Robotic prostatectomy is associated with increased patient travel and treatment delay

Disparities in access to robotic technology and perioperative outcomes among patients treated with radical prostatectomy

BACKGROUND

Most radical prostatectomies are completed with robotic assistance. While studies have previously evaluated perioperative outcomes of robot-assisted radical prostatectomy (RARP), this study investigates disparities in access and clinical outcomes of RARP.

STUDY DESIGN

The National Cancer Database (NCDB) was used to identify patients who received radical prostatectomy for cancer between 2010 and 2017 with outcomes through 2018. RARP was compared to open radical prostatectomy (ORP). Odds of receiving RARP were evaluated while adjusting for covariates. Overall survival was evaluated using a propensity-score matched cohort.

RESULTS

Overall, 354 752 patients were included with 297 676 (83.9%) receiving RARP. Patients who were non-Hispanic Black (82.8%) or Hispanic (81.3%) had lower rates of RARP than non-Hispanic White (84.0%) or Asian patients (87.7%, p < 0.001). Medicaid or uninsured patients were less likely to receive RARP (75.5%) compared to patients with Medicare or private insurance (84.4%, p < 0.001). Medicaid or uninsured status was associated with decreased odds of RARP in adjusted multivariable analysis (OR 0.61, 95% CI 0.49-0.76). RARP was associated with decreased perioperative mortality and improved overall survival compared to ORP.

CONCLUSION

Patients who were underinsured were less likely to receive RARP. Improved access to RARP may lead to decreased disparities in perioperative outcomes for prostate cancer.

Leveraging 5G technology for robotic surgery and cancer care

Background

The field of robotic surgery has seen significant advancements in the past few years and it has been adopted in many large hospitals in the United States and worldwide as a standard for various procedures in recent years. However, the location of many hospitals in urban areas and a lack of surgical expertise in the rural areas could lead to increased travel time and treatment delays for patients in need of robotic surgical management, including cancer patients. The fifth generation (5G) networks have been deployed by various telecom companies in multiple countries worldwide. Our aim is to update the readers about the novel technology and the current scenario of surgical procedures performed using 5G technology. In this article, we also discuss how the technology could aid cancer patients requiring surgical management, the future perspectives, the potential challenges, and the limitations, which would need to overcome prior to widespread real‐life use of the technology for cancer care.

Recent findings

The expansion of 5G technology has enabled some countries to conduct remote surgical procedures, tele‐mentored and real‐time interactive procedures on animal models, cadavers, and humans, demonstrating that 5G networks could offer a potential solution to previously experienced latency and reliability hurdles during the remote surgeries performed in the 2000s.

Conclusion

New technological advancements could serve as a ground for emerging novel therapeutic applications. While limitations and challenges related to the 5G infrastructure, cost, compatibility, and security exist; researching to overcome the limitations and comprehend the potential benefits of integrating the technology into practice would be imminent before widespread clinical use. Remote and tele‐mentored 5G‐powered procedures could offer a new tool in improving the care of patients requiring robotic surgical management such as prostate cancer patients.

Population demographics in geographic proximity to hospitals with robotic platforms do not correlate with disparities in access to robotic surgery

BACKGROUND

Disparities in access to robotic surgery have been shown on the local, regional, and national level. This study aims to see if the location of hospitals with robotic platforms (HWR) correlates with population trends to explain the disparity in access to robotic surgery.

METHODS

Hospitals with da Vinci surgical systems were identified by compiling data from the publicly available da Vinci surgeon locator website. Demographic, and economic data were compiled. Multivariate logistic regression and place-based analysis were used to determine population characteristics associated with geographic proximity to HWR.

RESULTS

The United States has 1971 HWR (5.93 hospitals with robots per 1 million people). The states with the most HWR are Texas (203), California (175), and Florida (162). Multivariate logistic regression analysis of Texas counties determined population (OR 1.97, 95% CI 1.40-3.38) education level (OR 1.64, 95% CI 1.07-3.21), and urban designation (OR 1.15, 95% CI 1.05-1.31) remained significantly associated with HWR. When applied to a national level, population remained associated with higher numbers of HWR (R = 0.945), however level of education and urbanization were not.

CONCLUSIONS

Based on this study of population-level data, disparities in access to robotic surgery seen in prior literature cannot be explained exclusively by sociodemographic factors related to the geographic proximity of HWR. This suggests other biases are involved in the lack of robotic procedures performed among minority and underprivileged populations.

The Impact of Geographic Location on Saskatchewan Prostate Cancer Patient Treatment Choices: A Multilevel and Spatial Analysis

OBJECTIVE

The purpose of this study was to estimate the relationship between remoteness and the initial chosen treatment (active surveillance/watchful waiting (AS/WW), radiation therapy (RT), surgery, chemotherapy (CT), or hormonal therapy (HT) for prostate cancer (PCa).

METHODS

This study built 2 multilevel generalized linear models via a binomial link for each treatment type (one with only covariates and one with 2 additional study variables to the covariate model). The study also used cluster analysis using the Global and local Moran's I spatial statistics to find any complementary results to the above models.

RESULTS

This study found that patients living in the rural areas have lower odds (OR = 0.59; 95% CI, 0.45-0.77; P < .001) of having surgery compared to patients living in the greater urban areas. Among patients whose closest PCa assessment center is Regina, patients living in the greater urban areas have higher odds (OR = 1.66; 95% CI, 1.03-2.68; P = .039) of choosing RT compared to patients living in the rural areas. There was no statistically significant effect of remoteness on whether one chose HT or AS/WW.

CONCLUSIONS

There are regional disparities to PCa treatment utilization. Living in rural areas affects choosing surgery and, in certain localized geographical regions, affects choosing RT. For non-curative treatments (ie, AS/WW and HT), we did not find any association with geographical remoteness.

Treatment Facility Volume and Survival in Patients with Advanced Prostate Cancer

BACKGROUND

Despite improvements in medical management of advanced prostate cancer (aPC), it continues to be a leading cause of cancer death in men. Contemporary management of men with aPC is complex and requires resources to be more readily available at high-volume facilities.

OBJECTIVE

To determine the relationship between facility volume and survival in men with aPC.

DESIGN, SETTING, AND PARTICIPANTS

The National Cancer Database (NCDB) was queried from 2004 to 2013 for aPC, defined as T4, N+, or M+ disease, identifying 64815 patients. Six predefined patient cohorts were evaluated. Cohort "A" included all patients with aPC. "B" cohorts included only M0 patients. "C" cohorts included only M1 patients. Facilities were divided into quartiles based on median treatment volume (patients/yr).

INTERVENTION

Diagnosis and management of aPC at an NCDB-reporting facility.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Overall survival (OS) was assessed as a function of facility volume. Multivariable Cox regression models were fitted. Cox regressions using natural cubic splines were used to test for nonlinear relationships between volume and OS.

RESULTS AND LIMITATIONS

OS improved as facility volume increased (top quartile vs bottom quartile, hazard ratio 0.82, 95% confidence interval 0.77-0.88, p<0.001) and was consistent across patient cohorts. Spline models demonstrate a continuous decrease in hazard of death as volume increases. Limitations include the retrospective analysis and a lack of precise treatment information.

CONCLUSIONS

In this retrospective analysis of nearly 65000 men who presented with aPC, we demonstrate an association between higher facility volume and improvements in OS. This OS advantage persisted with similar magnitudes of effect after narrowing the cohorts by disease and treatment characteristics.

PATIENT SUMMARY

In this retrospective review of the National Cancer Database, we analyzed the association between treatment facility volume and survival in men who are diagnosed with advanced prostate cancer. We found that survival improved as volume increased, indicating a possible imbalance of resources and expertise that favors higher-volume facilities.

Enhanced Recovery After Surgery Protocols in Major Urologic Surgery

The purpose of the review

The analysis of the components of enhanced recovery after surgery (ERAS) protocols in urologic surgery.

Recent findings

ERAS protocols has been studied for over 20 years in different surgical procedures, mostly in colorectal surgery. The concept of improving patient care and reducing postoperative complications was also applied to major urologic surgery and especially procedure of radical cystectomy. This procedure is technically challenging, due to a major surgical resection and high postoperative complication rate that may reach 65%. Several clinical pathways were introduced to improve perioperative course and reduce the length of hospital stay. These protocols differ from ERAS modalities in other surgeries. The reasons for this are longer operative time, increased risk of perioperative transfusion and infection, and urinary diversion achieved using transposed intestinal segments. Previous studies in this area analyzed the need for mechanical bowel preparation, postoperative nasogastric tube decompression, as well as the duration of urinary drainage. Furthermore, the attention has also been drawn to perioperative fluid optimization, pain management, and bowel function.

Summary

Notwithstanding partial resemblance between the pathways in major urologic surgery and other pelvic surgeries, there are still scarce guidelines for ERAS protocols in urology, which is why further studies should assess the importance of preoperative medical optimization, implementation of thoracic epidural anesthesia and analgesia, and perioperative nutritional management.

Does surgical delay for radical prostatectomy affect patient pathological outcome? A retrospective analysis from a Canadian cohort

INTRODUCTION

We sought to assess the impact of surgical wait time (SWT) to robot-assisted radical prostatectomy (RARP) on final pathological outcome.

METHODS

A retrospective review of RARP patient records operated between 2006 and 2015 was conducted. SWT was defined as period from prostate biopsy to surgery. Primary outcome was the impact on postoperative Cancer of the Prostate Risk Assessment (CAPRA-S) score. Patients were stratified according to D'Amico risk categories. Univariate analysis (UVA) and multivariable (MVA) analysis with a generalized linear model was used to evaluate the effect of SWT and other predictive factors on pathological outcome in individual risk group and on the overall sample.

RESULTS

A total of 835 patients were eligible for analysis. Mean SWT was significantly different between the three D'Amico groups, with mean SWT of 180.22 days (95% confidence interval [CI] 169.03; 191.41), 159.14 days (95% CI 152.38; 165.90), and 138.96 days (95% CI 124.60; 153.33) for low-, intermediate-, and high-risk groups, respectively (p<0.001). After stratification by D'Amico risk group, no significant association was observed between SWT and CAPRA-S score in the three risk categories on UVA and MVA. Predictors of higher CAPRA-S score in the multivariable model in the overall cohort were: older age (p=0.014), biopsy Gleason score (p<0.001), percentage of positive cores (p<0.001), and clinical stage (p<0.001).

CONCLUSIONS

In the present study evaluating SWT for RARP in a Canadian socialized system, increased delay for surgery does not appear to impact the pathological outcome. Further studies are required to evaluate the impact of wait time on biochemical recurrence-free survival, cancer-specific survival, and overall survival.

Accessibility to surgical robot technology and prostate-cancer patient behavior for prostatectomy

Background

To examine how surgical robot emergence affects prostate-cancer patient behavior in seeking radical prostatectomy focusing on geographical accessibility.

Methods

In Japan, robotic surgery was approved in April 2012. Based on data in the Japanese Diagnosis Procedure Combination database between April 2012 and March 2014, distance to nearest surgical robot and interval days to radical prostatectomy (divided by mean interval in 2011: % interval days to radical prostatectomy) were calculated for individual radical prostatectomy cases at non-robotic hospitals. Caseload changes regarding distance to nearest surgical robot and robot introduction were investigated. Change in % interval days to radical prostatectomy was evaluated by multivariate analysis including distance to nearest surgical robot, age, comorbidity, hospital volume, operation type, hospital academic status, bed volume and temporal progress.

Results

% Interval days to radical prostatectomy became wider for distance to nearest surgical robot <30 km. When a surgical robot emerged within 30 and 10 km, the prostatectomy caseload in non-robot hospitals reduced by 13 and 18% within 6 months, respectively, while the robot hospitals gained +101% caseload (P < 0.01 for all) Multivariate analyses including 9759 open and 5052 non-robotic minimally invasive radical prostatectomies in 483 non-robot hospitals revealed a significant inverse association between distance to nearest surgical robot and % interval days to radical prostatectomy (B = -17.3% for distance to nearest surgical robot ≥30 km and -11.7% for 10-30 km versus distance to nearest surgical robot <10 km), while younger age, high-volume hospital, open-prostatectomy provider and temporal progress were other significant factors related to % interval days to radical prostatectomy widening (P < 0.05 for all).

Conclusions

Robotic surgery accessibility within 30 km would make patients less likely select conventional surgery. The nearer a robot was, the faster the caseload reduction was.

Socioeconomic status is associated with urinary diversion utilization after radical cystectomy for bladder cancer

PURPOSE

To assess socioeconomic disparities in urinary diversion utilization in a contemporary American cohort.

METHODS

In the National Cancer Database, we identified 4538 patients who underwent cystectomy with urinary diversion for clinical T1-2N0M0 bladder cancer from 2010 to 2013. Multivariable logistic regression was used to identify predictors of urinary diversion type: ileal conduit (IC), continent cutaneous reservoir (CCR), or orthotopic neobladder (ON). Covariates included age, gender, race, income, Charlson score, clinical T stage, hospital cystectomy volume, teaching status, and surgical approach. Subgroup analysis by hospital volume (low, intermediate, or high) and teaching status (academic or non-academic) was performed to ascertain the impact of regionalization on urinary diversion use.

RESULTS

The final cohort included 4066 (89.6 %) patients with IC, 292 (6.4 %) with CCR, and 180 (4.0 %) with ON. On multivariable analysis, younger age (p < .01), higher income (p < .01), and high cystectomy volume predicted increased use of CCR and ON. Female gender predicted increased use of CCR versus IC (p < .01), and academic hospital status predicted increased use of ON versus IC (p = .04). On subgroup analysis, after further adjustment for hospital volume and teaching status, higher income remained an independent predictor of ON use.

CONCLUSIONS

Despite regionalization of care, higher income patients are more likely to receive complex urinary diversions after radical cystectomy. Other related socioeconomic factors, especially patient education, may influence this practice pattern.