Évaluation médico-economique de l’impact de mesures d’adaptation au virage de la chirurgie robot-assistée en urologie

INTRODUCTION

The development of robot-assisted urological surgery is held back by the lack of robust medico-economic analyses and their heterogeneity. We conducted a medico-economic study to evaluate the implementation of measures to optimize the transition to robotic surgery.

METHOD

We carried out a single-center, controlled study from the point of view of the public healthcare establishment for 4 years. Economic data collection was based on a micro-costing method and revenues from stay-related groups. Clinical data corresponded to mean lengths of stay, operating duration, complications and stays in intensive care. The measures to optimize the transition to robotic, implemented mid-study period, enabled before/after comparison.

RESULTS

Altogether, 668 patients undergoing robotic surgery were included. Robotic activity increased significantly from periods 1 to 2 to 256% (P=<0.001) as did the overall proportion of robotic by 45% to 85% (P=<0.001). The mean lengths of stay fell significantly, 6.8 d vs. 5.1 d (P<0.001). Costs and revenues increased significantly, resulting in a persistent deficit for the activity €226K vs. €382K (P=<0.001). With increased volume of activity, the deficit per operation and the cost per minute of robotic operating room fell significantly, €3,284 vs. €1,474/procedure (P=<0.001) and €27 vs €24/min (P=<0.029), tending towards a break-even point (=zero deficit) at 430 operations per year.

CONCLUSIONS

Robotic-assisted surgery can be significantly optimized by implementing measures for the robotic turn to reach a break-even point at 430 operations per year. A better multidisciplinary case mix could lower the break-even volume of activity in short term.

LEVEL OF EVIDENCE

3.

[Outcomes following the triage of patients for urological cancer and non-cancer surgery during Covid-19 pandemic peak]

Introduction

Lors de la première vague épidémique Covid-19, des mesures de triage, sans PCR systématique, étaient mises en place pour sélectionner les patients à opérer. Notre étude a comparé leurs résultats chirurgicaux après triage à ceux d’un groupe contrôle.

Matériel

L’analyse portait sur l’ensemble des patients initialement programmés dans un centre Covid de référence et inclus consécutivement, du 15 mars au 1^er mai 2020 (NCT04352699). Leurs données étaient recueillies prospectivement et ultérieurement comparées à celles des patients opérés 1 an auparavant sur la même période dans ce centre. Le critère d’évaluation principal était l’admission post-opératoire en unité de soins intensifs (USI). La morbidité, la mortalité postopératoire, le report d’interventions, les tests PCR étaient évalués. Des analyses de sous-groupes étaient réalisés pour les patients opérés de cancer.

Résultats

Après triage, 96 des 142 interventions programmées ont dû être reportées. Sur les opérés, 48 (68 %) l’étaient pour cancer. Au total, aucun cas de pneumonie Covid-19 post-opératoire n’a été identifié. Trois patients (4 %) ont été admis en USI, dont un finalement décédé pour sepsis urinaire. Chez ces patients, les RT-PCR étaient négatives. Globalement, comparativement au groupe contrôle, aucune différence d’admission en USI, ni de taux de mortalité post-opératoire n’ont été rapportées.

Conclusions

Le triage de la première vague n’a pas surexposé les patients sélectionnés à un risque de complication ou de décès post-opératoire, particulièrement pas pour ceux opérés pour cancer. En revanche, 67 % des patients ont été reportés, avec un risque associé à des retard de soins pouvant conduire au décès.

Niveau de preuve

3.

Induction of glycollate oxidase activity in mustard seedlings under the influence of continuous irradiation with red and far-red light

1. A method was developed for the measurement of glycollate oxidase activity in buffered extracts of white mustard seedlings (Sinapis alba L.). 2. After 36 hours germination in darkness, the activity of the enzyme was followed during the further development of the seedlings kept in darkness or irradiated continuously with red or far-red light. In irradiated seedlings as well as in dark-grown controls, most of the activity was found in the cotyledons. 3. Kinetics of activity induction were studied for both the whole seedlings and the cotyledons. In permanent darkness enzymatic activity increased up to 60 hours after sowing; then a nearly constant activity level was maintained. When the seedlings were exposed to continuous far-red light, an increase of enzymatic activity was observed. This light-mediated increase showed a lag-phase wich was dependent on the age of the seedlings. When irradiation was started 36 hours after sowing, it took at least 12 hours for the differences between light and dark activity to become significant; in seedlings irradiated 60 hours after sowing, the lag-phase -if any- was less than 6 hours. The magnitude of the photoresponse diminished with increasing age of the seedlings. After interruption of irradiation in the phase of vigorous activity induction, the activity kept rising for about 8 hours and resulted in a stable intermediary activity level. Continuous far-red light, started 36 hours after sowing, caused a threefold activity increase in cotyledons after 42 hours and the maximal level of activity was light-independent. An activity induction was also obtained under continuous irradiation with red light. When irradiation was started 36 hours after sowing, a lag-phase of about 6 hours was found. Then the activity rose to a constant level inferior to that in continuous far-red light. With 60 hours old seedlings, no significant differences were observed in the response to either red or far-red light. 4. The involvement of phytochrome in the photoresponse was shown by means of the conventional induction-reversion experiments. 5. The induction pattern of glycollate oxidase in mustard is compared with that of other glyoxysome enzymes and dicussed with respect to the problem of compartment biogenesis. Dissimilarities in the induction patterns of the individual enzymes indicate the absence of a uniform regulatory mechanism for the entire glyoxysome compartment of the cells.