Khurshid R. Ghani

Perioperative Outcomes of Robot-Assisted Radical Prostatectomy Compared With Open Radical Prostatectomy: Results From the Nationwide Inpatient Sample

BACKGROUND Prior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates. OBJECTIVE Assess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARPs supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique. DESIGN, SETTING, AND PARTICIPANTS As of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP (n=11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients (n=7389). INTERVENTION All patients underwent RARP or ORP. MEASUREMENTS We compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score-matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors. RESULTS AND LIMITATIONS Of 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score-matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.28-0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31-0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77-0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26-0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up. CONCLUSIONS RARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes.

Practice Patterns and Outcomes of Open and Minimally Invasive Partial Nephrectomy Since the Introduction of Robotic Partial Nephrectomy: Results from the Nationwide Inpatient Sample

PURPOSE We determined practice patterns and perioperative outcomes of open and minimally invasive partial nephrectomy in the United States since the introduction of a robot-assisted modifier in the Nationwide Inpatient Sample. MATERIALS AND METHODS We identified all patients with nonmetastatic disease treated with open, laparoscopic or robotic partial nephrectomy in the Nationwide Inpatient Sample between October 2008 and December 2010. Utilization rates were assessed by year, patient and hospital characteristics. We evaluated the perioperative outcomes of open vs robotic and open vs laparoscopic partial nephrectomy using binary logistic regression models adjusted for patient and hospital covariates. RESULTS In a weighted sample of 38,064 partial nephrectomies 66.9%, 23.9% and 9.2% of the procedures were open, robotic and laparoscopic operations, respectively. In 2010 the relative annual increase in open, robotic and laparoscopic partial nephrectomy was 7.9%, 45.4% and 6.1%, respectively. Compared to open partial nephrectomy patients treated with minimally invasive partial nephrectomy were less likely to receive blood transfusion (robotic vs laparoscopic OR 0.56, p <0.001 vs OR 0.68, p = 0.016), postoperative complication (OR 0.63, p <0.001 vs OR 0.78, p <0.009) or prolonged length of stay (OR 0.27 vs OR 0.41, each p <0.001). Only patients who underwent the robotic procedure were less likely to experience an intraoperative complication (robotic vs laparoscopic OR 0.69, p = 0.014 vs OR 0.67, p = 0.069). Excess hospital charges were higher after robotic surgery (OR 1.35, p <0.001). CONCLUSIONS The dissemination of robotic surgery for partial nephrectomy in the United States has been rapid and safe. Compared to open partial nephrectomy the robotic procedure had lower odds than laparoscopic partial nephrectomy for most study outcomes except hospital charges. Robotic partial nephrectomy has now supplanted laparoscopic partial nephrectomy as the most common minimally invasive approach for partial nephrectomy.

Bleeding after transrectal ultrasonography-guided prostate biopsy: a study of 7-day morbidity after a six-, eight- and 12-core biopsy protocol

To compare, in a prospective study, bleeding (in three categories, i.e. haematuria, haematospermia and rectal) and consultations with the general practitioner (GP), after a six‐, eight‐ or 12‐core prostate biopsy, as data on whether taking more prostate core biopsies increases bleeding complications are not conclusive.

Fundamental Skills of Robotic Surgery: A Multi-institutional Randomized Controlled Trial for Validation of a Simulation-based Curriculum

OBJECTIVE To develop and establish effectiveness of simulation-based robotic curriculum--fundamental skills of robotic surgery (FSRS). METHODS FSRS curriculum was developed and incorporated into a virtual reality simulator, Robotic Surgical Simulator (RoSS). Fifty-three participants were randomized into an experimental group (EG) or control group (CG). The EG was asked to complete the FSRS and 1 final test on the da Vinci Surgical System (dVSS). The dVSS test consisted of 3 tasks: ball placement, suture pass, and fourth arm manipulation. The CG was directly tested on the dVSS then offered the chance to complete the FSRS and re-tested on the dVSS as a crossover (CO) group. RESULTS Sixty-five percent of participants had never formally trained using laparoscopic surgery. Ball placement: the EG demonstrated shorter time (142 vs 164 seconds, P = .134) and more precise (1.5 vs 2.5 drops, P = .014). The CO took less time (P <.001) with greater precision (P <.001). Instruments were rarely lost from the field. Suture pass: the EG demonstrated better camera utilization (4.3 vs 3.0, P = .078). Less instrument loss occurred (0.5 vs 1.1, P = .026). Proper camera usage significantly improved (P = .009). Fourth arm manipulation: the EG took less time (132 vs 157 seconds, P = .302). Meanwhile, loss of instruments was less frequent (0.2 vs 0.8, P = .076). Precision in the CO improved significantly (P = .042) and camera control and safe instrument manipulation showed improvement (1.5 vs 3.5, 0.2 vs 0.9, respectively). CONCLUSION FSRS curriculum is a valid, feasible, and structured curriculum that demonstrates its effectiveness by significant improvements in basic robotic surgery skills.

Robot-Assisted Versus Open Radical Prostatectomy: The Differential Effect of Regionalization, Procedure Volume and Operative Approach

PURPOSE The use of robot-assisted radical prostatectomy has increased rapidly despite the absence of randomized, controlled trials showing the superiority of this approach. While recent studies suggest an advantage for perioperative complication rates, they fail to account for the volume-outcome relationship. We compared perioperative outcomes after robot-assisted and open radical prostatectomy, while considering the impact of this established relationship. MATERIALS AND METHODS Using the NIS (Nationwide Inpatient Sample), we abstracted data on patients treated with radical prostatectomy in 2009. Univariable and multivariable logistic regression analyses were done to compare the rates of blood transfusion, intraoperative and postoperative complications, prolonged length of stay, increased hospital charges and mortality between robot-assisted and open radical prostatectomy overall and across volume quartiles. RESULTS An estimated 77,616 men underwent radical prostatectomy, including a robot-assisted and an open procedure in 63.9% and 36.1%, respectively. Low volume centers averaged 26.2 robot-assisted and 5.2 open cases, while very high volume centers averaged 578.8 robot-assisted and 150.2 open cases. Overall, patients treated with the robot-assisted procedure experienced a lower rate of adverse outcomes than those treated with the open procedure for all measured categories. Across equivalent volume quartiles robot-assisted radical prostatectomy outcomes were generally favorable. However, the open procedure at high volume centers resulted in a lower postoperative complication rate (OR 0.59, 95% CI 0.46-0.75), elevated hospital charges (OR 0.75, 95% CI 0.64-0.87) and a comparable blood transfusion rate (OR 1.38, 95% CI 0.93-2.02) relative to the robot-assisted procedure at low volume centers. CONCLUSIONS Regionalization has occurred to a greater extent for robot-assisted than for open radical prostatectomy with an associated benefit in overall outcomes. Nonetheless, low volume institutions experienced inferior outcomes relative to the highest volume centers irrespective of approach. These findings demonstrate the importance of accounting for hospital volume when examining the benefit of a surgical technique.

Disparities in access to care at high-volume institutions for uro-oncologic procedures

Socioeconomic status represents an established barrier to health care access. Age, sex, and race may also play a role. The authors examined whether these affect the access to high‐volume hospitals for uro‐oncologic procedures in the United States.

Trends in Percutaneous Nephrolithotomy Use and Outcomes in the United States

PURPOSE We investigated recent trends in the use and perioperative outcomes of percutaneous nephrolithotomy in the United States in a population based cohort. MATERIALS AND METHODS We obtained the records of patients treated with percutaneous nephrolithotomy between 1999 and 2009 from the Nationwide Inpatient Sample (NIS). A weighted sample was used to estimate national utilization rates. Trends in age, comorbidity, perioperative complications and in-hospital mortality were analyzed. Temporal trends were quantified by the estimated annual percent change. We evaluated the association between patient and hospital characteristics, including complications, prolonged length of stay and in-hospital mortality, using logistic regression models adjusted for clustering. RESULTS During 1999 to 2009, percutaneous nephrolithotomy use increased in men and women from 3.0/100,000 and 2.99/100,000 to 3.63/100,000 and 4.07/100,000, respectively. Women showed the largest increases in percutaneous nephrolithotomy use with an estimated annual percent change of 4.49% (95% CI 2.7-6.3, p <0.001) vs 2.90% (95% CI 1.5-4.3, p = 0.003) in men. Baseline comorbidity in patients undergoing percutaneous nephrolithotomy increased with time. Overall complications increased from 12.2% to 15.6% (p <0.001), while mortality remained stable at 0.0% to 0.4%. The transfusion rate was 4.0%. Sepsis increased from 1.2% to 2.4% of cases (p <0.001). Patients were at risk for complications if they were older, more ill and treated in more recent years. Age was significantly associated with increased odds of mortality. CONCLUSIONS Percutaneous nephrolithotomy use in the United States has increased and females are now the majority gender. Although mortality remains low, rates of sepsis and overall complications have increased. Broad use of percutaneous nephrolithotomy, especially in older and more ill patients, may account for these changes.

Temporal Trends, Practice Patterns, and Treatment Outcomes for Infected Upper Urinary Tract Stones in the United States

BACKGROUND The incidence of infected urolithiasis is unknown, and evidence describing the optimal management strategy for obstruction is equivocal. OBJECTIVE To examine the trends of infected urolithiasis in the United States, the practice patterns of competing treatment modalities, and to compare adverse outcomes. DESIGN, SETTING, AND PARTICIPANTS A weighted estimate of 396385 adult patients hospitalized with infected urolithiasis was extracted from the Nationwide Inpatient Sample, 1999-2009. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Time trend analysis examined the incidence of infected urolithiasis and associated sepsis, as well as rates of retrograde ureteral catheterization and percutaneous nephrostomy (PCN) for urgent/emergent decompression. Propensity-score matching compared the rates of adverse outcomes between approaches. RESULTS AND LIMITATIONS Between 1999 and 2009, the incidence of infected urolithiasis in women increased from 15.5 (95% confidence interval [CI], 15.3-15.6) to 27.6 (27.4-27.8)/100 000); men increased from 7.8 (7.7-7.9) to 12.1 (12.0-12.3)/100000. Rates of associated sepsis increased from 6.9% to 8.5% (p=0.013), and severe sepsis increased from 1.7% to 3.2% (p<0.001); mortality rates remained stable at 0.25-0.20% (p=0.150). Among those undergoing immediate decompression, 113 459 (28.6%), PCN utilization decreased from 16.1% to 11.2% (p=0.001), with significant regional variability. In matched analysis, PCN showed higher rates of sepsis (odds ratio [OR]: 1.63; 95% CI, 1.52-1.74), severe sepsis (OR: 2.28; 95% CI, 2.06-2.52), prolonged length of stay (OR: 3.18; 95% CI, 3.01-3.34), elevated hospital charges (OR: 2.71; 95%CI, 2.57-2.85), and mortality (OR: 3.14; 95%CI, 13-4.63). However, observational data preclude the assessment of timing between outcome and intervention, and disease severity. CONCLUSIONS Between 1999 and 2009, women were twice as likely to have infected urolithiasis. Rates of associated sepsis and severe sepsis increased, but mortality rates remained stable. Analysis of competing treatment strategies for immediate decompression demonstrates decreasing utilization of PCN, which showed higher rates of adverse outcomes. These findings should be viewed as preliminary and hypothesis generating, demonstrating the pressing need for further study.

Emergency Department Visits in the United States for Upper Urinary Tract Stones: Trends in Hospitalization and Charges

PURPOSE Using the Nationwide Emergency Department Sample (NEDS) we examined trends in visits, hospitalization and charges for patients with upper urinary tract stones who presented to the emergency department in the United States. MATERIALS AND METHODS All visits with a primary diagnosis of kidney calculus (ICD-9-CM code 592.0), ureter calculus (592.1) or urinary calculus unspecified (592.9) were extracted from NEDS between 2006 and 2009. A weighted sample was used to calculate incidence rates. Temporal trends were quantified by the estimated annual percent change. Patient and hospital characteristics associated with hospitalization were evaluated using logistic regression models adjusted for clustering. RESULTS Between 2006 and 2009 there were 3,635,054 emergency department visits for upper urinary tract stones. The incidence increased from 289 to 306/100,000 individuals. More men visited than women but women showed significant increases in visits (estimated annual percent change 2.85%, p = 0.018). Total monthly emergency department visits ranged from 5.8% in February to 8.4% in August. Overall 12.0% of patients were hospitalized and the hospitalization rate remained stable (estimated annual percent change -1.02%, p = 0.634). Patients were more likely to be hospitalized if they were female, more ill, seen at an urban teaching or low volume hospital, or had Medicaid or Medicare (each p <0.001). Sepsis was associated with the highest likelihood of hospital admission (OR 69.64, p <0.001). In 2009 charges for emergency department visits increased to

National Trends and Disparities in the Use of Minimally Invasive Adult Pyeloplasty

5 billion (estimated annual percent change 10.06%, p = 0.003). CONCLUSIONS Women showed significant annual increases in emergency department visits for upper urinary tract stones. While emergency department charges increased substantially, hospitalization rates remained stable. Greater use of computerized tomography and medical expulsive therapy could be the reasons for this observation, which warrants further study.