Aaron D. Martin

Robot-assisted radical cystectomy versus open radical cystectomy: A complete cost analysis

OBJECTIVESnTo perform a complete cost analysis comparing robot assisted radical cystectomy (RARC) versus open radical cystectomy (ORC).nnnMATERIAL AND METHODSnAfter institutional review board approval for data collection, we prospectively recorded perioperative outcomes and costs, such as hospital stay, transfusion rate, readmission rate, and medications for consecutive patients undergoing RARC or ORC. Using actual cost data, we developed a cost decision tree model to determine typical perioperative costs for both RARC and ORC. Multivariate sensitivity analysis was performed to elucidate which variables had the greatest impact on overall cost. Breakeven points with ORC were calculated using our model to better evaluate variable influence. In addition to the above modeled analysis, actual patient costs, including complications 30 days from surgery, were also compared for each procedure.nnnRESULTSnOur model analysis showed that operative time and length of stay had the greatest impact on perioperative costs. Robotic cystectomy became more expensive than open cystectomy at the following break-even points: operating room (OR) time greater than 361 minutes, length of stay greater than 6.6 days, or robotic OR supply cost exceeding

Outcomes of laparoscopic radical nephrectomy in the setting of vena caval and renal vein thrombus: Seven-year experience

5853. RARC was 16% more expensive when only comparing direct operative costs. Interestingly, actual total patient costs revealed a 38% cost advantage favoring RARC due to increased hospitalization costs for ORC in our cohort.nnnCONCLUSIONSnRARC can provide a cost-effective alternative to ORC with operative time and length of stay being the most critical cost determinants. Higher complication rates with ORC make total actual costs much higher than RARC.

Robot-assisted radical cystectomy: Intermediate survival results at a mean follow-up of 25 months

PURPOSEnWe present our experience with laparoscopic radical nephrectomy for T(3b) disease focusing on thrombus within the vena cava.nnnPATIENTS AND METHODSnA total of 14 patients with T(3b) disease were identified from a retrospective laparoscopic renal cancer database from 2000 to 2007. Patient demographics, clinical stage, preoperative imaging, intraoperative parameters, final pathology, and postoperative course were analyzed. In patients with a large tumor thrombus, the infraumbilical extraction excision was performed early and a gel port was placed. This was used when laparoscopic milking or determination of the distal extent of the tumor thrombus was difficult.nnnRESULTSnPreoperative imaging identified T(3b) disease in all but four patients. Four patients had caval involvement seen on imaging, with one extending well above 2 to 3 cm above the renal vein. Of the 14 patients, procedures in 13 were completed laparoscopically. There was one conversion early in the experience because of a positive frozen section of the renal vein; however, additional vein and caval margins were negative. There was one complication-a pulmonary embolism 5 days postoperatively, managed with anticoagulation, with no disease recurrence 4 years later.nnnCONCLUSIONnIn patients with T(3b) disease, laparoscopy is feasible and safe. Using advanced laparoscopic techniques to milk the tumor thrombus into the proximal renal vein with laparoscopic vascular instruments is critical to success in a purely laparoscopic thrombectomy. Placement of a gel port in the extraction incision early in the procedure may aid in hand-milking of the tumor thrombus into the renal vein in cases of extensive inferior vena cava involvement.

Cost Analysis of Open Radical Cystectomy Versus Robot-assisted Radical Cystectomy

Study Type – Therapy (case series)u2028Level of Evidenceu20034

Interval from prostate biopsy to robot-assisted radical prostatectomy: effects on perioperative outcomes.

Bladder cancer is the fourth and ninth most common malignancy in males and females, respectively, in the U.S. and one of the most costly cancers to manage. With the current economic condition, physicians will need to become more aware of cost-effective therapies for the treatment of various malignancies. Robot-assisted radical cystectomy (RARC) is the latest minimally invasive surgical option for muscle-invasive bladder cancer. Current reports have shown less blood loss, a shorter hospital stay, and a lower morbidity with RARC, as compared with the traditional open radical cystectomy (ORC), although long-term oncologic results of RARC are still maturing. There are few studies that have assessed the cost outcomes of RARC as compared with ORC. Currently, ORC appears to offer a direct cost advantage due to the high purchase and maintenance cost of the robotic platform, although when the indirect costs of complications and extended hospital stay with ORC are considered, RARC may be less expensive than the traditional open procedure. In order to accurately evaluate the cost effectiveness of RARC versus ORC, prospective randomized trials between the two surgical techniques with long-term oncologic efficacy are needed.

Incontinence after radical prostatectomy: A patient centered analysis and implications for preoperative counseling

To determine whether shorter intervals (<4 and 6u2003weeks) between prostate biopsy and robot‐assisted radical prostatectomy (RARP) have a detrimental effect on perioperative outcomes, as recent studies showed that open RP shortly after prostate biopsy does not adversely influence surgical difficulty or efficacy, but RARP relies solely on visual cues rather than tactile sensation to determine posterior surgical planes of dissection.

Outpatient Prostatectomy: Too Much Too Soon or Just What the Patient Ordered

PURPOSEnIncontinence after radical prostatectomy is common yet poorly defined in the current literature. We aimed to accurately characterize incontinence after robot-assisted radical prostatectomy to achieve improved preoperative patient counseling.nnnMATERIALS AND METHODSnAfter receiving institutional review board approval we performed a cross-sectional survey of the first 600 patients with prostate cancer who underwent robot-assisted radical prostatectomy at our institution. The International Consultation on Incontinence Modular Questionnaire-Lower Urinary Tract Symptoms Quality of Life and Urinary Incontinence Short Form were used to evaluate incontinence and quality of life after robot-assisted radical prostatectomy. Surveys were mailed by a third party. Data were analyzed on the prevalence of incontinence after robot-assisted radical prostatectomy. More specifically we characterized in detail the nature of incontinence and its effect on quality of life.nnnRESULTSnThe response rate was 68% (408 of 600 participants). Response time since surgery was 2.5 months to 4 years. Overall incontinence bother scores and ratings of life interference were quite low. Patients reported that most incontinence occurred during physical activity but 35% reported interference with sleep. Of the patients 31% experienced some anxiety due to urinary difficulties and 51% had to occasionally change clothes due to leakage. Patients did not report much interference with traveling, visiting friends or family and family life. The most bothersome aspects of incontinence were its effects on partner relationship, sexual life and energy levels.nnnCONCLUSIONSnDespite patient concerns of incontinence after prostatectomy they report little interference with quality of life.

Laparoscopic bilateral native nephrectomies with simultaneous kidney transplantation.

OBJECTIVESnTo evaluate the feasibility of performing a robot-assisted radical prostatectomy (RARP) as an outpatient procedure while maintaining patient satisfaction and safety. Herein we report our experience, selection criteria, and discharge criteria for outpatient RARP.nnnMETHODSnWe performed a prospective study with 11 patients undergoing extraperitoneal RARP. These patients were counseled before the procedure that they would go home the same evening of the procedure. The patients were then surveyed by a third party shortly after they returned home, using the Patient Judgement System-24, a previously validated instrument for patient satisfaction. Sociodemographic data, comorbidities, and outcomes were collected for analysis.nnnRESULTSnAll patients were successfully discharged the same day of surgery. Mean patient age was 62.2 years with a mean body mass index of 26 kg/m(2). Mean operative time was 117.6 minutes, console time was 76.7 minutes, and estimated blood loss was 168.2 mL. Mean indwelling catheter time was 7.5 days. No complications occurred in this series of patients. Satisfaction was unanimously high in all patients surveyed, with most scores over 90% on the Patient Judgement System-24. No patient reported any ill effects from the shortened stay or felt rushed to leave the hospital.nnnCONCLUSIONSnThe early experience with extraperitoneal RARP as a same day surgery is promising. Preoperative patient counseling and selection is paramount. Patient satisfaction is not adversely affected by the shortened stay. Surgeon experience, assessment of intraoperative findings, and adequate postoperative assessment are essential.

Does a history of previous surgery or radiation to the prostate affect outcomes of robot―assisted radical prostatectomy?

Study Type – Therapy (case series)

Bleeding after holmium laser enucleation of the prostate: Lessons learned the hard way

To evaluate retrospectively whether or not previous treatment to the prostate alters the perioperative outcomes from robot‐assisted radical prostatectomy (RARP) after the initial ‘learning curve’, as there are conflicting data on outcomes of RP in patients with previous treatment to the prostate.