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Kuklinski D, Vogel J, Henschke C, Pross C, Geissler A. Robotic-assisted surgery for prostatectomy - does the diffusion of robotic systems contribute to treatment centralization and influence patients' hospital choice? HEALTH ECONOMICS REVIEW 2023; 13:29. [PMID: 37162648 PMCID: PMC10170785 DOI: 10.1186/s13561-023-00444-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 04/26/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Between 2008 and 2018, the share of robotic-assisted surgeries (RAS) for radical prostatectomies (RPEs) has increased from 3 to 46% in Germany. Firstly, we investigate if this diffusion of RAS has contributed to RPE treatment centralization. Secondly, we analyze if a hospital's use of an RAS system influenced patients' hospital choice. METHODS To analyze RPE treatment centralization, we use (bi-) annual hospital data from 2006 to 2018 for all German hospitals in a panel-data fixed effect model. For investigating RAS systems' influence on patients' hospital choice, we use patient level data of 4614 RPE patients treated in 2015. Employing a random utility choice model, we estimate the influence of RAS as well as specialization and quality on patients' marginal utilities and their according willingness to travel. RESULTS Despite a slight decrease in RPEs between 2006 and 2018, hospitals that invested in an RAS system could increase their case volumes significantly (+ 82% compared to hospitals that did not invest) contributing to treatment centralization. Moreover, patients are willing to travel longer for hospitals offering RAS (+ 22% than average travel time) and for specialization (+ 13% for certified prostate cancer treatment centers, + 9% for higher procedure volume). The influence of outcome quality and service quality on patients' hospital choice is insignificant or negligible. CONCLUSIONS In conclusion, centralization is partly driven by (very) high-volume hospitals' investment in RAS systems and patient preferences. While outcome quality might improve due to centralization and according specialization, evidence for a direct positive influence of RAS on RPE outcomes still is ambiguous. Patients have been voting with their feet, but research yet has to catch up.
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Affiliation(s)
- David Kuklinski
- Chair for Healthcare Management, School of Medicine, University of St. Gallen, St. Jakob-Strasse 21, 9000, St. Gallen, Switzerland
| | - Justus Vogel
- Chair for Healthcare Management, School of Medicine, University of St. Gallen, St. Jakob-Strasse 21, 9000, St. Gallen, Switzerland.
| | - Cornelia Henschke
- Department of Health Care Management, Berlin University of Technology, Berlin Centre of Health Economics Research, Strasse Des 17. Juni 135, 10623, Berlin, Germany
| | - Christoph Pross
- Department of Health Care Management, Berlin University of Technology, Strasse Des 17. Juni 135, 10623, Berlin, Germany
| | - Alexander Geissler
- Chair for Healthcare Management, School of Medicine, University of St. Gallen, St. Jakob-Strasse 21, 9000, St. Gallen, Switzerland
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Guijarro A, Castro A, Hernández V, de la Peña E, Sánchez-Rosendo L, Jiménez E, Pérez-Férnandez E, Llorente C. Population based study of morbidity and mortality rates associated to radical prostatectomy cases in Spain. Actas Urol Esp 2022; 46:619-628. [PMID: 36280035 DOI: 10.1016/j.acuroe.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/28/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION There is no population-based study that accounts for the number of radical prostatectomies (RP) carried out in Spain, nor regarding the morbidity and mortality of this intervention. Our objective is to study the morbidity and mortality of RP in Spain from 2011 to 2015 and to evaluate the geographic variation. MATERIAL AND METHODS We designed a retrospective observational study of all patients submitted to RP in Spain during five consecutive years (2011-2015). The data was extracted from the «Conjunto Mínimo Básico de Datos» (CMBD). We have evaluated geographic variations in terms of morbidity and hospital stay, and the impact of the mean annual surgical volume for each center on these variables. RESULTS Between 2011-2015, a total of 37,725 RPs were performed in 221 Spanish public hospitals. The mean age of the series was 63.9±3.23 years. Of all RPs, 50% were performed through an open approach, and 43.4% have been operated on in hospitals with <500 beds. We observed an important variability in the distribution of the cases operated on in the different regions. The regions that perform more RPs are Andalusia, Catalonia, Galicia, and Madrid. Our study shows a complication rate of 8.6%, with hemorrhage and the need for transfusion being the most frequent (5.3 and 4%, respectively). There are significant differences in bleeding rates and hospital stay among regions, which are maintained after adjusting for patient characteristics and type of hospital. When studying the annual surgical volume of each hospital, we find that the impact on the rate of hemorrhage or transfusion is linear; however, hospital stay remains stable at around 5 days from 60 RPs/year. CONCLUSIONS In national terms, morbidity and mortality rates after RP are comparable to those described in the literature. This study reveals a clear dispersion in the hospitals that carry out this intervention, showing clear differences in terms of morbidity and hospital stay between the different regions.
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Affiliation(s)
- A Guijarro
- Servicio de Urología, Hospital Universitario Fundación Alcorcón, Madrid, Spain.
| | - A Castro
- Servicio de Urología, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - V Hernández
- Servicio de Urología, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - E de la Peña
- Servicio de Urología, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - L Sánchez-Rosendo
- Servicio de Urología, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - E Jiménez
- Servicio de Urología, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - E Pérez-Férnandez
- Unidad de Investigación, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - C Llorente
- Servicio de Urología, Hospital Universitario Fundación Alcorcón, Madrid, Spain
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Guijarro A, Castro A, Hernández V, de la Peña E, Sánchez-Rosendo L, Jiménez E, Pérez-Férnandez E, Llorente C. Estudio poblacional de casuística y morbimortalidad de la prostatectomía radical en España. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Labban M, Dasgupta P, Song C, Becker R, Li Y, Kreaden US, Trinh QD. Cost-effectiveness of Robotic-Assisted Radical Prostatectomy for Localized Prostate Cancer in the UK. JAMA Netw Open 2022; 5:e225740. [PMID: 35377424 PMCID: PMC8980901 DOI: 10.1001/jamanetworkopen.2022.5740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The cost-effectiveness of different surgical techniques for radical prostatectomy remains a subject of debate. Emergence of recent critical clinical data and changes in surgical equipment costs due to their shared use by different clinical specialties necessitate an updated cost-effectiveness analysis in a centralized, largely government-funded health care system such as the UK National Health Service (NHS). OBJECTIVE To compare robotic-assisted radical prostatectomy (RARP) with open radical prostatectomy (ORP) and laparoscopic-assisted radical prostatectomy (LRP) using contemporary data on clinical outcomes, costs, and surgical volumes in the UK. DESIGN, SETTING, AND PARTICIPANTS This economic analysis used a Markov model developed to compare the cost-effectiveness of RARP, LRP, and ORP to treat localized prostate cancer. The model was constructed from the perspective of the UK NHS. The model simulated 65-year-old men who underwent radical prostatectomy for localized prostate cancer and were followed up for a 10-year period. Data were analyzed from May 1, 2020, to July 31, 2021. EXPOSURES Robotic-assisted radical prostatectomy, LRP, and ORP. MAIN OUTCOMES AND MEASURES Quality-adjusted life-years (QALYs), costs (direct medical costs and costs outside the NHS), and incremental cost-effectiveness ratios (ICERs). RESULTS Compared with LRP, RARP cost £1785 (US $2350) less and had 0.24 more QALYs gained; thus, RARP was a dominant option compared with LRP. Compared with ORP, RARP had 0.12 more QALYs gained but cost £526 (US $693) more during the 10-year time frame, resulting in an ICER of £4293 (US $5653)/QALY. Because the ICER was below the £30 000 (US $39 503) willingness-to-pay threshold, RARP was more cost-effective than ORP in the UK. The most sensitive variable influencing the cost-effectiveness of RARP was the lower risk of biochemical recurrence (BCR). Scenario analysis indicated RARP would remain more cost-effective than ORP as long as the BCR hazard ratios comparing RARP vs ORP were less than 0.99. CONCLUSIONS AND RELEVANCE These findings suggest that in the UK, RARP has an ICER lower than the willingness-to-pay threshold and thus is likely a cost-effective surgical treatment option for patients with localized prostate cancer compared with ORP and LRP. The results were mainly driven by the lower risk of BCR for RARP. These findings may differ in other health care settings where different thresholds and costs may apply.
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Affiliation(s)
- Muhieddine Labban
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Prokar Dasgupta
- MRC (Medical Research Council) Centre for Transplantation, Guy’s Hospital Campus, King’s College London, King’s Health Partners, London, United Kingdom
| | - Chao Song
- Global Health Economics and Outcome Research, Intuitive Surgical Inc, Atlanta, Georgia
| | | | - Yanli Li
- Global Health Economics and Outcome Research, Intuitive Surgical Inc, Sunnyvale, California
| | - Usha Seshadri Kreaden
- Biostatistics & Global Evidence Management, Intuitive Surgical Inc, Sunnyvale, California
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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John JB, Pascoe J, Fowler S, Walton T, Johnson M, Aning J, Challacombe B, Bufacchi R, Dickinson AJ, McGrath JS. A ‘real-world’ standard for radical prostatectomy: Analysis of the British Association of Urological Surgeons Complex Operations Reports, 2016–2018. JOURNAL OF CLINICAL UROLOGY 2022. [DOI: 10.1177/20514158211063964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To produce comprehensive and detailed benchmarking data allowing surgeons and patients to compare practice against, by using all recorded radical prostatectomies across a 3-year period in England. Patients and methods: The British Association of Urological Surgeons (BAUS) manages the radical prostatectomy (RP) Complex Operations Database. Surgical departments upload data which they can review and amend before lockdown and data cleansing. Analysis of 2016–2018 data held on the BAUS Complex Operations Database was performed for 21,973 patients undergoing RP in England, producing procedure-specific benchmarking data. General linear models were used to assess differences in patient selection between different operative modalities. Analysis involved assessment of case selection, operative decisions and outcomes, case volume and pathological outcomes. Results: Using national Hospital Episode Statistics, the BAUS RP dataset was estimated 91% complete. Median age was 65 and 96% were American Society of Anesthesiologists (ASA) Grades 1–2. Over 80% had RP performed in a high-volume centre (>100 annual RPs) and 88% had Gleason grade group (GGG) ⩾2 disease on biopsy. Robotic-assisted RP (RARP), laparoscopic RP (LRP) and open RP (ORP) were performed in 85%, 7.2% and 7.7% of cases, respectively. Patient and disease characteristics differed across surgical modalities. Transfusion rates were 0.14% in RARP, 0.38% in LRP and 1.8% in ORP. Increased positive surgical margin (PSM) rates were observed with increasing prostate-specific antigen (PSA), GGG and T-stage, with comparable PSM rates across surgical modalities. Lymph node dissection was performed more commonly in high-risk cases (cT3, PSA > 20, GGG ⩾ 4). Pathological upstaging was common. Median length of stay was 1, 2 and 3 days for RARP, LRP and ORP, respectively. ORP had Clavien–Dindo complications ⩾3 and unplanned hospital readmissions. Conclusion: This analysis has enabled the first set of UK national RP standards to be produced allowing procedure, patient and disease-specific national, centre and individual comparisons. The present degree of service centralisation, operative modalities, and specific aspects of surgical practice can be observed. Level of evidence: 2b
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Affiliation(s)
| | - John Pascoe
- Royal Devon and Exeter NHS Foundation Trust, UK
| | - Sarah Fowler
- The British Association of Urological Surgeons, UK
| | | | - Mark Johnson
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK
| | | | | | - Rory Bufacchi
- Italian Institute of Technology, Italy
- Department of Neuroscience, Physiology and Pharmacology, University College London (UCL), UK
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Sehmbi AS, Sridhar AN, Sahadevan K, Rai BP, Nwangwu P, Mohammed A, Freeman A, Mottrie A, Olsson MJ, Wiklund NP, Nathan MS, Briggs TP, Kelly JD, Rajan P. Early outcomes of robot-assisted radical prostatectomy following completion of a structured training curriculum: a single surgeon cohort study. JOURNAL OF CLINICAL UROLOGY 2021. [DOI: 10.1177/2051415820938176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Technical skills in robot-assisted radical prostatectomy (RARP) are not mandated by the Intercollegiate Surgical Curriculum Programme. The European Association of Urology Robotic Urology Section (ERUS) developed a structured curriculum; however, surgeons’ outcomes data from subsequent independent practice are limited. We describe the initial post-ERUS curriculum RARP outcomes for a United Kingdom (UK)-based surgeon. Patients and methods: This was a prospective single surgeon cohort study of 272 patients who underwent RARP between February 2016 and October 2019 in a high-volume UK centre and who were followed up at approximately 3 and 12 months. Positive surgical margins (PSMs), and 3- and 12-month continence rates were obtained and used to generate learning curves, with point of plateau estimated from logarithmic trendlines. Results: Overall (⩾3 mm) PSM rate for pT2 was 14.9% (5.4%) and pT3 was 22.6% (3.2%). Where data were available, 70.5% (of n=251) and 95.5% (of n=154) patients achieved social continence (0–1 pads) at 3 and 12 months, respectively. PSM and 3-month social continence rates plateaued at ~175 and ~100 cases, respectively. Conclusion: Following completion of the ERUS RARP curriculum, early oncological and functional outcomes consistent with published standards are rapidly achievable in independent practice. These data exemplify the potential value of a standardised RARP training curriculum to mitigate possible compromises in outcomes. Level of evidence: IV
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Affiliation(s)
- Arjan S Sehmbi
- Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Cancer Research UK Barts Centre, Queen Mary University of London, UK
| | - Ashwin N Sridhar
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | | | - Bhavan P Rai
- Department of Urology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
| | - Pamela Nwangwu
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - Anna Mohammed
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, UK
| | - Alexandre Mottrie
- ORSI Academy, Melle, Belgium
- Division of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium
| | - Mats J Olsson
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden
| | - N Peter Wiklund
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden
- Department of Urology, Icahn School of Medicine at Mount Sinai Health System, New York, USA
| | - M Senthil Nathan
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - Timothy P Briggs
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - John D Kelly
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
- Division of Surgery and Interventional Sciences, University College London, UK
| | - Prabhakar Rajan
- Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Cancer Research UK Barts Centre, Queen Mary University of London, UK
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
- Department of Urology, Barts Health NHS Trust, London, UK
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7
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Aning JJ, Parry MG, van der Meulen J, Fowler S, Payne H, McGrath JS, Challacombe B, Clarke NW. How reliable are surgeon-reported data? A comparison of the British Association of Urological Surgeons radical prostatectomy audit with the National Prostate Cancer Audit Hospital Episode Statistics-linked database. BJU Int 2021; 128:482-489. [PMID: 33752249 DOI: 10.1111/bju.15399] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 03/04/2021] [Accepted: 03/16/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To evaluate the accuracy and completeness of surgeon-reported radical prostatectomy outcome data across a national health system by comparison with a national dataset gathered independently from clinicians directly involved in patient care. PATIENTS AND METHODS Data submitted by surgeons to the British Association of Urological Surgeons (BAUS) radical prostatectomy audit for all men undergoing radical prostatectomy between 2015 and 2016 were assessed by cross linkage to the National Prostate Cancer Audit (NPCA) database. Specific data items collected in both databases were selected for comparison analysis. Data completeness and agreement were assessed by percentages and Cohen's kappa statistic. RESULTS Data from 4707 men in the BAUS and NPCA databases were matched for comparison. Compared with the NPCA, dataset completeness was higher in the BAUS dataset for type of nerve-sparing procedure (92% vs 42%) and postoperative margin status (89% vs 48%) but lower for readmission (87% vs 100%) and Charlson score (80% vs 100%). For all other variables assessed completeness was comparable. Agreement and data reliability were high for most variables. However, despite good agreement, the inter-cohort reliability was poor for readmission, M stage and Charlson score (κ < 0.30). CONCLUSIONS For the first time in urology we show that surgeon-reported data from the BAUS radical prostatectomy audit can reliably be used to benchmark peri-operative radical prostatectomy outcomes. For comorbidity data, to assist with risk analysis, and longer-term outcomes, NPCA routinely collected data provide a more comprehensive source.
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Affiliation(s)
- Jonathan J Aning
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Matthew G Parry
- London School of Hygiene and Tropical Medicine, London, UK.,Royal College of Surgeons of England, London, UK
| | | | - Sarah Fowler
- British Association of Urological Surgeons, London, UK
| | | | - John S McGrath
- Exeter Surgical Health Services Research Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Ben Challacombe
- Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Noel W Clarke
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
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Beech B, Follett G, Ghosh S, Rudzinski JK, McLarty R, Haines T, Dean N, Tong S, Fairey AS. Are urologic surgeons performing robot-assisted radical prostatectomy at the University of Alberta meeting surgical quality performance benchmarks? The PROCURE-02 quality assurance study. Can Urol Assoc J 2019; 14:E369-E372. [PMID: 32209214 DOI: 10.5489/cuaj.6292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Robot-assisted radical prostatectomy (RARP) is a standard of care primary treatment for men with clinically localized prostate cancer (CLPC). The 2010 Canadian Urological Association (CUA) consensus guideline examining surgical quality performance for radical prostatectomy suggested benchmarks for surgical performance. To date, no study has examined whether Canadian surgeons are achieving these benchmarks. We determined the proportion of University of Alberta (UA) urologic surgeons achieving the CUA surgical quality performance outcome (SQPO) benchmarks. METHODS A retrospective quality assurance analysis of prospectively collected data from the PROstate Cancer Urosurgery Repository of Edmonton (PROCURE) was performed. Men who underwent RARP for CLPC between September 2007 and May 2018 by one of seven surgeons were analyzed. SQPO were an unadjusted pT2-R1 resection rate <25%, blood transfusion rate <10%, rectal injury rate <1%, and 90-day mortality rate <1%. Descriptive statistics were used to determine the proportion of surgeons achieving the benchmarks. RESULTS Data were evaluable for 2821 men. Seven of seven (100%) surgeons achieved a blood transfusion rate <10%, rectal injury rate <1%, and 90-day mortality rate <1%. However, only six of seven surgeons achieved an unadjusted pT2-R1 resection rate <25%; one surgeon had an unadjusted pT2-R1 resection rate of 27.9%. Limitations include the lack of centralized pathology review for surgical margin status by a dedicated genitourinary pathologist. CONCLUSIONS UA surgeons are achieving the CUA SQPO benchmarks for blood transfusion, rectal injury, and perioperative mortality. However, not all UA urologists are achieving a pT2-R1 resection rate <25%. Surgical quality performance initiatives designed to improve cancer control may be warranted.
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Affiliation(s)
- Ben Beech
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Graeme Follett
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Sunita Ghosh
- Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Jan K Rudzinski
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Ryan McLarty
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Trevor Haines
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Nick Dean
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Steve Tong
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Adrian S Fairey
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
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Bullock N, Simpkin A, Fowler S, Varma M, Kynaston H, Narahari K. Pathological upgrading in prostate cancer treated with surgery in the United Kingdom: trends and risk factors from the British Association of Urological Surgeons Radical Prostatectomy Registry. BMC Urol 2019; 19:94. [PMID: 31623595 PMCID: PMC6798468 DOI: 10.1186/s12894-019-0526-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Accurate grading at the time of diagnosis if fundamental to risk stratification and treatment decision making in patients with prostate cancer. Whilst previous studies have demonstrated significant pathological upgrading and downgrading following radical prostatectomy (RP), these were based on historical cohorts and do not reflect contemporary patient selection and management practices. The aim of this national, multicentre observational study was to characterise contemporary rates and risk factors for pathological upgrading after RP in the United Kingdom (UK). METHODS All RP entries on the British Association of Urological Surgeons (BAUS) Radical Prostatectomy Registry database of prospectively entered cases undertaken between January 2011 and December 2016 were extracted. Those patients with full preoperative PSA, clinical stage, needle biopsy and subsequent RP pathological grade information were included. Upgrade was defined as any increase in Gleason grade from initial needle biopsy to pathological assessment of the entire surgical specimen. Statistical analysis and multivariate logistic regression were undertaken using R version 3.5 (R Foundation for Statistical Computing, Vienna, Austria). RESULTS A total of 17,598 patients met full inclusion criteria. Absolute concordance between initial biopsy and pathological grade was 58.9% (n = 10,364), whilst upgrade and downgrade rates were 25.5% (n = 4489) and 15.6% (n = 2745) respectively. Upgrade rate was highest in those with D'Amico low risk compared with intermediate and high-risk disease (55.7% versus 19.1 and 24.3% respectively, P < 0.001). Although rates varied between year of surgery and geographical regions, these differences were not significant after adjusting for other preoperative diagnostic variables using multivariate logistic regression. CONCLUSIONS Pathological upgrading after RP in the UK is lower than expected when compared with other large contemporary series, despite operating on a generally higher risk patient cohort. As new diagnostic techniques that may reduce rates of pathological upgrading become more widely utilised, this study provides an important benchmark against which to measure future performance.
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Affiliation(s)
- Nicholas Bullock
- Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, UK
- Department of Urology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Andrew Simpkin
- School of Mathematics, Statistics and Applied Mathematics, National University of Ireland, Galway, Ireland
| | - Sarah Fowler
- British Association of Urological Surgeons, London, UK
| | - Murali Varma
- Department of Cellular Pathology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Howard Kynaston
- Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, UK
- Department of Urology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Krishna Narahari
- Department of Urology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
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Payne SR, Fowler S, Mundy AR. Analysis of a 7-year national online audit of the management of open reconstructive urethral surgery in men. BJU Int 2019; 125:304-313. [PMID: 31419368 DOI: 10.1111/bju.14897] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To conduct an audit of the management of urethral pathology in men presenting for reconstructive urethral surgery in the UK. METHODS Between 1 June 2010 and 31 May 2017, data on men presenting with urethral pathologies requiring reconstruction were entered onto a secure online data platform. Surgeon-entered information was collected in 95 fields regarding the stricture aetiology, prior management, mode of presentation, type of surgery and outcomes, with a potential 283 variable responses in the 95 fields. Data were analysed to compare UK practice with that reported in the contemporary literature and with guidelines. RESULTS Data on 4809 men were entered by 39 centres and 50 surgeons. Field completeness was 70.7%, 74.3% and 53.7% for preoperative, operative and follow-up data, respectively. Referral for stricture reconstruction frequently followed two prior endoscopic procedures and the stricture was not always assessed anatomically before surgery. Urinary retention was a common symptom in men awaiting reconstruction. Short unifocal strictures of the anterior urethra were the commonest reason for referral, whilst lichen sclerosus and hypospadias generated a significant volume of revisional stricture surgery. Lower numbers of very complex interventions are required for the management of posterior urethral pathology. Although precise criteria for determining success are not clear, management of urethral reconstruction in the UK was found to have a low risk of Clavien-Dindo grade 3 or higher complications, and was associated with outcomes similar to those reported in contemporary series except in the management of posterior urethral fistulae. CONCLUSIONS Online databases can provide volume data on the management of reconstructive urethral surgery across a multiplicity of centres in one country. They can also indicate compliance with accepted standards of, and expected outcomes from, this tertiary practice.
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Affiliation(s)
| | | | - Anthony R Mundy
- University College London Hospitals NHS Foundation Trust, London, UK
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Aning JJ, Reilly GS, Fowler S, Challacombe B, McGrath JS, Sooriakumaran P. Perioperative and oncological outcomes of radical prostatectomy for high-risk prostate cancer in the UK: an analysis of surgeon-reported data. BJU Int 2019; 124:441-448. [DOI: 10.1111/bju.14687] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jonathan J. Aning
- Bristol Urological Institute; North Bristol NHS Trust; Southmead Hospital; Westbury-on-Trym, Bristol UK
| | - Gavin S. Reilly
- Centre for Statistics in Medicine; Botnar Research Centre; University of Oxford; Oxford UK
| | - Sarah Fowler
- British Association of Urological Surgeons; London UK
| | - Ben Challacombe
- King's Health Partners; Guys Hospital; King's College London; London UK
| | - John S. McGrath
- Exeter Surgical Health Services Research Unit; Royal Devon and Exeter Hospital; Exeter UK
| | - Prasanna Sooriakumaran
- University College London Hospital NHS Foundation Trust; London UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
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Holmer C, Kreis ME. Systematic review of robotic low anterior resection for rectal cancer. Surg Endosc 2017; 32:569-581. [DOI: 10.1007/s00464-017-5978-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/05/2017] [Indexed: 01/30/2023]
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Sachdeva A, Veeratterapillay R, Voysey A, Kelly K, Johnson MI, Aning J, Soomro NA. Positive surgical margins and biochemical recurrence following minimally-invasive radical prostatectomy - An analysis of outcomes from a UK tertiary referral centre. BMC Urol 2017; 17:91. [PMID: 28969608 PMCID: PMC5625596 DOI: 10.1186/s12894-017-0262-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/24/2017] [Indexed: 12/05/2022] Open
Abstract
Background Positive surgical margins are a strong prognostic marker of disease outcome following radical prostatectomy, though prior evidence is largely from a PSA-screened population. We therefore aim to evaluate the biochemical recurrence in men with positive surgical margins (PSM) after minimally-invasive radical prostatectomy (MIRP) in a UK tertiary centre. Methods Retrospective study of men undergoing laparoscopic or robotic-assisted radical prostatectomy between 2002 and 2014. Men with positive surgical margins (PSM) were identified and their biochemical recurrence (BCR) rate compared with men without PSM. The primary outcome measures were BCR rates and time to BCR. Cox regression was used to estimate adjusted hazard ratios for biochemical recurrence rate (BCR), accounting for potential confounders. Results Five hundred ninety-two men were included for analysis. Pre-operative D’Amico risk stratification showed 37.5%, 53.3% and 9.3% of patients in the low, intermediate and high-risk groups, respectively. On final pathological analysis, the proportion of patients with local staging pT2, pT3a and pT3b was 68.8%, 25.2% and 6.1% respectively. Overall positive margin rate was 30.6%. On multivariate analysis, the only pre-operative factor associated with PSM was age >65years. Patients with PSM were more likely to have higher tumour volume and more advanced pathological local stage. The BCR rate was 10.7% in margin-positive patients and 5.1% in margin-negative patients, at median 4.4-year follow-up. Upon multivariate analysis, high pre-operative PSA and high Gleason group were the only significant predictors of BCR (P<0.05). Conclusions In comparison to patients with negative surgical margins, those with PSM do not translate into worse medium-term oncological outcomes in the majority of cases amongst our cohort. We found that high pre-operative PSA and high Gleason group were the only significant predictors of BCR. Electronic supplementary material The online version of this article (10.1186/s12894-017-0262-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ashwin Sachdeva
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK.,Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, UK
| | - Rajan Veeratterapillay
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Antonia Voysey
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Katherine Kelly
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Mark I Johnson
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Jonathan Aning
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Naeem A Soomro
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK. .,Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, UK.
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Cui HW, Turney BW, Griffiths J. The Preoperative Assessment and Optimization of Patients Undergoing Major Urological Surgery. Curr Urol Rep 2017; 18:54. [PMID: 28589402 PMCID: PMC5486597 DOI: 10.1007/s11934-017-0701-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Improving patient outcomes from major urological surgery requires not only advancement in surgical technique and technology, but also the practice of patient-centered, multidisciplinary, and integrated medical care of these patients from the moment of contemplation of surgery until full recovery. This review examines the evidence for recent developments in preoperative assessment and optimization that is of relevance to major urological surgery. RECENT FINDINGS Current perioperative medicine recommendations aim to improve the short-term safety and long-term effectiveness of surgical treatments by the delivery of multidisciplinary integrated medical care. New strategies to deliver this aim include preoperative risk stratification using a frailty index and cardiopulmonary exercise testing for patients undergoing intra-abdominal surgery (including radical cystectomy), preoperative management of iron deficiency and anemia, and preoperative exercise intervention. Proof of the utility and validity for improving surgical outcomes through advances in preoperative care is still evolving. Evidence-based developments in this field are likely to benefit patients undergoing major urological surgery, but further research targeted at high-risk patients undergoing specific urological operations is required.
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Affiliation(s)
- Helen W. Cui
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Oxford, UK
| | - Benjamin W. Turney
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Oxford, UK
| | - John Griffiths
- Nuffield Department of Anaesthetics, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Oxford, OX3 9DU UK
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Surgical method influences specimen margins and biochemical recurrence during radical prostatectomy for high-risk prostate cancer: a systematic review and meta-analysis. World J Urol 2017; 35:1481-1488. [DOI: 10.1007/s00345-017-2021-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/06/2017] [Indexed: 12/21/2022] Open
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High volume is the key for improving in-hospital outcomes after radical prostatectomy: a total population analysis in Germany from 2006 to 2013. World J Urol 2016; 35:1045-1053. [DOI: 10.1007/s00345-016-1982-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/30/2016] [Indexed: 02/07/2023] Open
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National trends and differences in morbidity among surgical approaches for radical prostatectomy in Germany. World J Urol 2016; 34:1515-1520. [DOI: 10.1007/s00345-016-1813-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/16/2016] [Indexed: 10/22/2022] Open
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Recovery of Baseline Erectile Function in Men Following Radical Prostatectomy for High-Risk Prostate Cancer: A Prospective Analysis Using Validated Measures. J Sex Med 2016; 13:435-43. [DOI: 10.1016/j.jsxm.2016.01.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 01/09/2016] [Accepted: 01/12/2016] [Indexed: 11/19/2022]
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Novara G, Ficarra V, Zattoni F, Fedeli U. Recourse to radical prostatectomy and associated short-term outcomes in Italy: a country-wide study over the last decade. BJU Int 2015; 116:862-7. [DOI: 10.1111/bju.13000] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Giacomo Novara
- Department of Surgery, Oncology, and Gastroenterology; Urology Clinic; University of Padova; Padova Italy
| | - Vincenzo Ficarra
- Department of Experimental and Clinical Medical Sciences; Urologic Clinic; University of Udine; Udine Italy
| | - Filiberto Zattoni
- Department of Surgery, Oncology, and Gastroenterology; Urology Clinic; University of Padova; Padova Italy
| | - Ugo Fedeli
- Epidemiological Department; Veneto Region Italy
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Dirkmann D, Groeben H, Farhan H, Stahl DL, Eikermann M. Effects of parecoxib on analgesia benefit and blood loss following open prostatectomy: a multicentre randomized trial. BMC Anesthesiol 2015; 15:31. [PMID: 25767411 PMCID: PMC4357198 DOI: 10.1186/s12871-015-0015-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 02/24/2015] [Indexed: 11/23/2022] Open
Abstract
Background This multi-centre, prospective, randomized, double-blind, placebo-controlled study was designed to test the hypotheses that parecoxib improves patients’ postoperative analgesia without increasing surgical blood loss following radical open prostatectomy. Methods 105 patients (64 ± 7 years old) were randomized to receive either parecoxib or placebo with concurrent morphine patient controlled analgesia. Cumulative opioid consumption (primary objective) and the overall benefit of analgesia score (OBAS), the modified brief pain inventory short form (m-BPI-sf), the opioid-related symptom distress scale (OR-SDS), and perioperative blood loss (secondary objectives) were assessed. Results In each group 48 patients received the study medication for 48 hours postoperatively. Parecoxib significantly reduced cumulative opioid consumption by 24% (43 ± 24.1 mg versus 57 ± 28 mg, mean ± SD, p=0.02), translating into improved benefit of analgesia (OBAS: 2(0/4) versus 3(1/5.25), p=0.01), pain severity (m-BPI-sf: 1(1/2) versus 2(2/3), p < 0.01) and pain interference (m-BPI-sf: 1(0/1) versus 1(1/3), p=0.001), as well as reduced opioid-related side effects (OR-SDS score: 0.3(0.075/0.51) versus 0.4(0.2/0.83), p=0.03). Blood loss was significantly higher at 24 hours following surgery in the parecoxib group (4.3 g⋅dL−1 (3.6/4.9) versus (3.2 g⋅dL−1 (2.4/4.95), p=0.02). Conclusions Following major abdominal surgery, parecoxib significantly improves patients’ perceived analgesia. Parecoxib may however increase perioperative blood loss. Further trials are needed to evaluate the effects of selective cyclooxygenase-2 inhibitors on blood loss. Trial registration ClinicalTrials.gov Identifier: NCT00346268
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Affiliation(s)
- Daniel Dirkmann
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Universitätsklinikum Essen, Hufelandstrasse 55, Essen, D-45144 Germany
| | - Harald Groeben
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Kliniken Essen Mitte, Henricistrasse 92, Essen, 45136 Germany
| | - Hassan Farhan
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | - David L Stahl
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | - Matthias Eikermann
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Universitätsklinikum Essen, Hufelandstrasse 55, Essen, D-45144 Germany ; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
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