Wesley W. Ludwig

The Effect of Repair Costs on the Profitability of a Ureteroscopy Program

BACKGROUND AND PURPOSE Ureteroscopy (URS) is a common treatment for patients with stone disease. One of the disadvantages of this approach is the great capital expense associated with the purchase and repair of endoscopic equipment. In some cases, these costs can outpace revenues and lead to an unprofitable and unsustainable enterprise. We sought to characterize the profitability of our URS program when accounting for endoscope maintenance and repair costs. MATERIALS AND METHODS We identified all URS cases performed at a single hospital during fiscal year 2013 (FY2013). Charges, collection rates, and fixed and variable costs including annual equipment repair costs were obtained. The net margin and break-even point of URS were derived on a per-case basis. RESULTS For 190 cases performed in FY2013, total endoscope repair costs totaled

Inguinal Hernia Repair During Extraperitoneal Robot-Assisted Laparoscopic Radical Prostatectomy.

115,000, resulting in an average repair cost of

Improving time to continence after robot-assisted laparoscopic prostatectomy: augmentation of the total anatomic reconstruction technique by adding dynamic detrusor cuff trigonoplasty and suprapubic tube placement.

605 per case. The vast majority of cases (94.2%) were conducted in the outpatient setting, which generated a net margin of

Reducing the Cost of Robotic Partial Nephrectomy Through Innovative Instrument Use

659 per case, while inpatient cases yielded a net loss of

Robotic Primary RPLND for Stage I Testicular Cancer: a Review of Indications and Outcomes

455. URS was ultimately associated with a net positive margin approaching

Prostate specific antigen testing after radical prostatectomy: can we stop at 20 years?

600 per case. On break-even analysis, URS remained profitable until repair costs reached

Prostate MRI prior to radical prostatectomy: effects on nerve sparing and pathological margin status

1200 per case. CONCLUSIONS Based on these findings, an established URS program can sustain profitability even with large equipment repair costs. Nonetheless, our findings serve to emphasize the importance of controlling costs, particularly in the current setting of decreasing reimbursement. A multifaceted approach, based on improving endoscope durability and exploring digital and disposable platforms, will be critical in maintaining the sustainability of URS.

Instrument Life for Robot-Assisted Laparoscopic Radical Prostatectomy and Partial Nephrectomy: Are Ten Lives for Most Instruments Justified?

INTRODUCTION One third of men undergoing radical prostatectomy have a comorbid inguinal hernia (IH). Previous studies have shown that adding total extraperitoneal (TEP) IH repair to extraperitoneal laparoscopic radical prostatectomy (LRP) lacks adverse effects. However, outcomes of extraperitoneal robot-assisted laparoscopic radical prostatectomy (RALP) and TEP are unknown. We compared RALP+TEP with LRP+TEP and also with RALP alone. METHODS Eleven RALP+TEP cases were retrospectively compared with 26 LRP+TEP cases and 22 control RALP without TEP. Outcomes compared between groups included operative time, estimated blood loss (EBL), discharge hematocrit (hct), time to diet advancement, length of hospital stay (LOS), postoperative complications, and hernia recurrence. RESULTS Unilateral TEP added 32 minutes to RALP and 31 minutes to LRP, whereas bilateral TEP added 80 minutes to RALP and 36 minutes to LRP. There were no differences between RALP+TEP and LRP+TEP or RALP without TEP controls in regard to EBL, discharge hct, time to diet advancement, LOS, or postoperative complications. One patient developed an anterior mesh seroma, which resolved without intervention. No IH recurrences were noted on the mean follow-up of 33 months in the RALP group and 50 months in the LRP cohort. CONCLUSIONS Unilateral and bilateral TEP added operative time to RALP but had equivalent outcomes to both LRP+TEP and RALP alone. This is likely due to the similar surgical space used for RALP and TEP, which obviates the need for substantial further dissection. For men with prostate cancer and comorbid IH, combined RALP+TEP appears to be an appropriate surgical combination.

Robotic Systems in Urological Surgery: Current State and Future Directions

After robot-assisted laparoscopic prostatectomy, total anatomic reconstruction (TR) with the additions of a circumapical urethral dissection, a dynamic detrusor cuff trigonoplasty, and placement of a suprapubic catheter was performed in 49 patients from June to July 2012. Continence at 6 weeks after catheter removal was assessed for an initial group of 23 patients, and also at 2 weeks in an additional 26 patients who most recently had undergone surgery. Follow-up appointments and telephone interviews were used to assess pad use and continence. Of the initial 23 patients receiving the modified TR, 60.9% had 0 pad use at 6 weeks. By 2 weeks, 65.4% of the most recent 26 patients operated on achieved continence with 0-1 pad use. Preservation and reconstruction of the pelvic floor and supporting bladder structures leads to an earlier return of continence. These key steps need to be validated and confirmed in larger and randomized trials.

A User-Friendly Application to Automate CT Renal Stone Measurement

With healthcare expenditures in the United States predicted to double in the next decade, there is growing pressure for cost containment [1]. The widespread adoption of robotic surgery has come under increasing scrutiny because of added expense with questionably commensurate patient outcomes [2]. The cost of robotic supplies, including instruments, represents a significant portion of operative costs. These are dictated by the vendor, allowing little flexibility for cost reduction. Here, we present an example of instrument innovation during robotic partial nephrectomy (RPN) that permits notable cost and supply savings. RPN costs a median of