical care pathway to discharge after RP has changed dramatically at our institution over the past 20 years. RALRP appears to result in a higher proportion of 'off-pathway' patients, primarily due to ileus, compared with RRP and LRP. However, very few patients were discharged 'off-pathway'.
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Affiliation(s)
- Phillip M Pierorazio
- The James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD, USA
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12
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Reply by Authors. J Urol 2012. [DOI: 10.1016/j.juro.2011.12.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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13
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Duffey B, Varda B, Konety B. Quality of evidence to compare outcomes of open and robot-assisted laparoscopic prostatectomy. Curr Urol Rep 2011; 12:229-36. [PMID: 21365234 DOI: 10.1007/s11934-011-0180-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Robot-assisted laparoscopic radical prostatectomy (RALP) has gained widespread acceptance in the treatment of prostate cancer. While it increasingly is becoming the surgical approach of choice in many centers, limited data exist directly comparing it to radical retropubic prostatectomy (RRP). This review examines the evidence comparing RALP to RRP. The outcomes evaluated are arranged into perioperative, oncologic, and functional outcomes. Of the 21 publications meeting our selection criteria, Level II, III, and IV evidence were found in 9, 1, and 11 articles, respectively. Overall, RALP was associated with lower blood loss, transfusion rates, length of stay, and higher cost when compared to RRP. Definitive conclusions regarding complications and oncologic and functional outcomes are not yet possible, and will require longer-term follow-up and well-designed randomized controlled trials.
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Affiliation(s)
- Branden Duffey
- Department of Urology, University of Minnesota, MMC 394, 420 Delaware Street Southeast, Minneapolis, MN 55403, USA
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14
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A Population-Based Analysis of Temporal Perioperative Complication Rates After Minimally Invasive Radical Prostatectomy. Eur Urol 2011; 60:564-71. [DOI: 10.1016/j.eururo.2011.06.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 06/16/2011] [Indexed: 11/18/2022]
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