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Maynou L, McGuire A, Serra-Sastre V. Efficiency and productivity gains of robotic surgery: The case of the English National Health Service. HEALTH ECONOMICS 2024; 33:1831-1856. [PMID: 38733282 DOI: 10.1002/hec.4838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 03/10/2024] [Accepted: 04/08/2024] [Indexed: 05/13/2024]
Abstract
This paper examines the effect of new medical technology (robotic surgery) on efficiency gains and productivity changes for surgical treatment in patients with prostate cancer from the perspective of a public health sector organization. In particular, we consider three interrelated surgical technologies within the English National Health System: robotic, laparoscopic and open radical prostatectomy. Robotic and laparoscopic techniques are minimally invasive procedures with similar clinical benefits. While the clinical benefits in adopting robotic surgery over laparoscopic intervention are unproven, it requires a high initial investment cost and carries high on-going maintenance costs. Using data from Hospital Episode Statistics for the period 2000-2018, we observe growing volumes of prostatectomies over time, mostly driven by an increase in robotic-assisted surgeries, and further analyze whether hospital providers that adopted a robot see improved measures of throughput. We then quantify changes in total factor and labor productivity arising from the use of this technology. We examine the impact of robotic adoption on efficiency gains employing a staggered difference-in-difference estimator and find evidence of a 50% reduction in length of stay (LoS), 49% decrease in post-LoS and 44% and 46% decrease in postoperative visits after 1 year and 2 years, respectively. Productivity analysis shows the growth in radical prostatectomy volume is sustained with a relatively stable number of urology surgeons. The robotic technique increases total production at the hospital level between 21% and 26%, coupled with a 29% improvement in labor productivity. These benefits lend some, but not overwhelming support for the large-scale hospital investments in such costly technology.
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Affiliation(s)
- Laia Maynou
- Department of Econometrics, Statistics and Applied Economics, Universitat de Barcelona, Barcelona, Spain
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Center for Research in Health and Economics (CRES), Universitat Pompeu Fabra, Barcelona, Spain
| | - Alistair McGuire
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Victoria Serra-Sastre
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Department of Economics, City, University of London, London, UK
- Office of Health Economics, London, UK
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2
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Maynou L. The diffusion of robotic surgery: examining technology use in the English NHS. Health Policy 2022; 126:325-336. [DOI: 10.1016/j.healthpol.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 01/03/2023]
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Loftus TJ, Filiberto AC, Balch J, Ayzengart AL, Tighe PJ, Rashidi P, Bihorac A, Upchurch GR. Intelligent, Autonomous Machines in Surgery. J Surg Res 2020; 253:92-99. [PMID: 32339787 DOI: 10.1016/j.jss.2020.03.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/22/2020] [Accepted: 03/08/2020] [Indexed: 02/08/2023]
Abstract
Surgeons perform two primary tasks: operating and engaging patients and caregivers in shared decision-making. Human dexterity and decision-making are biologically limited. Intelligent, autonomous machines have the potential to augment or replace surgeons. Rather than regarding this possibility with denial, ire, or indifference, surgeons should understand and steer these technologies. Closer examination of surgical innovations and lessons learned from the automotive industry can inform this process. Innovations in minimally invasive surgery and surgical decision-making follow classic S-shaped curves with three phases: (1) introduction of a new technology, (2) achievement of a performance advantage relative to existing standards, and (3) arrival at a performance plateau, followed by replacement with an innovation featuring greater machine autonomy and less human influence. There is currently no level I evidence demonstrating improved patient outcomes using intelligent, autonomous machines for performing operations or surgical decision-making tasks. History suggests that if such evidence emerges and if the machines are cost effective, then they will augment or replace humans, initially for simple, common, rote tasks under close human supervision and later for complex tasks with minimal human supervision. This process poses ethical challenges in assigning liability for errors, matching decisions to patient values, and displacing human workers, but may allow surgeons to spend less time gathering and analyzing data and more time interacting with patients and tending to urgent, critical-and potentially more valuable-aspects of patient care. Surgeons should steer these technologies toward optimal patient care and net social benefit using the uniquely human traits of creativity, altruism, and moral deliberation.
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Affiliation(s)
- Tyler J Loftus
- Department of Surge ry, University of Florida Health, Gainesville, Florida
| | - Amanda C Filiberto
- Department of Surge ry, University of Florida Health, Gainesville, Florida
| | - Jeremy Balch
- Department of Surge ry, University of Florida Health, Gainesville, Florida
| | | | - Patrick J Tighe
- Departments of Biomedical Engineering, Computer and Information Science and Engineering, and Electrical and Computer Engineering, University of Florida, Gainesville, Florida
| | - Parisa Rashidi
- Departments of Anesthesiology, Orthopedics, and Information Systems/Operations Management, University of Florida Health, Gainesville, Florida
| | - Azra Bihorac
- Department of Medicine, University of Florida Health, Gainesville, Florida
| | - Gilbert R Upchurch
- Department of Surge ry, University of Florida Health, Gainesville, Florida.
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Pucheril D, Fletcher SA, Chen X, Friedlander DF, Cole AP, Krimphove MJ, Fields AC, Melnitchouk N, Kibel AS, Dasgupta P, Trinh QD. Workplace absenteeism amongst patients undergoing open vs. robotic radical prostatectomy, hysterectomy, and partial colectomy. Surg Endosc 2020; 35:1644-1650. [PMID: 32291540 DOI: 10.1007/s00464-020-07547-y] [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] [Received: 11/23/2019] [Accepted: 04/04/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is controversy regarding the widespread uptake of robotic surgery across several surgical disciplines. While it has been shown to confer clinical benefits such as decreased blood loss and shorter hospital stays, some argue that the benefits of this technology do not outweigh its high cost. We performed a retrospective insurance-based analysis to investigate how undergoing robotic surgery, compared to open surgery, may impact the time in which an employed individual returns to work after undergoing major surgery. METHODS We identified a cohort of US adults with employer-sponsored insurance using claims data from the MarketScan database who underwent either open or robotic radical prostatectomy, hysterectomy/myomectomy, and partial colectomy from 2012 to 2016. We performed multiple regression models incorporating propensity scores to assess the effect of robotic vs. open surgery on the number of absent days from work, adjusting for demographic characteristics and baseline absenteeism. RESULTS In a cohort of 1157 individuals with employer-sponsored insurance, those undergoing open surgery, compared to robotic surgery, had 9.9 more absent workdays for radical prostatectomy (95%CI 5.0 to 14.7, p < 0.001), 25.3 for hysterectomy/myomectomy (95%CI 11.0-39.6, p < 0.001), and 29.8 for partial colectomy (95%CI 14.8-44.8, p < 0.001) CONCLUSION: For the three major procedures studied, robotic surgery was associated with fewer missed days from work compared to open surgery. This information helps payers, patients, and providers better understand some of the indirect benefits of robotic surgery relative to its cost.
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Affiliation(s)
- Daniel Pucheril
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sean A Fletcher
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Xi Chen
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David F Friedlander
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander P Cole
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marieke J Krimphove
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Adam C Fields
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nelya Melnitchouk
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam S Kibel
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Prokar Dasgupta
- MRC Centre for Transplantation, NIHR Biomedical Research Centre, King's College, London, UK
| | - Quoc-Dien Trinh
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, ASB II-3, Boston, MA, 02115, USA.
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Plym A, Clements M, Voss M, Holmberg L, Stattin P, Lambe M. Duration of sick leave after active surveillance, surgery or radiotherapy for localised prostate cancer: a nationwide cohort study. BMJ Open 2020; 10:e032914. [PMID: 32156761 PMCID: PMC7064067 DOI: 10.1136/bmjopen-2019-032914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To compare the loss of working time due to sick leave by treatment strategy for localised prostate cancer. DESIGN Nationwide cohort study. SETTING Sweden. PARTICIPANTS A total of 15 902 working-aged men with localised low or intermediate-risk prostate cancer diagnosed during 2007-2016 from the Prostate Cancer Data Base Sweden, together with 63 464 prostate cancer-free men. Men were followed until 2016. PRIMARY AND SECONDARY OUTCOME MEASURES Using multistate Markov models, we calculated the proportion of men on work, sick leave, disability pension and death, together with the amount of time spent in each state. All-cause and cause-specific estimates were calculated. RESULTS During the first 5 years after diagnosis, men with active surveillance as their primary treatment strategy spent a mean of 17 days (95% CI 15 to 19) on prostate cancer-specific sick leave, as compared with 46 days (95% CI 44 to 48) after radical prostatectomy and 44 days (95% CI 38 to 50) after radiotherapy. The pattern was similar after adjustment for cancer and sociodemographic characteristics. There were no differences between the treatment strategies in terms of days spent on sick leave due to depression, anxiety or stress. Five years after diagnosis, over 90% of men in all treatment strategies were free from sick leave, disability pension receipt and death from any cause. CONCLUSIONS Men on active surveillance experienced less impact on working life compared with men who received radical prostatectomy or radiotherapy. From a long-term perspective, there were no major differences between treatment strategies. Our findings can inform men diagnosed with localised prostate cancer on how different treatment strategies may affect their working lives.
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Affiliation(s)
- Anna Plym
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mark Clements
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Margaretha Voss
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Lars Holmberg
- Translational Urology and Oncology Research, King's College London, London, UK
- Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Mats Lambe
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Regional Cancer Center, Uppsala University Hospital, Uppsala, Sweden
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Impact of Robotic Surgery on Sick Leave and Return to Work in Patients Undergoing Radical Prostatectomy: An Evidence-Based Analysis. UROLOGY PRACTICE 2020. [DOI: 10.1097/upj.0000000000000069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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Varda BK, Wang Y, Chung BI, Lee RS, Kurtz MP, Nelson CP, Chang SL. Has the robot caught up? National trends in utilization, perioperative outcomes, and cost for open, laparoscopic, and robotic pediatric pyeloplasty in the United States from 2003 to 2015. J Pediatr Urol 2018; 14. [PMID: 29530407 PMCID: PMC6105565 DOI: 10.1016/j.jpurol.2017.12.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Since 2010, there have been few new data comparing perioperative outcomes and cost between open (OP) and robotic pyeloplasty (RP). In a post-adoption era, the value of RP may be converging with that of OP. OBJECTIVE To 1) characterize national trends in pyeloplasty utilization through 2015, 2) compare adjusted outcomes and median costs between OP and RP, and 3) determine the primary cost drivers for each procedure. STUDY DESIGN We performed a retrospective cohort study using the Premier database, which provides a nationally representative sample of U.S. hospitalizations between 2003 and 2015. ICD9 codes and itemized billing were used to abstract our cohorts. Trends in utilization and cost were calculated and then stratified by age. We used propensity scores to weight our cohorts and then applied regression models to measure differences in the probability of prolonged operative time (pOT), prolonged length of stay (pLOS), complications, and cost. RESULTS During the study period 11,899 pyeloplasties were performed: 75% open, 10% laparoscopic, and 15% robotic. The total number of pyeloplasty cases decreased by 7% annually; OP decreased by a rate of 10% while RP grew by 29% annually. In 2015, RP accounted for 40% of cases. The largest growth in RPs was among children and adolescents. The average annual rate of change in cost for RP and OP was near stagnant: -0.5% for open and -0.2% for robotic. The summary table provides results from our regression analyses. RP conferred an increased likelihood of pOT, but a reduced likelihood of pLOS. The odds of complications were equivalent. RP was associated with a significantly higher median cost, but the absolute difference per case was $1060. DISCUSSION Despite advantages in room and board costs for RP, we found that the cost of equipment and OR time continue to make it more expensive. Although the absolute difference may be nominal, we likely underestimate the true cost because we did not capture amortization, hidden or down-stream costs. In addition, we did not measure patient satisfaction and pain control, which may provide the non-monetary data needed for comparative value. CONCLUSION Despite an overall decline in pyeloplasties, RP utilization continues to increase. There has been little change in cost over time, and RP remains more expensive because of equipment and OR costs. The robotic approach confers a reduced likelihood of pLOS, but an increased likelihood of pOT. Complication rates are low and similar in each cohort.
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Affiliation(s)
- Briony K Varda
- Department of Urology, Boston Children's Hospital, Harvard Medical School, MA, USA.
| | - Ye Wang
- Division of Urologic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | | | - Richard S Lee
- Department of Urology, Boston Children's Hospital, Harvard Medical School, MA, USA
| | - Michael P Kurtz
- Department of Urology, Boston Children's Hospital, Harvard Medical School, MA, USA
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Harvard Medical School, MA, USA
| | - Steven L Chang
- Division of Urologic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, MA, USA
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Ullrich A, Rath HM, Otto U, Kerschgens C, Raida M, Hagen-Aukamp C, Bergelt C. Return to work in prostate cancer survivors - findings from a prospective study on occupational reintegration following a cancer rehabilitation program. BMC Cancer 2018; 18:751. [PMID: 30029637 PMCID: PMC6053748 DOI: 10.1186/s12885-018-4614-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/20/2018] [Indexed: 01/21/2023] Open
Abstract
Background This prospective multicentre-study aimed to analyze return to work (RTW) among prostate cancer survivors 12 months after having attended a cancer rehabilitation program and to identify risk factors for no and late RTW. Methods Seven hundred eleven employed prostate cancer survivors treated with radical prostatectomy completed validated self-rating questionnaires at the beginning, the end, and 12 months post rehabilitation. Disease-related data was obtained from physicians and medical records. Work status and time until RTW were assessed at 12-months follow-up. Data were analyzed by univariate analyses (t-tests, chi-square-tests) and multivariate logistic regression models (OR with 95% CI). Results The RTW rate at 12-months follow-up was 87% and the median time until RTW was 56 days. Univariate analyses revealed significant group differences in baseline personal characteristics and health status, psychosocial well-being and work-related factors between survivors who had vs. had not returned to work. Patients’ perceptions of not being able to work (OR 3.671) and feeling incapable to return to the former job (OR 3.162) were the strongest predictors for not having returned to work at 12-months follow-up. Being diagnosed with UICC tumor stage III (OR 2.946) and patients’ perceptions of not being able to work (OR 4.502) were the strongest predictors for late RTW (≥ 8 weeks). Conclusions A high proportion of prostate cancer survivors return to work after a cancer rehabilitation program. However, results indicate the necessity to early identify survivors with low RTW motivation and unfavorable work-related perceptions who may benefit from intensified occupational support during cancer rehabilitation. Electronic supplementary material The online version of this article (10.1186/s12885-018-4614-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anneke Ullrich
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Center for Psychosocial Medicine, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Hilke Maria Rath
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Center for Psychosocial Medicine, Martinistrasse 52, 20246, Hamburg, Germany
| | - Ullrich Otto
- Rehabilitation Clinics Hartenstein GmbH, Clinic Quellental, Bad Wildungen, Germany
| | | | - Martin Raida
- HELIOS Rehabilitation Clinic Bergisch-Land, Wuppertal, Germany
| | | | - Corinna Bergelt
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Center for Psychosocial Medicine, Martinistrasse 52, 20246, Hamburg, Germany
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von Mechow S, Graefen M, Haese A, Tennstedt P, Pehrke D, Friedersdorff F, Beyer B. Return to work following robot-assisted laparoscopic and open retropubic radical prostatectomy: A single-center cohort study to compare duration of sick leave. Urol Oncol 2018; 36:309.e1-309.e6. [PMID: 29551549 DOI: 10.1016/j.urolonc.2018.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 01/16/2018] [Accepted: 02/13/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE To compare the duration of sick leave in patients with localized prostate cancer after robot-assisted radical prostatectomy (RARP) and open retropubic RP (ORP) at a German high-volume prostate cancer center. METHODS The data of 1,415 patients treated with RP at Martini Klinik, Prostate Cancer Center between 2012 and 2016 were, retrospectively, analyzed. Information on employment status, monthly revenues and days of work missed due to sickness were assessed via online questionnaire. Additional data were retrieved from our institutional database. Medians and interquartile ranges (IQR) were reported for continuous data. Cox proportional hazard analysis was performed to compare both surgical techniques for return to work time after RP. RESULTS Median time elapsed between surgery and return to work comprised 42 days in patients undergoing RARP (IQR: 21-70) and ORP (IQR: 28-84, P = 0.05). In Cox regression analysis, surgical approach showed no impact on return to work time (RARP vs. ORP hazard ratio = 1, 95% CI: 0.91-1.16, P = 0.69). Return to work time was significantly associated with employment status, physical workload and monthly income (all P<0.001). Limitation of this study is the nonrandomized design in a single-center. CONCLUSIONS As the surgical approach did not show any influence on the number of days missed from work in patients undergoing RP, no superiority of either RARP or ORP could be identified for return to work time in a German cohort. Both surgical approaches are safe options usually allowing the patients to resume normal activities including work after an appropriate convalescence period.
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Affiliation(s)
- Stefanie von Mechow
- Martini Clinic Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Charité University Hospital, Berlin, Germany.
| | - Markus Graefen
- Martini Clinic Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Haese
- Martini Clinic Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre Tennstedt
- Martini Clinic Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Dirk Pehrke
- Martini Clinic Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Burkhard Beyer
- Martini Clinic Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Jacobs BL, Seelam R, Lai JC, Hanley JM, Wolf JS, Hollenbeck BK, Hollingsworth JM, Dick AW, Setodji CM, Saigal CS. Cost Analysis of Treatments for Ureteropelvic Junction Obstruction. J Endourol 2017; 31:204-209. [PMID: 27927021 DOI: 10.1089/end.2016.0722] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Ureteropelvic junction obstruction is a common urologic condition that accounts for approximately $12 million in inpatient spending annually. Few studies have assessed the costs related to treatment. We sought to examine the cost of care for patients treated for ureteropelvic junction obstruction. PATIENTS AND METHODS We used the MarketScan® database to identify adults from 18 to 64 years old treated with minimally invasive pyeloplasty, open pyeloplasty, and endopyelotomy for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was total expenditures related to the surgical episode, defined as the period from 30 days prior until 30 days after the index surgery. We fit a multinomial linear regression model to evaluate cost of the surgical episode, adjusting for age, gender, comorbidity, benefit plan type, and region of residence. RESULTS We identified 1251 endopyelotomies, 717 open pyeloplasties, and 1048 minimally invasive pyeloplasties. The adjusted mean costs were $16,379 for endopyelotomy, $22,421 for open pyeloplasty, and $22,843 for minimally invasive pyeloplasty (p < 0.0001, ANCOVA). Both open and minimally invasive pyeloplasties were more costly than endopyelotomy (both p < 0.0001, comparison between groups). However, the cost of open and minimally invasive pyeloplasties was similar (p = 0.57, comparison between groups). CONCLUSIONS Among the three treatments, endopyelotomy was the least expensive in the immediate perioperative period. Open and minimally invasive pyeloplasties were similar in cost, but both more expensive than endopyelotomies. The similar cost between the two pyeloplasty approaches provides additional evidence that minimally invasive pyeloplasty should be considered the standard treatment for ureteropelvic junction obstruction.
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Affiliation(s)
- Bruce L Jacobs
- 1 Department of Urology, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Rachana Seelam
- 2 University of California , Los Angeles, and RAND Corporation, Santa Monica, California
| | - Julie C Lai
- 2 University of California , Los Angeles, and RAND Corporation, Santa Monica, California
| | - Janet M Hanley
- 2 University of California , Los Angeles, and RAND Corporation, Santa Monica, California
| | - J Stuart Wolf
- 3 Dell Medical School of the University of Texas , Austin, Texas
| | - Brent K Hollenbeck
- 4 Department of Urology, Division of Health Services Research, University of Michigan , Ann Arbor, Michigan.,5 Department of Urology, Division of Oncology, University of Michigan , Ann Arbor, Michigan
| | - John M Hollingsworth
- 4 Department of Urology, Division of Health Services Research, University of Michigan , Ann Arbor, Michigan.,6 Department of Urology, Division of Endourology, University of Michigan , Ann Arbor, Michigan
| | - Andrew W Dick
- 2 University of California , Los Angeles, and RAND Corporation, Santa Monica, California
| | - Claude M Setodji
- 2 University of California , Los Angeles, and RAND Corporation, Santa Monica, California
| | - Christopher S Saigal
- 2 University of California , Los Angeles, and RAND Corporation, Santa Monica, California.,7 Department of Urology, David Geffen School of Medicine , Santa Monica, California
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12
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Park M, Kim SC, Chung JS, Park SH, Park SS, Oh SJ, Lee D, Rha KH, Oh CK. Simultaneous robotic low anterior resection and prostatectomy for adenocarcinoma of rectum and prostate: initial case report. SPRINGERPLUS 2016; 5:1768. [PMID: 27795910 PMCID: PMC5059363 DOI: 10.1186/s40064-016-3456-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 10/04/2016] [Indexed: 11/25/2022]
Abstract
Background We report a case of synchronous rectal and prostate cancer treated successfully with simultaneous da Vinci robotic-assisted low anterior resection of the rectum and robotic-assisted laparoscopic radical prostatectomy to address both cancers. Case presentation Recently, minimally invasive surgical techniques using da Vinci robot® system (Intuitive Surgical, Sunnyvale, USA) were introduced as curative surgical modality of prostate and rectal malignancies. Herein, we report an initial case of simultaneous robotic low anterior resection and robotic prostatectomy for adenocarcinoma of rectum and prostate sharing a considerable number of port sites. Conclusion Simultaneous robotic-assisted low anterior resection could be performed with robotic-assisted radical prostatectomy safely and effectively in synchronous rectal and prostate cancer.
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Affiliation(s)
- Myungchan Park
- Department of Urology, Haeundae Paik Hospital, Inje University College of Medicine, 248, Jwadongsunhwan-ro, Haeundae-gu, Busan, Korea
| | - Seong Cheol Kim
- Department of Urology, Haeundae Paik Hospital, Inje University College of Medicine, 248, Jwadongsunhwan-ro, Haeundae-gu, Busan, Korea
| | - Jae-Seung Chung
- Department of Urology, Haeundae Paik Hospital, Inje University College of Medicine, 248, Jwadongsunhwan-ro, Haeundae-gu, Busan, Korea
| | - Sang Hyun Park
- Department of Urology, Haeundae Paik Hospital, Inje University College of Medicine, 248, Jwadongsunhwan-ro, Haeundae-gu, Busan, Korea
| | - Seok San Park
- Department of Urology, Haeundae Paik Hospital, Inje University College of Medicine, 248, Jwadongsunhwan-ro, Haeundae-gu, Busan, Korea
| | - Sung Jin Oh
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Donghoon Lee
- Department of Convergence Medical Science, Institute of Health Sciences, School of Medicine, Gyeongsang National University, Jinju, Korea
| | - Koon Ho Rha
- Department of Urology, Yonsei University College of Medicine, Seoul, Korea
| | - Cheol Kyu Oh
- Department of Urology, Haeundae Paik Hospital, Inje University College of Medicine, 248, Jwadongsunhwan-ro, Haeundae-gu, Busan, Korea
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Angenete E, Angerås U, Börjesson M, Ekelund J, Gellerstedt M, Thorsteinsdottir T, Steineck G, Haglind E. Physical activity before radical prostatectomy reduces sick leave after surgery - results from a prospective, non-randomized controlled clinical trial (LAPPRO). BMC Urol 2016; 16:50. [PMID: 27531014 PMCID: PMC4986175 DOI: 10.1186/s12894-016-0168-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 08/08/2016] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Studies have reported that early physical rehabilitation after surgical procedures is associated with improved outcome measured as shorter hospital stay and enhanced recovery. The aim of this study was to explore the relationship between the preoperative physical activity level and subsequent postoperative complications, sick-leave and hospital stay after radical prostatectomy for prostate cancer in the setting of the LAPPRO trial (LAParoscopic Prostatectomy Robot Open). METHODS LAPPRO is a prospective controlled trial, comparing robot-assisted laparoscopic and open surgery for localized prostate cancer between 2008 and 2011. 1569 patients aged 64 or less with an occupation were included in this sub-study. The Gleason score was <7 in 52 % of the patients. Demographics and the level of self-assessed preoperative physical activity, length of hospital stay, complications, quality of life, recovery and sick-leave were extracted from clinical record forms and questionnaires. Multivariable logistic regression, with log-link and logit-link functions, was used to adjust for potential confounding variables. RESULTS The patients were divided into four groups based on their level of activity. As the group with lowest engagement of physical activity was found to be significantly different in base line characteristics from the other groups they were excluded from further analysis. Among patients that were physically active preoperativelly (n = 1467) there was no significant difference between the physical activity-groups regarding hospital stay, recovery or complications. However, in the group with the highest self-assessed level of physical activity, 5-7 times per week, 13 % required no sick leave, compared to 6.3 % in the group with a physical activity level of 1-2 times per week only (p < 0.0001). CONCLUSIONS In our study of med operated with radical prostatectomy, a high level of physical activity preoperatively was associated with reduced need for sick leave after radical prostatectomy compared to men with lower physical activity. TRIAL REGISTRATION The trial is registered at the ISCRTN register. ISRCTN06393679 .
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Affiliation(s)
- E Angenete
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SSORG, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden.
| | - U Angerås
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SSORG, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | - M Börjesson
- Swedish School of Sport and Health Sciences, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - J Ekelund
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SSORG, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | | | - T Thorsteinsdottir
- Faculty of Nursing, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - G Steineck
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Oncology and Pathology, Division of Clinical Cancer Epidemiology, Karolinska Institutet, Solna, Sweden
| | - E Haglind
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SSORG, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
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Gettman MT. Assessing Work Disability After Radical Prostatectomy. Eur Urol 2016; 70:72-73. [PMID: 26810116 DOI: 10.1016/j.eururo.2016.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 01/05/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Matthew T Gettman
- Department of Urology, Mayo Clinic College of Medicine, Rochester, MN, USA.
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15
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Work Disability After Robot-assisted or Open Radical Prostatectomy: A Nationwide, Population-based Study. Eur Urol 2016; 70:64-71. [PMID: 26782345 DOI: 10.1016/j.eururo.2015.12.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/29/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Robot-assisted radical prostatectomy (RARP) has been associated with reduced bleeding and shorter hospital stays than open retropubic radical prostatectomy (RRP), but it is unclear whether these differences translate into shorter absence from work. OBJECTIVE To investigate short- and long-term rates of work disability following RARP and RRP. DESIGN, SETTING, AND PARTICIPANTS We conducted a nationwide population-based cohort study of 2571 men of working age treated with RARP or RRP between 2007 and 2009 identified in the National Prostate Cancer Register of Sweden. Information about physician-certified sick leave and disability pension was retrieved from the Swedish Social Insurance Agency through 2012. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We used Cox regression to calculate time to return to work (RTW, or duration of sick leave) after surgery and used generalised estimating equations to analyse days lost from work (because of sick leave and disability pension) after RTW. RESULTS AND LIMITATIONS Men treated with RARP returned to work after a median of 35 d, whereas the corresponding time for RRP was 48 d (p<0.001). The difference was seen early; within the first month, men treated with RARP returned to work nearly four times faster than men treated with RRP (adjusted relative RTW rate 3.76; 95% confidence interval [CI], 3.04-4.66). During a median of 3.6 yr after return to work, men treated with RARP lost fewer days from work per person-year than men treated with RRP-12 d versus 15 d-but the association was not statistically significant (p=0.10). The adjusted rate ratio was 1.08 (95% CI, 0.82-1.42). One limitation is the nonrandomised design of this study. CONCLUSIONS RARP was associated with a faster RTW compared with RRP, but the surgical method did not influence long-term rates of work disability in terms of days lost from work after RTW. PATIENT SUMMARY We compared disease-related absence from work between two surgical methods for the removal of the prostate. Robot-assisted surgery was associated with a faster return to work compared with open surgery but did not influence absence from work in a long-term perspective.
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Sotelo RJ, Haese A, Machuca V, Medina L, Nuñez L, Santinelli F, Hernandez A, Kural AR, Mottrie A, Giedelman C, Mirandolino M, Palmer K, Abaza R, Ghavamian R, Shalhav A, Moinzadeh A, Patel V, Stifelman M, Tuerk I, Canes D. Safer Surgery by Learning from Complications: A Focus on Robotic Prostate Surgery. Eur Urol 2015; 69:334-44. [PMID: 26385157 DOI: 10.1016/j.eururo.2015.08.060] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 08/31/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND The uptake of robotic surgery has led to changes in potential operative complications, as many surgeons learn minimally invasive surgery, and has allowed the documentation of such complications through the routine collection of intraoperative video. OBJECTIVE We documented intraoperative complications from robot-assisted radical prostatectomy (RARP) with the aim of reporting the mechanisms, etiology, and necessary steps to avoid them. Our goal was to facilitate learning from these complications to improve patient care. DESIGN, SETTING, AND PARTICIPANTS Contributors delivered videos of complications that occurred during laparoscopic and robotic prostatectomy between 2010 and 2015. SURGICAL PROCEDURE Surgical footage was available for a variety of complications during RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Based on these videos, a literature search was performed using relevant terms (prostatectomy, robotic, complications), and the intraoperative steps of the procedures and methods of preventing complications were outlined. RESULTS AND LIMITATIONS As a major surgical procedure, RARP has much potential for intra- and postoperative complications related to patient positioning, access, and the procedure itself. However, with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, we suggest that the majority of such complications are preventable. CONCLUSIONS Considering the complexity of the procedure, RARP is safe and reproducible for the surgical management of prostate cancer. Insight from experienced surgeons may allow surgeons to avoid complications during the learning curve. PATIENT SUMMARY Robot-assisted radical prostatectomy has potential for intra- and postoperative complications, but with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, most complications are preventable.
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Affiliation(s)
- René J Sotelo
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela; University of Southern California, Los Angeles, CA, USA.
| | - Alexander Haese
- Martini Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany
| | - Victor Machuca
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela
| | - Luis Medina
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela
| | - Luciano Nuñez
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela
| | | | | | | | | | | | | | | | - Ronney Abaza
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Arieh Shalhav
- Duchossois Center for Advanced Medicine, Chicago, IL, USA
| | - Alireza Moinzadeh
- Lahey Hospital and Medical Center Institute of Urology, Burlington, MA, USA
| | - Vipul Patel
- Global Robotics Institute, Celebration, FL, USA
| | | | - Ingolf Tuerk
- St. Elizabeth's Medical Center, Brighton, MA, USA
| | - David Canes
- Lahey Hospital and Medical Center Institute of Urology, Burlington, MA, USA
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17
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Müller S, Grønning LE, Nilsen FS, Mygland V, Patel HRH. Robotic and minimal access surgery: technology and surgical outcomes of radical prostatectomy for prostate cancer. Expert Rev Anticancer Ther 2014; 14:1317-21. [PMID: 25266367 DOI: 10.1586/14737140.2014.965689] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the 1990s, minimal access surgery has been utilized in urology. In the past 15 years, robotic surgery has evolved and become a natural part of minimal access surgery. The dissemination has been fast and the opportunity of prospective trials has been missed. Nevertheless, robotic surgery has obvious benefits for the surgeon and patient. Even though the scientific evidence is not strong, robotic surgery is here to stay. However, there are lessons to learn from the implementation of the da Vinci system with regards to patient safety and prospective evaluation of the new technology. The future of surgery will include technologies derived from robotic surgery.
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Affiliation(s)
- Stig Müller
- Department of Urology, Akershus University Hospital, Sykehusveien 23, Lørenskog 1478, Norway
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18
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Williams SB, Prado K, Hu JC. Economics of robotic surgery: does it make sense and for whom? Urol Clin North Am 2014; 41:591-6. [PMID: 25306170 DOI: 10.1016/j.ucl.2014.07.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The authors performed a literature review to identify cost-effectiveness research as it pertains to robotic surgery. There is increased utilization of robotic surgery in urology with limited comparative effectiveness research demonstrating superiority over conventional, less costly treatment options. Further research into identifying determinants for optimal utilization of robotics and newer technology is needed.
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Affiliation(s)
- Stephen B Williams
- Department of Urology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1373, Houston, TX 77030, USA
| | - Kris Prado
- Department of Urology, David Geffen School of Medicine at UCLA, 924 Westwood, Boulevard, STE 1000, Los Angeles, CA 90024, USA
| | - Jim C Hu
- Department of Urology, David Geffen School of Medicine at UCLA, 924 Westwood, Boulevard, STE 1000, Los Angeles, CA 90024, USA.
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19
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Dahl S, Steinsvik EAS, Dahl AA, Loge JH, Cvancarova M, Fosså SD. Return to work and sick leave after radical prostatectomy: a prospective clinical study. Acta Oncol 2014; 53:744-51. [PMID: 24195691 DOI: 10.3109/0284186x.2013.844357] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND To evaluate work status at three months after radical prostatectomy (RP) in patients with prostate cancer (PCa) in relation to socio-demographics, urinary incontinence and bother, medical complications health-related quality of life (HRQOL) and surgical methods. To identify pre-RP available factors that can predict the duration of immediate post-RP sick leave. MATERIAL AND METHODS This prospective questionnaire-based study included 264 men with PCa<65 years, who were active in the work force before RP. Urinary incontinence and bother were assessed using the Expanded Prostate Cancer Index Composite-50 (EPIC-50). HRQOL was measured using SF-12. Medical complications comprised self- reported new morbidities and re-hospitalizations within three months after RP. Patients' work status was defined as either "stable/improved" or "declined" at three months compared to work status at baseline. Duration of immediate post-RP sick leave was considered as prolonged when lasting >6 weeks. Associations were analyzed using logistic regression analyses. RESULTS Almost 30% of the patients had declined work status three months after RP. Change of physical HRQOL was the only factor remaining significantly associated with declined work status in the multivariate analysis. Half of the patients had prolonged immediate sick leave. Having physically strenuous work was the strongest predictor for this outcome. CONCLUSIONS Long periods of sick leave and reduced workforce participation after RP should be considered potential adverse effects of this treatment.
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Affiliation(s)
- Sigrun Dahl
- National Resource Center for Late Effects after Cancer, Oslo University Hospital, The Norwegian Radium Hospital , Oslo , Norway
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20
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Teljeur C, O'Neill M, Moran PS, Harrington P, Flattery M, Murphy L, Ryan M. Economic evaluation of robot-assisted hysterectomy: a cost-minimisation analysis. BJOG 2014; 121:1546-53. [DOI: 10.1111/1471-0528.12836] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2014] [Indexed: 11/28/2022]
Affiliation(s)
- C Teljeur
- Health Information and Quality Authority; Dublin Ireland
| | - M O'Neill
- Health Information and Quality Authority; Dublin Ireland
| | - PS Moran
- Health Information and Quality Authority; Dublin Ireland
| | - P Harrington
- Health Information and Quality Authority; Dublin Ireland
| | - M Flattery
- Health Information and Quality Authority; Dublin Ireland
| | - L Murphy
- Health Information and Quality Authority; Dublin Ireland
| | - M Ryan
- Health Information and Quality Authority; Dublin Ireland
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21
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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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22
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Geraerts I, Van Poppel H, Devoogdt N, Laenen A, De Groef A, Van Kampen M. Progression and predictors of physical activity levels after radical prostatectomy. BJU Int 2014; 114:185-92. [PMID: 24112623 DOI: 10.1111/bju.12465] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the progression of all aspects (total, occupational, sports, household) of physical activity (PA) over time after radical prostatectomy (RP) and to find predictive factors for a decrease in PA. PATIENTS AND METHODS In all, 240 men planned for open or robot-assisted RP were analysed. All patients completed the Flemish Physical Activity Computerised Questionnaire before RP concerning PA over the past year and at 6 weeks, 3, 6 and 12 months after RP for the PA of the past month. A linear model for repeated measures was used to evaluate the progression of continuous variables over time and the effect of various predictors for the progression of patients over time. A logistic regression model for repeated measures was used to evaluate binary measures. RESULTS Total, occupational, sports and household PA levels were significantly decreased at 6 weeks after RP, but recovered quickly to approximately baseline levels from that time. Predictive factors for decreased PA levels at 6 weeks after RP were a younger age (total PA level), being unskilled/semi-skilled (occupational PA level) and being unemployed/retired (household PA level). RP type (open vs robot-assisted) did not influence the different PA levels at 6 weeks, 3, 6 or 12 months after RP. The severity of first day incontinence and urine loss measured at 6 weeks and 3, 6 and 12 months after RP significantly affected total and/or household PA level at all time-points. CONCLUSIONS This is the first study to investigate the progression of all aspects of PA (total, occupational, sports and household) after RP and to find predictive factors for a decrease in PA. All PA levels were significantly decreased at 6 weeks after RP and recovered quickly to approximately baseline levels from that time. Patients that had robot-assisted RP did not have a faster recovery of PA than those that had open RP. Severity of first day incontinence and urine loss measured at 6 weeks and 3, 6 and 12 months after RP were significantly related to total and/or household PA level at all time-points.
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Affiliation(s)
- Inge Geraerts
- Department of Rehabilitation Science, KU Leuven, Leuven, Belgium
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23
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Prasad SM, Large MC, Patel AR, Famakinwa O, Galocy RM, Karrison T, Shalhav AL, Zagaja GP. Early removal of urethral catheter with suprapubic tube drainage versus urethral catheter drainage alone after robot-assisted laparoscopic radical prostatectomy. J Urol 2014; 192:89-95. [PMID: 24440236 DOI: 10.1016/j.juro.2014.01.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Retrospective single institution data suggest that postoperative pain after robot-assisted laparoscopic radical prostatectomy is decreased by early removal of the urethral catheter with suprapubic tube drainage. In a randomized patient population we determined whether suprapubic tube drainage with early urethral catheter removal would improve postoperative pain compared with urethral catheter drainage alone. MATERIALS AND METHODS Men with a body mass index of less than 40 kg/m(2) who had newly diagnosed prostate cancer and elected robot-assisted laparoscopic radical prostatectomy were included in analysis. Block randomization by surgeon was used and randomization assignment was done after completing the urethrovesical anastomosis. In patients assigned to suprapubic tube drainage the urethral catheter was removed on postoperative day 1 and all catheters were removed on postoperative day 7. Visual analog pain scale and satisfaction questionnaires were administered on postoperative days 0, 1 and 7. RESULTS A total of 29 patients were randomized to the urethral catheter vs 29 to the suprapubic tube plus early urethral catheter removal at the time of interim futility analysis. Mean visual analog pain scale scores did not differ between the groups at any time point and a similar percent of patients cited the catheter as the greatest bother with nonsignificant differences in treatment related satisfaction. Complications during postoperative week 1 did not vary between the groups. Based on interim results the trial was terminated due to lack of effect. CONCLUSIONS Patients randomized to suprapubic tube vs urethral catheter drainage for the week after prostatectomy had similar pain, catheter related bother and treatment related satisfaction in the perioperative period. We no longer routinely offer suprapubic tube drainage with early urethral catheter removal at our institution.
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Affiliation(s)
- Sandip M Prasad
- Department of Urology, Medical University of South Carolina, Charleston, South Carolina.
| | - Michael C Large
- Section of Urology, University of Chicago Hospitals, Chicago, Illinois
| | - Amit R Patel
- Department of Urology, DuPage Medical Group, Downers Grove, Illinois
| | | | - R Matthew Galocy
- Section of Urology, University of Chicago Hospitals, Chicago, Illinois
| | - Theodore Karrison
- Department of Health Studies, University of Chicago Hospitals, Chicago, Illinois
| | - Arieh L Shalhav
- Section of Urology, University of Chicago Hospitals, Chicago, Illinois
| | - Gregory P Zagaja
- Section of Urology, University of Chicago Hospitals, Chicago, Illinois
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Fode M, Sønksen J, Jakobsen H. Radical prostatectomy: initial experience with robot-assisted laparoscopic procedures at a large university hospital. Scand J Urol 2013; 48:252-8. [PMID: 24341725 DOI: 10.3109/21681805.2013.868514] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to compare oncological and functional outcomes between robot-assisted laparoscopic radical prostatectomy (RALP) and retropubic radical prostatectomy (RRP) during the initial phase with RALP at a large university hospital. MATERIAL AND METHODS Patient and tumour characteristics, surgeon, nerve sparing, surgical margins and blood loss were recorded prospectively in patients who underwent RRP or RALP between April 2008 and May 2012. Patients filled out the Danish Prostate Symptom Score (DAN-PSS) and International Index of Erectile Function 5 (IIEF-5) questionnaires before surgery and at follow-up and they were asked to report their use of pads/diapers. Potency was defined as an IIEF-5 score of at least 17 with or without phosphodiesterase-5 inhibitors. Patients using up to one pad daily for security reasons only were considered continent. Positive surgical margins, blood loss and functional outcomes were compared between groups. RESULTS Overall, 453 patients were treated with RRP and 585 with RALP. On multivariate logistic regression analyses, the type of surgery did not affect surgical margins (p = 0.96) or potency at 12 months (p = 0.7). Patients who had undergone RRP had an increased chance of reporting subjective continence at 12 months (odds ratio 2.6, p = 0.014). There was no difference in the proportion of RRP and RALP patients who underwent surgical treatment for incontinence (p = 0.57). On multivariate linear regression analysis, RALP was an independent predictor of a low perioperative blood loss (RRP:RALP ratio = 2.89, p < 0.0001). CONCLUSIONS RALP is a safe procedure with regard to perioperative and oncological results. However, it is important to be aware that functional outcomes may be compromised in the initial phase when introducing RALP.
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Affiliation(s)
- Mikkel Fode
- Department of Urology, Herlev Hospital , Herlev , Denmark
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25
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Relationships between perioperative physical activity and urinary incontinence after radical prostatectomy: an observational study. BMC Urol 2013; 13:67. [PMID: 24289104 PMCID: PMC4219599 DOI: 10.1186/1471-2490-13-67] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 11/28/2013] [Indexed: 11/28/2022] Open
Abstract
Background Higher physical activity levels are continence-protective in non-prostate cancer populations. Primary aims of this study were to investigate changes in physical activity levels over the perioperative period in patients having radical prostatectomy, and relationships between perioperative physical activity levels and post-prostatectomy urinary incontinence. Methods A prospective analysis of patients having radical prostatectomy and receiving perioperative physiotherapy including pelvic floor muscle training and physical activity prescription (n = 33). Physical activity levels were measured using the International Physical Activity Questionnaire and/or the SenseWear Pro3 Armband at four timepoints: before preoperative physiotherapy, the week before surgery, and 3 and 6 weeks postoperatively. Urinary incontinence was measured at 3 and 6 weeks postoperatively using a 24-hour pad test and the International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form (ICIQ). Results Physical activity levels changed significantly over the perioperative period (p < 0.001). At 6 weeks postoperatively, physical activity levels did not differ significantly from baseline (p = 0.181), but remained significantly lower than the week before surgery (p = 0.002). There was no significant interaction effect between preoperative physical activity category and time on the 24-hour pad test (p = 0.726) or ICIQ (p = 0.608). Nor were there any significant correlations between physical activity levels and the 24-hour pad test and ICIQ at 3 or 6 weeks postoperatively. Conclusions This study provides novel data on perioperative physical activity levels for patients having radical prostatectomy. There was no relationship between perioperative physical activity levels and post-prostatectomy urinary incontinence, although participants had high overall preoperative physical activity levels and low overall urinary incontinence.
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Verdier E, Doré B, Fromont G, Pirès C, Lecoq B, Dezael JC, Irani J. [Open versus laparoscopic radical prostatectomy: a French center experience]. Prog Urol 2013; 24:173-9. [PMID: 24560206 DOI: 10.1016/j.purol.2013.08.313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/09/2013] [Accepted: 08/08/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare peri-operative outcomes of open radical prostatectomy (ORP) to laparoscopic radical prostatectomy (LRP) in a single French institution. METHODS Between 1998 and 2003, 72 patients underwent ORP followed by 279 LRP between 2003 and 2010 for a clinically localized prostate cancer. Demographic, peri-operative and pathological data in the ORP and LRP groups were analyzed and compared. RESULTS In the ORP group, compared to the LRP group, the following significant differences were found: patients were older (63.1 years versus 65.6), initial PSA was higher (10.2 ng/mL versus 6.7) and the proportion of T1c was higher (62.8 % versus 80.6 %). Operative blood loss (1500 mL versus 500) and length of hospitalization (9.0 days versus 6.3) were higher in the ORP group (P<0.001). Operative time was longer in the LRP group (250 min versus 160; P<0 .001). There was no significant difference regarding length of catheterization (average of 8.5 days). Anastomotic strictures were more frequent following ORP (P<0.001). Positive margins proportion in the ORP group (7.1 %) was lower than that observed in the LRP group (28.7 %) (P=0.001). Patients in the ORP group achieved early continence more frequently (P<0.01) but at 12 months postoperatively there was no significant difference. CONCLUSION Patients in the LRP group had lower operative blood losses and a shorter length of hospitalization. However, in the ORP group, operative time was shorter and positive margins rate was lower.
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Affiliation(s)
- E Verdier
- Service d'urologie, CHU de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France.
| | - B Doré
- Service d'urologie, CHU de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
| | - G Fromont
- Service d'anatomo-cyto-pathologie, CHU de Poitiers, rue de la Milétrie, 86000 Poitiers, France
| | - C Pirès
- Service d'urologie, centre hospitalier Camille-Guérin, rue Docteur-Luc-Montagnier, 86100 Chatellerault, France
| | - B Lecoq
- Service d'urologie, centre hospitalier Camille-Guérin, rue Docteur-Luc-Montagnier, 86100 Chatellerault, France
| | - J-C Dezael
- Service d'urologie, clinique de l'Alliance, boulevard Alfred-Nobel, BP 30729, 37542 Saint-Cyr-Sur-Loire cedex, France
| | - J Irani
- Service d'urologie, CHU de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
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Huang KH, Carter SC, Shih YCT, Hu JC. Robotic and standard open radical prostatectomy: oncological and quality-of-life outcomes. J Comp Eff Res 2013; 2:293-9. [DOI: 10.2217/cer.13.23] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Prostate cancer is the second leading cause of cancer death among men in the USA. Use of robot-assisted radical prostatectomy (RARP) for the management of localized prostate cancer has increased dramatically in recent years. This review focuses on comparing quality of life following RARP versus retropubic radical prostatectomy. RARP is associated with improved perioperative outcomes, such as reduced blood loss and fewer transfusions. In addition, cancer control after RARP versus retropubic radical prostatectomy is equivalent, with similar incidences of positive surgical margins and comparable early oncological outcomes. RARP appears to provide advantages in recovery of continence, potency and quality of life compared with retropubic radical prostatectomy; however, methodological limitations exist in current literature.
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Affiliation(s)
- Kuo-How Huang
- Institute of Urologic Oncology, Department of Urology, David Geffen School of Medicine, University of California, LA, USA
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Stacey C Carter
- Institute of Urologic Oncology, Department of Urology, David Geffen School of Medicine, University of California, LA, USA
| | - Ya-Chen Tina Shih
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, IL, USA
| | - Jim C Hu
- Institute of Urologic Oncology, Department of Urology, David Geffen School of Medicine, University of California, LA, USA.
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Moran PS, O'Neill M, Teljeur C, Flattery M, Murphy LA, Smyth G, Ryan M. Robot-assisted radical prostatectomy compared with open and laparoscopic approaches: a systematic review and meta-analysis. Int J Urol 2013; 20:312-21. [PMID: 23311943 DOI: 10.1111/iju.12070] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 12/10/2012] [Indexed: 12/11/2022]
Abstract
Medline and Embase were searched for studies comparing robot-assisted radical prostatectomy with open prostatectomy and conventional laparoscopic prostatectomy. Random effects meta-analysis was used to calculate a pooled estimate of effect. The 95% prediction intervals are also reported. One randomized study and 50 observational studies were identified. The results show that compared with open surgery, robot-assisted surgery is associated with fewer positive surgical margins for pT2 tumors (relative risk 0.63, 95% confidence interval 0.49-0.81, P < 0.001) and improved outcomes for sexual function at 12 months (relative risk 1.60, 95% confidence interval 1.33-1.93, P = <0.001), and, to a lesser extent, urinary function at 12 months (relative risk 1.06, 95% confidence interval 1.02-1.11, P < 0.01). Compared with conventional laparoscopic prostatectomy, robot-assisted surgery is associated with a slight increase in urinary function at 12 months (relative risk 1.09, 95% confidence interval 1.02 to 1.17, P = 0.013). The overall methodological quality of the included studies was low, with high levels of heterogeneity. The use of prediction intervals as an aid to decision making in regard to the introduction of this technology is examined. Clinically significant improvements in positive surgical margins rates for pT2 tumors and sexual function at 12 months associated with robot-assisted surgery in comparison with open surgery should be interpreted with caution given the limitations of the evidence. Differences between robot-assisted and conventional laparoscopic surgery are minimal.
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Affiliation(s)
- Patrick S Moran
- Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland.
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Lim SK, Kim KH, Shin TY, Rha KH. Current status of robot-assisted laparoscopic radical prostatectomy: How does it compare with other surgical approaches? Int J Urol 2012; 20:271-84. [DOI: 10.1111/j.1442-2042.2012.03193.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 09/17/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Sey Kiat Lim
- Department of Urology; Urological Science Institute; Yonsei University College of Medicine; Seoul; South Korea
| | - Kwang Hyun Kim
- Department of Urology; Urological Science Institute; Yonsei University College of Medicine; Seoul; South Korea
| | - Tae-Young Shin
- Department of Urology; Urological Science Institute; Yonsei University College of Medicine; Seoul; South Korea
| | - Koon Ho Rha
- Department of Urology; Urological Science Institute; Yonsei University College of Medicine; Seoul; South Korea
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Bolenz C, Freedland SJ, Hollenbeck BK, Lotan Y, Lowrance WT, Nelson JB, Hu JC. Costs of radical prostatectomy for prostate cancer: a systematic review. Eur Urol 2012; 65:316-24. [PMID: 22981673 DOI: 10.1016/j.eururo.2012.08.059] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 08/28/2012] [Indexed: 12/29/2022]
Abstract
CONTEXT Robot-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted as a new approach for radical prostatectomy (RP) in patients with prostate cancer (PCa). The use of new technology may increase costs for RP. OBJECTIVE To summarize data on direct costs of various approaches to RP and to discuss the consequences of cost differences. EVIDENCE ACQUISITION A systematic literature search was performed in March 2012 using the PubMed, Web of Science, and Cochrane Library databases. A complex search strategy was applied. Articles were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Articles reporting on direct costs of RP (open retropubic [RRP], radical perineal [RPP], laparoscopic [LRP], RALP) in men with clinically localized PCa were eligible for study inclusion. EVIDENCE SYNTHESIS Of 1218 articles initially screened by title, the multistep, systematic search identified 11 studies presenting direct costs of different approaches to RP. Of the 11 studies, 7 compared the costs of different RP approaches. Minimally invasive RP (MIRP) (ie, LRP or RALP) was more expensive than RRP in most studies, mainly due to increased surgical instrumentation costs. In the comparative studies, costs ranged from (in US dollars) $5058 to $11,806 for MIRP and from $4075 to $6296 for RRP, with RALP having the highest direct costs. In one study applying standardized, health economic-evaluation criteria, RALP was not found to be cost effective. Limitations of this review include significant differences in observational study designs and an absence of prospective comparative studies. Moreover, there are limited post-RP data on the costs of adjuvant treatments and other health care-related expenses after PCa surgery. CONCLUSIONS Few studies compared direct costs of different approaches to RP. The use of new technology, particularly RALP, results in added costs for the procedure. Cost effectiveness of new technologies should be assessed before widespread adoption. To date, in the lone study to evaluate this, RALP was not found to be cost effective from a health care, economic standpoint. However, longer follow-up of patients is required to better evaluate its impact on overall costs and quality of PCa care.
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Affiliation(s)
- Christian Bolenz
- Department of Urology, Mannheim Medical Center, University of Heidelberg, Mannheim, Germany.
| | - Stephen J Freedland
- Department of Surgery - Durham VA Medical Center, and Departments of Surgery (Urology) and Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Yair Lotan
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William T Lowrance
- Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Joel B Nelson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jim C Hu
- David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
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Lavery HJ, Levinson AW, Samadi DB. Robotic-assisted vs. open radical prostatectomy: When can we stop the debate? Urol Oncol 2012. [DOI: 10.1016/j.urolonc.2011.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tewari A, Sooriakumaran P, Bloch DA, Seshadri-Kreaden U, Hebert AE, Wiklund P. Positive Surgical Margin and Perioperative Complication Rates of Primary Surgical Treatments for Prostate Cancer: A Systematic Review and Meta-Analysis Comparing Retropubic, Laparoscopic, and Robotic Prostatectomy. Eur Urol 2012; 62:1-15. [DOI: 10.1016/j.eururo.2012.02.029] [Citation(s) in RCA: 301] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 02/14/2012] [Indexed: 12/11/2022]
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Abstract
PURPOSE OF REVIEW With the expanding use of new technology in the treatment of clinically localized prostate cancer (PCa), the financial burden on the healthcare system and the individual has been important. Robotics offer many potential advantages to the surgeon and the patient. We assessed the potential cost-effectiveness of robotics in urological surgery and performed a comparative cost analysis with respect to other potential treatment modalities. RECENT FINDINGS The direct and indirect costs of purchasing, maintaining, and operating the robot must be compared to alternatives in treatment of localized PCa. Some expanding technologies including intensity-modulated radiation therapy are significantly more expensive than robotic surgery. Furthermore, the benefits of robotics including decreased length of stay and return to work are considerable and must be measured when evaluating its cost-effectiveness. SUMMARY Robot-assisted laparoscopic surgery comes at a high cost but can become cost-effective in mostly high-volume centers with high-volume surgeons. The device when utilized to its maximum potential and with eventual market-driven competition can become affordable.
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Yu HY, Hevelone ND, Lipsitz SR, Kowalczyk KJ, Hu JC. Use, costs and comparative effectiveness of robotic assisted, laparoscopic and open urological surgery. J Urol 2012; 187:1392-8. [PMID: 22341274 DOI: 10.1016/j.juro.2011.11.089] [Citation(s) in RCA: 189] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Indexed: 02/08/2023]
Abstract
PURPOSE Although robotic assisted laparoscopic surgery has been aggressively marketed and rapidly adopted, there are few comparative effectiveness studies that support its purported advantages compared to open and laparoscopic surgery. We used a population based approach to assess use, costs and outcomes of robotic assisted laparoscopic surgery vs laparoscopic surgery and open surgery for common robotic assisted urological procedures. MATERIALS AND METHODS From the Nationwide Inpatient Sample we identified the most common urological robotic assisted laparoscopic surgery procedures during the last quarter of 2008 as radical prostatectomy, nephrectomy, partial nephrectomy and pyeloplasty. Robotic assisted laparoscopic surgery, laparoscopic surgery and open surgery use, costs and inpatient outcomes were compared using propensity score methods. RESULTS Robotic assisted laparoscopic surgery was performed for 52.7% of radical prostatectomies, 27.3% of pyeloplasties, 11.5% of partial nephrectomies and 2.3% of nephrectomies. For radical prostatectomy robotic assisted laparoscopic surgery was more prevalent than open surgery among white patients in high volume, urban hospitals (all p≤0.015). Geographic variations were found in the use of robotic assisted laparoscopic surgery vs open surgery. Robotic assisted laparoscopic surgery and laparoscopic surgery vs open surgery were associated with shorter length of stay for all procedures, with robotic assisted laparoscopic surgery being the shortest for radical prostatectomy and partial nephrectomy (all p<0.001). For most procedures robotic assisted laparoscopic surgery and laparoscopic surgery vs open surgery resulted in fewer deaths, complications, transfusions and more routine discharges. However, robotic assisted laparoscopic surgery was more costly than laparoscopic surgery and open surgery for most procedures. CONCLUSIONS While robotic assisted and laparoscopic surgery are associated with fewer deaths, complications, transfusions and shorter length of hospital stay compared to open surgery, robotic assisted laparoscopic surgery is more costly than laparoscopic and open surgery. Additional studies are needed to better delineate the comparative and cost-effectiveness of robotic assisted laparoscopic surgery relative to laparoscopic surgery and open surgery.
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Affiliation(s)
- Hua-yin Yu
- Division of Urology, Brigham and Women's/Faulkner Hospital, Harvard Medical School, Boston, Massachusetts
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Kowalczyk KJ, Weinburg AC, Gu X, Yu HY, Lipsitz SR, Williams SB, Hu JC. Comparison of outpatient narcotic prescribing patterns after minimally invasive versus retropubic and perineal radical prostatectomy. J Urol 2011; 186:1843-8. [PMID: 21944990 DOI: 10.1016/j.juro.2011.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Indexed: 11/17/2022]
Abstract
PURPOSE Studies comparing pain after minimally invasive vs retropubic and perineal radical prostatectomy are conflicting. We characterized population based outpatient narcotic prescribing patterns after minimally invasive, retropubic and perineal radical prostatectomy. MATERIALS AND METHODS We evaluated outpatient prescription data after minimally invasive, retropubic and perineal radical prostatectomy from 2003 to 2006 using MarketScan®. Baseline and postoperative narcotic prescriptions were identified using the National Drug Code. Total prescribed narcotic strength in morphine sulfate equivalents, the number of prescriptions filled and costs were compared. We performed multivariate analysis adjusted for surgical approach, age, comorbidity, baseline narcotic use, health plan and geographic region. RESULTS We identified 2,206 minimally invasive, 8,037 retropubic and 463 perineal radical prostatectomies with no differences in baseline narcotic prescription use. Perineal and retropubic operations were associated with greater total morphine sulfate equivalent use than the minimally invasive operation. Perineal prostatectomy was associated with more narcotic refills than minimally invasive and retropubic prostatectomy (42.3% vs 20.2% and 28.9%, respectively, p <0.001). Median narcotic costs were lower for minimally invasive than for perineal and retropubic prostatectomy. On adjusted analysis perineal radical prostatectomy, younger age, baseline narcotic use and preferred provider organization health plan were associated with greater morphine sulfate equivalents and narcotic refills while minimally invasive surgery was associated with fewer refills and lower costs but not with total morphine sulfate equivalents. There was significant geographic variation in narcotic use and costs. CONCLUSIONS Postoperatively minimally invasive radical prostatectomy required fewer narcotic refills and had lower narcotic costs while perineal radical prostatectomy required the greatest amount of narcotics. However, minimally invasive vs retropubic radical prostatectomy morphine sulfate equivalent requirements did not differ on adjusted analysis. While our findings support the purported advantage of minimally invasive radical prostatectomy of less postoperative pain, confirmatory prospective studies with objective outcomes are needed.
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Affiliation(s)
- Keith J Kowalczyk
- Division of Urologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts 02130, USA.
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Eldefrawy A, Katkoori D, Abramowitz M, Soloway MS, Manoharan M. Active surveillance vs. treatment for low-risk prostate cancer: a cost comparison. Urol Oncol 2011; 31:576-80. [PMID: 21616691 DOI: 10.1016/j.urolonc.2011.04.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 04/13/2011] [Accepted: 04/17/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Radical prostatectomy (RP) and radiation therapy are standard curative approaches for low-risk prostate cancer (PC). Active surveillance (AS) is becoming an increasingly accepted management alternative for low-risk PC. Our aim is to compare the cumulative medical costs of treatment vs. AS. METHODS AND MATERIALS We collected data on the cumulative medical costs of open radical retropubic prostatectomy (RRP), robotic-assisted radical prostatectomy (RARP), external beam radiotherapy (EBRT), brachytherapy (BT), and AS at our institution. For physicians' reimbursements, Medicare values of our region were used to maintain uniformity. For inpatient costs other than reimbursements, we used the mean cost at our institution. The costs of RRP and RARP involve preoperative investigations, medical clearance, physicians' fees, inpatient costs, and pathologic examination of prostatectomy specimen and follow-up. The inpatient costs include the operating room, disposable equipment, anesthesia, post-anesthesia care, transfusion, and hospital stay. The cost of EBRT involves the cost of consultation, planning, simulation and treatment sessions, and follow-up. BT costs involved radiotherapy planning as well as inpatients costs. AS protocol involves regular visits, transrectal ultrasound guided biopsies, prostate specific antigen (PSA) testing. To evaluate the cost of treating complications, treatment after AS, and treatment for recurrence, we created a Markov model based on recent studies and our experience. RESULTS The cumulative costs of RRP are $9,732 (1 year), $10,360 (2 years), $12,209 (5 years), and $15,084 (10 years). While for RARP, the costs are $17,824 (1 year), $18,308 (2 years), $20,117 (5 years), and $22,762 (10 years). The costs of EBRT are $20,730 (1 year), $20,969 (2 years), $22,043 (5 years), and $23,953 (10 years). BT costs are $14,061 (1 year), $14,300 (2 years), $15,374 (5 years), and $17,284 (10 years). The costs of AS are $1,154 (1 year), $2,308 (2 years), $8,761 (5 years), and $13,116 (10 years). CONCLUSIONS The cumulative medical costs of RARP and EBRT are much higher than BT, RRP, and AS. AS is associated with a different cost distribution in which the initial cost is low and relatively higher cost of follow-up. Despite the higher follow-up cost, AS remains the most cost effective alternative for low-risk PC.
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Affiliation(s)
- Ahmed Eldefrawy
- Department of Urology, Miller School of Medicine, University of Miami, Miami, FL 33101, USA
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Current world literature. Curr Opin Urol 2011; 21:257-64. [PMID: 21455039 DOI: 10.1097/mou.0b013e3283462c0f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hohwü L, Borre M, Ehlers L, Venborg Pedersen K. A short-term cost-effectiveness study comparing robot-assisted laparoscopic and open retropubic radical prostatectomy. J Med Econ 2011; 14:403-9. [PMID: 21604962 DOI: 10.3111/13696998.2011.586621] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate cost effectiveness and cost utility comparing robot-assisted laparoscopic prostatectomy (RALP) versus retropubic radical prostatectomy (RRP). METHODS In a retrospective cohort study a total of 231 men between the age of 50 and 69 years and with clinically localised prostate cancer underwent radical prostatectomy (RP) at the Department of Urology, Aarhus University Hospital, Skejby from 1 January 2004 to 31 December 2007, were included. The RALP and RRP patients were matched 1:2 on the basis of age and the D'Amico Risk Classification of Prostate Cancer; 77 RALP and 154 RRP. An economic evaluation was made to estimate direct costs of the first postoperative year and an incremental cost-effectiveness ratio (ICER) per successful surgical treatment and per quality-adjusted life-year (QALY). A successful RP was defined as: no residual cancer (PSA <0.2 ng/ml, preserved urinary continence and erectile function. A one-way sensitivity analysis was made to investigate the impact of changing one variable at a time. RESULTS The ICER per extra successful treatment was €64,343 using RALP. For indirect costs, the ICER per extra successful treatment was €13,514 using RALP. The difference in effectiveness between RALP and RRP procedures was 7% in favour of RALP. In the present study no QALY was gained 1 year after RALP, however this result is uncertain due to a high degree of missing data. The sensitivity analysis did not change the results noticeably. LIMITATIONS The study was limited by the design resulting in a low percentage of information on the effect of medication for erectile dysfunction and only short-term quality of life was measured at 1 year postoperatively. CONCLUSION RALP was more effective and more costly. A way to improve the cost effectiveness may be to perform RALP at fewer high volume urology centres and utilise the full potential of each robot.
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Affiliation(s)
- Lena Hohwü
- Department of Urology, Aarhus University Hospital, Skejby, Aarhus, Denmark
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Bolenz C, Gupta A, Hotze T, Ho R, Cadeddu JA, Roehrborn CG, Lotan Y. Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer. Eur Urol 2009; 57:453-8. [PMID: 19931979 DOI: 10.1016/j.eururo.2009.11.008] [Citation(s) in RCA: 189] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 11/02/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Demand and utilization of minimally invasive approaches to radical prostatectomy have increased in recent years, but comparative studies on cost are lacking. OBJECTIVE To compare costs associated with robotic-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and open retropubic radical prostatectomy (RRP). DESIGN, SETTING, AND PARTICIPANTS The study included 643 consecutive patients who underwent radical prostatectomy (262 RALP, 220 LRP, and 161 RRP) between September 2003 and April 2008. MEASUREMENTS Direct and component costs were compared. Costs were adjusted for changes over the time of the study. RESULTS AND LIMITATIONS Disease characteristics (body mass index, preoperative prostate-specific antigen, prostate size, and Gleason sum score 8-10) were similar in the three groups. Nerve sparing was performed in 85% of RALP procedures, 96% of LRP procedures, and 90% of RRP procedures (p<0.001). Lymphadenectomy was more commonly performed in RRP (100%) compared to LRP (22%) and RALP (11%) (p<0.001). Mean length of hospital stay was higher for RRP than for LRP and RALP. The median direct cost was higher for RALP compared to LRP or RRP (RALP: $6752 [interquartile range (IQR): $6283-7369]; LRP: $5687 [IQR: $4941-5905]; RRP: $4437 [IQR: $3989-5141]; p<0.001). The main difference was in surgical supply cost (RALP: $2015; LRP: $725; RRP: $185) and operating room (OR) cost (RALP: $2798; LRP: $2453; RRP: $1611; p<0.001). When considering purchase and maintenance costs for the robot, the financial burden would increase by $2698 per patient, given an average of 126 cases per year. CONCLUSIONS RALP is associated with higher cost, predominantly due to increased surgical supply and OR costs. These costs may have a significant impact on overall cost of prostate cancer care.
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Affiliation(s)
- Christian Bolenz
- Department of Urology, University of Texas Southwestern Medical Center at Dallas, TX 75390-9110, USA
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