Influence of surgeon and hospital volume on radical prostatectomy costs.

PURPOSE: While higher radical prostatectomy hospital and surgeon volume are associated with better outcomes, the effect of provider volume on health care costs remains unclear. We performed a population based study to characterize the effect of surgeon and hospital volume on radical prostatectomy costs. MATERIALS AND METHODS: We used SEER (Surveillance, Epidemiology and End Results)-Medicare linked data to identify 11,048 men who underwent radical prostatectomy from 2003 to 2009. We categorized hospital and surgeon radical prostatectomy volume into tertiles (low, intermediate, high) and assessed costs from radical prostatectomy until 90 days postoperatively using propensity adjusted analyses. RESULTS: Higher surgeon volume at intermediate volume hospitals (surgeon volume low $9,915; intermediate $10,068; high $9,451; p = 0.021) and high volume hospitals (surgeon volume low $11,271; intermediate $10,638; high $9,529; p = 0.002) was associated with lower radical prostatectomy costs. Extrapolating nationally, selective referral to high volume radical prostatectomy surgeons at high and intermediate volume hospitals netted more than $28.7 million in cost savings. Conversely, higher hospital volume was associated with greater radical prostatectomy costs for low volume surgeons (hospital volume low $9,685; intermediate $9,915; high $11,271; p = 0.010) and intermediate volume surgeons (hospital volume low $9,605; intermediate $10,068; high $10,638; p = 0.029). High volume radical prostatectomy surgeon costs were not affected by varying hospital volume, and among low volume hospitals radical prostatectomy costs did not differ by surgeon volume. CONCLUSIONS: Selective referral to high volume radical prostatectomy surgeons operating at intermediate and high volume hospitals nets significant cost savings. However, higher radical prostatectomy hospital volume was associated with greater costs for low and intermediate volume radical prostatectomy surgeons.

The impact of prostate size, median lobe, and prior benign prostatic hyperplasia intervention on robot-assisted laparoscopic prostatectomy: technique and outcomes.

BACKGROUND: Large prostate size, median lobes, and prior benign prostatic hyperplasia (BPH) surgery may pose technical challenges during robot-assisted laparoscopic prostatectomy (RALP). OBJECTIVE: To describe technical modifications to overcome BPH sequelae and associated outcomes. DESIGN, SETTINGS, AND PARTICIPANTS: A retrospective study of prospective data on 951 RALP procedures performed from September 2005 to November 2010 was conducted. Outcomes were analyzed by prostate weight, prior BPH surgical intervention (n=59), and median lobes >1 cm (n=42). SURGICAL PROCEDURE: RALP. MEASUREMENTS: Estimated blood loss (EBL), blood transfusions, operative time, positive surgical margin (PSM), and urinary and sexual function were measured. RESULTS AND LIMITATIONS: In unadjusted analysis, men with larger prostates and median lobes experienced higher EBL (213.5 vs 176.5 ml; p<0.001 and 236.4 vs 193.3 ml; p=0.002), and larger prostates were associated with more transfusions (4 vs 1; p=0.037). Operative times were longer for men with larger prostates (164.2 vs 149.1 min; p=0.002), median lobes (185.8 vs 155.0 min; p=0.004), and prior BPH surgical interventions (170.2 vs 155.4 min; p=0.004). Men with prior BPH interventions experienced more prostate base PSM (5.1% vs 1.2%; p=0.018) but similar overall PSM. In adjusted analyses, the presence of median lobes increased both EBL (p=0.006) and operative times (p<0.001), while prior BPH interventions also prolonged operative times (p=0.014). However, prostate size did not affect EBL, PSM, or recovery of urinary or sexual function. CONCLUSIONS: Although BPH characteristics prolonged RALP procedure times and increased EBL, prostate size did not affect PSM or urinary and sexual function.

Athermal division and selective suture ligation of the dorsal vein complex during robot-assisted laparoscopic radical prostatectomy: description of technique and outcomes.

BACKGROUND: Apical dissection and control of the dorsal vein complex (DVC) affects blood loss, apical positive margins, and urinary control during robot-assisted laparoscopic radical prostatectomy (RALP). OBJECTIVE: To describe technique and outcomes for athermal DVC division followed by selective suture ligation (DVC-SSL) compared with DVC suture ligation followed by athermal division (SL-DVC). DESIGN, SETTINGS, AND PARTICIPANTS: Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures. SURGICAL PROCEDURE: RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection. MEASUREMENTS: Blood loss, transfusions, operative time, apical and overall positive margins, urine leaks, catheterization duration, and urinary control at 5 and 12 mo evaluated using 1) the Expanded Prostate Cancer Index (EPIC) urinary function scale and 2) continence defined as zero pads per day. RESULTS AND LIMITATIONS: Men who underwent DVC-SSL versus SL-DVC were older (mean: 59.9 vs 57.8 yr, p<0.001), and relatively fewer white men underwent DVC-SSL versus SL-DVC (87.5% vs 96.7%, p<0.001). Operative times were also shorter for DVC-SSL versus SL-DVC (mean: 132 vs 147 min, p<0.001). Men undergoing DVC-SSL versus SL-DVC experienced greater blood loss (mean: 184.3 vs 175.6 ml, p=0.033), and one DVC-SSL versus zero SL-DVC were transfused (p=0.442). Overall (12.2% vs 12.0%, p=1.0) and apical (1.3% vs 2.7%, p=0.361) positive surgical margins were similar for DVC-SSL versus SL-DVC. Although 5-mo postoperative urinary function (mean: 72.9 vs 55.4, p<0.001) and continence (61.4% vs 39.6%, p<0.001) were better for DVC-SSL versus SL-DVC, 12-mo urinary outcomes were similar. In adjusted analyses, DVC-SSL versus SL-DVC was associated with shorter operative times (parameter estimate [PE]±standard error [SE]: 16.84±2.56, p<0.001), and better 5-mo urinary function (PE±SE: 19.93±3.09, p<0.001) and continence (odds ratio 3.39, 95% confidence interval 2.07-5.57, p<0.001). CONCLUSIONS: DVC-SSL versus SL-DVC improves early urinary control and shortens operative times due to fewer instrument changes with late versus early DVC control.