Impact of annual surgical volume on length of stay in patients undergoing minimally invasive prostatectomy: a population-based study

BACKGROUND

On average, patients remain hospitalized no more than 2 days after MIRP. The aim of our study was to examine the temporal trends in length of stay ≥ 3 days and to test the relationship between annual surgical volume (ASV) and annual hospital volume (AHV) and length of stay ≥ 3 days in patients undergoing MIRP.

MATERIAL AND METHODS

Within the Florida Hospital Inpatient Datafile, 2439 men who were treated with MIRP for prostate cancer between 2005 and 2008 were identified. Temporal trends were assessed and uni and multi-variable logistic regression models tested the relationship between ASV, AHV and length of stay ≥ 3 days.

RESULTS

The average length of stay decreased from 2.4 in 2005 to 1.7 days in 2008. Length of stay ≥ 3 days was recorded in 13.6% of patients and the proportion of patients staying more than ≥ 3 days decreased over time (25.5-12.2%; Chi Square trend p < 0.001). After stratification into low (<1-15 MIRPs) vs. intermediate (16-63 MIRPs) vs. high ASV tertiles (≥ 64 MIRPs) the proportion of patients with length of stay ≥ 3 days were 29.1; 13.2 and 11.1%. In multivariable logistic regression models predicting length of stay ≥ 3 days, ASV, year of surgery and comorbidities achieved independent predictor status and MIRP patients operated by highest ASV tertile surgeons were 71% (p < 0.001) less likely to be hospitalized for more than 3 days.

CONCLUSION

The length of stay after MIRP decreased between 2005 and 2008. Surgical expertise represented one of the main determinants of shorter length of stay.

Prostate weight as an independent predictor for both extracapsular extension and positive surgical margins during robotic- assisted laparoscopic radical prostatectomy

15608

Background: Pre-operative prediction of pathological stage represents the cornerstone of prostate cancer management. Patient counseling is routinely based on pre-operative PSA, Gleason score and clinical stage. In this study, we evaluated whether prostate weight (PW) is an independent predictor of extracapsular extension (ECE) and positive surgical margin (PSM). Methods: Between February 2003 and November 2006, 709 men underwent robotic-assisted laparoscopic radical prostatectomy (RLRP). Pre-operative parameters (patient age, pre-operative PSA, biopsy Gleason score, clinical stage) as well as pathological data (prostate weight, pathological stage) were prospectively gathered after IRB approval. Evaluation of the influence of these variables on ECE and PSM outcomes were assessed using both univariate and multivariate logistic regression analysis. Results: Mean overall patient age, pre-operative PSA and PW were 59.6 years, 6.5ng/ml and 52.9g (range 5.5–198.7g), respectively. Of the 393, 209 and 107 men with PW <50g, 50-<70g and >70g, ECE was observed in 20.1%, 15.3% and 9.3%, respectively (p=0.015). In the same patient cohorts, PSM was observed in 25.4%, 14.4% and 7.5%, respectively (p<0.001). In a multivariate logistic regression analysis, PW, in addition to pre-operative PSA, biopsy Gleason score and clinical stage, was an independent risk factor for ECE (p<0.001). Similarly, in multi-variate analysis, PW was observed to be a risk factor for PSM (p<0.001). Conclusions: PW is an independent predictor of both ECE and PSM, with an inverse relationship having been demonstrated between both variables. PW should be considered when counseling patients with prostate cancer treatment.

No significant financial relationships to disclose.

Adjuvant chemotherapy in lymph node positive bladder cancer

15526

Background: Lymph node-positive bladder cancer is a systemic disease in the majority of patients. Prescribing adjuvant chemotherapy shortly after surgery, when tumor burden is low seems reasonable, yet there is no proof that this treatment strategy improves survival. In this retrospective study, we compared the outcomes of patients with microscopic lymph node positive bladder cancer (pN1 or pN2) treated with radical cystectomy followed by adjuvant chemotherapy and those who declined chemotherapy. Methods: Sixty-seven patients with lymph node positive bladder cancer (pN1 in 26 patients and pN2 in 41) who underwent radical cystectomy between April 1995 and April 2005 were reviewed. Combined adjuvant chemotherapy (gemcitabine and cisplatin in most patients) was given to 35 patients (52%), but deferred by 32 (48%). The two groups were similar in performance status, postoperative complication rate and N stage but deferring patients were on average 4 years older and had a more advanced T stage. Results: Adjuvant chemotherapy was well tolerated with 28/35 patients (80%) completed all 4 cycles. Median overall survival of patients given adjuvant chemotherapy was 48 months compared to 8 months for deferring patients (hazard ratio 0.13, 95% CI 0.04–0.4, p<0.0001). Multivariate age adjusted analysis showed that adjuvant chemotherapy was an independent factor affecting overall survivals (hazard ratio 0.2, p<0.0001). Subgroup analysis demonstrated that chemotherapy provided survival benefit for patients with pN2 disease but not for patients with pN1 disease (p=0.0001 and p=0.235 respectively). Conclusions: This retrospective real-life study supports the use of adjuvant chemotherapy after radical cystectomy in patients with node positive bladder cancer, especially when more than one lymph node is involved.

No significant financial relationships to disclose.