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BJU International Mar 2021To evaluate how surgeon heterogeneity - the variation in outcomes between individual surgeons - influences functional and oncological outcomes after robot-assisted...
OBJECTIVES
To evaluate how surgeon heterogeneity - the variation in outcomes between individual surgeons - influences functional and oncological outcomes after robot-assisted laparoscopic prostatectomy (RALP) and retropubic radical prostatectomy (RRP), and to assess whether surgeon heterogeneity affects the comparison between RALP and RRP.
PATIENTS AND METHODS
Laparoscopic Prostatectomy Robot Open (LAPPRO) is a prospective, controlled, non-randomized trial performed at 14 Swedish centres with 68 operating surgeons. A total of 4003 men with localized prostate cancer were enrolled between 2008 and 2011. The endpoints were urinary incontinence, erectile dysfunction (ED) and recurrence at 24 months after surgery. Logistic regression models were built to evaluate surgeon heterogeneity and, secondarily, surgeon-specific factors were added to the models to investigate their influence on heterogeneity and the comparison between RALP and RRP.
RESULTS
Among surgeons who performed at least 20 surgeries during the study period (n=25), we observed statistically significant heterogeneity for incontinence (P = 0.001), ED (P < 0.001) and rate of recurrent disease (P < 0.001). The significant heterogeneity remained when analysing only experienced surgeons with a stated experience of at least 250 radical prostatectomies (n=12). Among all participating surgeons (n=68), differences in surgeon volume explained 42% of the observed heterogeneity for incontinence (P = 0.003), 11% for ED (P = 0.03) and 19% for recurrence (P = 0.01). Taking surgeon volume into account when comparing RALP and RRP had a significant impact on the results. The effect was greatest for functional outcomes, and the additional adjustments for the surgeons' previous experience changed whether the difference between techniques was statistically significant or not. The surgeons' annual volume had the greatest effect on the recurrence rate.
CONCLUSIONS
There was a large degree of heterogeneity among surgeons regarding both functional and oncological outcomes and this had a significant impact on the results when comparing RALP and RRP. Some of the observed heterogeneity was explained by differences in surgeon volume. Efforts to decrease heterogeneity are warranted and variation among surgeons must be accounted for when conducting comparative analyses between surgical techniques.
Topics: Aged; Clinical Competence; Erectile Dysfunction; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Prospective Studies; Prostatectomy; Prostatic Neoplasms; Robotic Surgical Procedures; Surgeons; Sweden; Treatment Outcome; Urinary Incontinence
PubMed: 32916021
DOI: 10.1111/bju.15238 -
TheScientificWorldJournal Feb 2006The da Vinci surgical robot has been shown to help shorten the learning curve for laparoscopic radical prostatectomy (LRP) for both laparoscopically skilled and naïve... (Review)
Review
The da Vinci surgical robot has been shown to help shorten the learning curve for laparoscopic radical prostatectomy (LRP) for both laparoscopically skilled and naïve surgeons[1,2]. This approach has shown equal or superior outcomes to conventional laparoscopic prostatectomy with regard to ease of learning, initial complication rates, conversion to open, blood loss, complications, continence, potency, and margin rates. Although the data are immature to compare oncologic and functional outcomes to open prostatectomy, preliminary data are promising. Herein, we review the technique and outcomes of robotic-assisted laparoscopic radical prostatectomy (RALP).
Topics: Humans; Laparoscopes; Laparoscopy; Male; Models, Anatomic; Operating Rooms; Prostate-Specific Antigen; Prostatectomy; Prostatic Neoplasms; Robotics; Surgery, Computer-Assisted
PubMed: 17619729
DOI: 10.1100/tsw.2006.394 -
Urology Journal 2007While radical retropubic prostatectomy has been the gold standard surgical approach, the explosion of minimally invasive methods has led to the search for less invasive... (Review)
Review
INTRODUCTION
While radical retropubic prostatectomy has been the gold standard surgical approach, the explosion of minimally invasive methods has led to the search for less invasive treatment options. We offer an overview of the evolution of laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic prostatectomy (RALP) in terms of the landmark publications and recent head-to-head comparisons, and we review our own experience.
MATERIALS AND METHODS
A Medline search was performed using the keywords prostate cancer, prostatectomy, laparoscopic, and robotic. All pertinent articles concerning localized prostate cancer were reviewed. The Montefiore experience consisted of a retrospective review of a prospectively maintained confidential database.
RESULTS
Several laparoscopic and robotic series were identified including review articles of each modality as well as studies directly comparing the two. Both LRP and RALP compare very favorably with conventional open surgery in terms of safety and oncologic efficacy. Both minimally invasive approaches offer decreased blood loss, transfusion rate, and length of hospital stay when contrasted with open surgery. When compared directly, LRP and RALP offer similar surgical, oncologic, and functional outcomes. However, RALP likely requires a shorter learning curve.
CONCLUSION
The use of minimally invasive techniques has revolutionized the surgical treatment of prostate cancer. Pure LRP has been shown to be feasible and reproducible. However, it has a steep learning curve and is difficult to learn. In contrast, RALP is easier to learn and is now the surgical treatment of choice in most centers of excellence in the United States. The superior optics with respect to visualization and magnification translates into a procedure that is equivalent, if not superior, with respect to perioperative parameters, oncologic outcomes, and functional outcomes to its open counterpart.
Topics: Clinical Competence; Humans; Laparoscopy; Length of Stay; Male; Postoperative Complications; Prostatectomy; Prostatic Neoplasms; Quality of Life; Robotics; Treatment Outcome
PubMed: 17987573
DOI: No ID Found -
JAMA Network Open Apr 2022The cost-effectiveness of different surgical techniques for radical prostatectomy remains a subject of debate. Emergence of recent critical clinical data and changes in...
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.
Topics: Aged; Cost-Benefit Analysis; Humans; Male; Prostatectomy; Prostatic Neoplasms; Robotic Surgical Procedures; State Medicine; United Kingdom
PubMed: 35377424
DOI: 10.1001/jamanetworkopen.2022.5740 -
Nigerian Journal of Clinical Practice Apr 2022Open suprapubic prostatectomy is attended by significant perioperative haemorrhage and need for blood transfusion.
The modified suprapubic prostatectomy technique is associated with improved hemostasis and decline in blood transfusion rate after open suprapubic prostatectomy compared to the freyers technique.
BACKGROUND
Open suprapubic prostatectomy is attended by significant perioperative haemorrhage and need for blood transfusion.
AIM
To share our experience on how the adoption of a modified suprapubic prostatectomy technique has led to improved hemostasis and decline in the blood transfusion rate after open suprapubic prostatectomy in our center.
PATIENTS AND METHODS
This was a retrospective study comparing two open prostatectomy techniques. The patients in group 1 had Freyer's suprapubic prostatectomy while the patients in group 2 had a modified suprapubic prostatectomy technique. The groups were compared for the effectiveness of hemostasis using change in packed cell volume, clot retention, blood transfusion, and requirement of continuous bladder irrigation.
RESULTS
Both groups were similar concerning age, body mass index (BMI), total prostate-specific antigen (PSA), prostate volume, presence of comorbidities, duration of surgery, and duration of follow-up. The clot retention rate was 34% in group 1 versus 16.4% in group 2, P = 0.030. The clot retention requiring bladder syringe evacuation occurred in 32.1% of the patients in group 1 versus 14.8% in group 2, P = 0.048. The mean change in the packed cell volume (PCV) in group 1 was 8.0 ± 5.3 versus 6.9 ± 3.5 in group 2, P = 0.175. The blood transfusion rate in group 1 was 40.0% versus 13.3% in group 2, P = 0.040. The complication rate in group 1 was 67.2% versus 41.9% in group 2, P = 0.004. A general decline in blood transfusion was noted from January 2011 to December 2019.
CONCLUSION
The modified suprapubic prostatectomy technique was associated with better hemostasis compared to the standard Freyer's prostatectomy technique. It should be a worthwhile addition to the numerous modifications of the original Freyer's suprapubic prostatectomy technique.
Topics: Blood Transfusion; Female; Hemostasis; Humans; Male; Prostatectomy; Retrospective Studies; Urinary Retention
PubMed: 35439901
DOI: 10.4103/njcp.njcp_1391_21 -
Archivio Italiano Di Urologia,... Nov 2023To compare the outcomes of bipolar Transurethral Enucleation Resection of the Prostate (TUERP) and simple retropubic prostatectomy in patients with prostate volumes... (Randomized Controlled Trial)
Randomized Controlled Trial
Evaluation of bipolar Transurethral Enucleation and Resection of the Prostate in terms of efficiency and patient satisfaction compared to retropubic open prostatectomy in prostates larger than 80 cc. A prospective randomized study.
OBJECTIVES
To compare the outcomes of bipolar Transurethral Enucleation Resection of the Prostate (TUERP) and simple retropubic prostatectomy in patients with prostate volumes larger than 80 cc.
PATIENTS AND METHODS
A prospective randomized study included all patients amenable to surgeries for benign prostate hyperplasia (BPH) with prostate size over 80 cc at a tertiary care hospital between January 2020 to February 2022. Bipolar TUERP and Retropubic open prostatectomy techniques were compared regarding patients' demographics, intraoperative parameters, outcomes, and peri-operative complications.
RESULTS
Ninety patients were included in our study and randomly assigned to bipolar TUERP (Group 1 = 45 patients) and retropubic open prostatectomy (Group 2 = 45 patients). The TUERP group demonstrated significantly lower operative time (77 ± 11 minutes vs. 99 ± 14 minutes, p < 0.001), hemoglobin drop (median = 1.1 vs. 2.5, p < 0.001), and resected tissue weight (71 ± 6.6 cc vs. 84.5 ± 10.6 cc, p < 0.001). Postoperatively, the TUERP group demonstrated significantly lower catheter time (median = 2 vs. 7 days, p < 0.001) and less hospital stay. IPSS, Qmax, and patient satisfaction were better in the TUERP group within six months of surgery. We reported 90-day complications after TUERP in 13.3% of patients compared to 17.8% after retropubic prostatectomy, with a statistically insignificant difference. Urethral stricture predominated after TUERP, while blood transfusion dominated in retropubic prostatectomy.
CONCLUSIONS
The present study found that TUERP had equivalent efficacy and safety to open retropubic prostatectomy for patients with BPH and prostate volumes > 80 ml.
Topics: Male; Humans; Prostate; Prostatic Hyperplasia; Prospective Studies; Transurethral Resection of Prostate; Patient Satisfaction; Treatment Outcome; Prostatectomy
PubMed: 37990975
DOI: 10.4081/aiua.2023.11629 -
International Braz J Urol : Official... 2011To compare the perioperative, short-term and long-term postoperative results of radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and... (Comparative Study)
Comparative Study Review
PURPOSE
To compare the perioperative, short-term and long-term postoperative results of radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robotic assisted laparoscopic prostatectomy (RALP) in the most recent studies evaluable.
MATERIALS AND METHODS
Using PubMed we have undertaken a search based on references from major and recent articles with considerable sample sizes.
RESULTS
The operative blood loss and the risk of transfusion were lower in the laparoscopic and robotic-assisted approaches. The surgical duration was shorter in the open and robotic group. Regarding the positive margins, continence and potency no substantial differences between the RRP, LRP, and RALP were found.
CONCLUSIONS
Our results suggest that no one surgical approach is superior in terms of functional and early oncologic outcomes. Potential advantages of any surgical approach have to be confirmed through longer-term follow-up and adequately designed clinical studies.
Topics: Erectile Dysfunction; Evidence-Based Medicine; Follow-Up Studies; Humans; Laparoscopy; Male; Prostatectomy; Robotics; Treatment Outcome; Urinary Incontinence
PubMed: 21557832
DOI: 10.1590/s1677-55382011000200002 -
Oncology (Williston Park, N.Y.) Sep 2004Radical prostatectomy and ultrasound-guided transperineal brachytherapy are both commonly used for the treatment of localized prostate cancer. No randomized trials are... (Comparative Study)
Comparative Study Review
Radical prostatectomy and ultrasound-guided transperineal brachytherapy are both commonly used for the treatment of localized prostate cancer. No randomized trials are available to compare these modalities. Therefore, the physician must rely on institutional reports of results to determine which therapy is most effective. While some investigators have concluded that both therapies are effective, others have concluded that radical prostatectomy should remain the gold standard for the treatment of this disease. This article reviews the major series available for both treatments and discusses the major controversies involved in making these comparisons. The data indicate that for low-risk disease, both treatments are effective, controlling disease in over 80% of the cases, with no evidence to support the use of one treatment over the other. Similarly, for intermediate-risk disease, the conclusion that one treatment is superior to the other cannot be drawn. Brachytherapy should be performed in conjunction with external-beam radiation therapy in this group of patients. For patients with high-risk disease, neither treatment consistently achieves biochemical control rates above 50%. Although radical prostatectomy and/or brachytherapy may play a role in the care of high-risk patients in the future, external-beam radiation therapy in combination with androgen deprivation has the best track record to date.
Topics: Biomarkers, Tumor; Brachytherapy; Clinical Trials as Topic; Follow-Up Studies; Humans; Male; Neoplasm Recurrence, Local; Prostatectomy; Prostatic Neoplasms; Risk Factors; Treatment Outcome
PubMed: 15526832
DOI: No ID Found -
Surgical Innovation Dec 2014Robotic prostatectomy has rapidly disseminated over the past decade. How managed care, thought by many to be a barrier to new technology, influences the dissemination of...
OBJECTIVE
Robotic prostatectomy has rapidly disseminated over the past decade. How managed care, thought by many to be a barrier to new technology, influences the dissemination of robotics is unknown. We sought to better understand the relationship between a market's managed-care penetration and the dissemination of robotic prostatectomy.
METHODS
We used SEER-Medicare data from 2003 through 2007 to identify men ≥66 years of age treated with radical prostatectomy for prostate cancer. We categorized Health Service Areas (HSAs) according to the degree of managed-care penetration (ie, low vs high). We assessed adoption of robotic prostatectomy and utilization among adopting HSAs using Cox proportional-hazards and Poisson regression models, respectively.
RESULTS
Compared with markets with little managed care, highly penetrated markets had more racial diversity (24% vs 15% nonwhite, P < .01), higher population densities (1987 vs 422 people/square mile, P < .01), and higher median incomes ($49 374 vs $36 236, P < .01). Robotic prostatectomy adoption and utilization increased over time in both HSA categories. Compared with low managed-care markets, those with high managed care adopted robotic prostatectomy more rapidly (eg, probability 0.37 [low] vs 0.52 [high] in 2007; P < .01). However, the postadoption utilization of robotic prostatectomy was constrained in these highly penetrated markets (eg, probability 0.66 [low] vs 0.52 [high] in 2007; P < .01).
CONCLUSIONS
High managed-care penetration was associated with more rapid robotic prostatectomy adoption. However, once adopted, utilization increased more slowly in these markets. Understanding this paradox is important as more technologies are unveiled in an increasingly cost-conscious health care environment.
Topics: Aged; Diffusion of Innovation; Humans; Male; Managed Care Programs; Proportional Hazards Models; Prostatectomy; Prostatic Neoplasms; Robotic Surgical Procedures; SEER Program; United States
PubMed: 25049319
DOI: 10.1177/1553350614524841 -
Minerva Urologica E Nefrologica = the... Feb 2019Cytreductive prostatectomy is an experimental surgical approach to metastatic prostate cancer (mPCa), with the scope of improving local symptoms and potentially...
INTRODUCTION
Cytreductive prostatectomy is an experimental surgical approach to metastatic prostate cancer (mPCa), with the scope of improving local symptoms and potentially ameliorate oncologic outcomes. Aim of the current systematic review is to analyze available evidence to support this approach and explore published data a future trial on cytoreductive prostatectomy.
EVIDENCE ACQUISITION
A systematic review was conducted searching all relevant studies published in PubMed, EMBASE, Cochrane Library, CINAHL, Google Scholar and Ovid database until August 1, 2018. A search was performed including the combination of following words: "cytoreductive" AND "prostatectomy" AND "prostate" AND "cancer"). Of the 49 initial papers identified, 28 were excluded after screening by the authors, leaving 21 articles eligible for the review.
EVIDENCE SYNTHESIS
In vitro and in vivo models support the concept of removing the primary tumor, considered a "sanctuary site," in order to reduce the metastatic potential of prostate cancer. Large retrospective population studies have reported improved oncologic outcomes for men undergoing cytoreductive prostatectomy, though such results are limited by the retrospective design and major selection biases. Little evidence from well designed prospective trials is available, yet a net improvement of overall survival has not been reported. Nonetheless, most studies reported a reduction of local complications after cytoreductive prostatectomy (<10%) compared to best systemic therapy (25-30%). Prospective randomized trials are underway: their results will help elucidate the true impact of cytoreductive prostatectomy on oncologic outcomes of mPCa.
CONCLUSIONS
Although supported from a biological point of view and albeit encouraging results of population-based studies, cytoreductive remains to date experimental. A true benefit on overall survival of mPCa is not supported by current evidence. The results of prospective trials are eagerly awaited.
Topics: Cytoreduction Surgical Procedures; Evidence-Based Medicine; Humans; Male; Prostatectomy; Prostatic Neoplasms
PubMed: 30547907
DOI: 10.23736/S0393-2249.18.03319-2