Impact of physician awareness on hospital charges for radical retropubic prostatectomy.

PURPOSE: We determine if physician awareness of hospital costs for radical retropubic prostatectomy affects physician practice patterns. MATERIALS AND METHODS: We reviewed 256 consecutive radical retropubic prostatectomies performed by 14 urologists during 4 years at a community hospital. After 2 years the physicians were provided information on factors that may decrease charges. RESULTS: Charges decreased significantly following intervention, from +f417,134 within the initial 2 years to +f413,826 within the last 2 years (p < 0.005). Significant decreases were noted for length of stay, need for intensive care, operating time and blood loss. CONCLUSIONS: Traditional methods of physician education can impact practice patterns to decrease hospital charges for radical retropubic prostatectomy.

The role of the physician in effecting change in hospital charge for radical prostatectomy.

BACKGROUND: Continuing effort is being made to provide the best medical care in a cost-effective manner, requiring an evaluation of factors that control charges. The number of cases of carcinoma of the prostate gland and the number of radical retropubic prostatectomies performed have increased in recent years, with an estimate of several hundred million dollars being spent annually on this procedure in the United States of America. Because physicians are reported to effect the majority of charges for a hospitalization, this study examines the influence of notification of the physician of hospital charges on the overall hospital charges for radical retropubic prostatectomy. STUDY DESIGN: Total hospital charge and duration per hospitalization were determined for all patients having radical prostatectomies performed at five community hospitals in Richmond, VA, between January 1991 and December 1993. Patients included 625 males diagnosed with carcinoma of the prostate gland undergoing radical prostatectomy by one of 20 urologists from several different private practice groups. Halfway into the time period studied, physicians were notified of data collection and of factors that seemed to have a role in hospital charges. Total hospital charges before and after physician notification were measured to determine whether or not physicians could effect hospital charges. RESULTS: Overall, hospital charges decreased significantly after notification of physicians in the study. The decline in total charges continued throughout the follow-up period. Duration of hospitalization decreased throughout the entire study period, while total charge per hospital day increased. CONCLUSIONS: Physician awareness of hospital charges for operative procedures and accompanying hospitalizations may influence the overall decrease in charges.

Color Doppler ultrasound for the diagnosis of segmental testicular infarction.

We report a case of segmental infarction of the testis associated with scrotal pain diagnosed by color Doppler ultrasound. Histological examination of the testis confirmed the diagnosis. Use of this imaging modality may obviate surgical exploration in select cases.

The interaction between electrosurgical generators, endoscopic electrodes, and tissue.

Endoscopic monopolar and bipolar devices were compared during cutting and coagulation. It was observed on appropriate animal models that the initial resistance (impedance) values recorded correspond to the normal tissue impedance at the electrode. The subsequent impedance values increase 25 to 50 ohms for the coagulator which relates to tissue desiccation and for the cutting electrodes the impedance increases greater than 1000 ohms during the arcing process. At similar power settings, typical monopolar generators produce maximum power at 300 to 500 ohms while typical bipolar generators produce maximum power at 25 to 100 ohms. With impedances greater than 1000 ohms, monopolar generators are capable of higher power output than are bipolar generators. Since cutting is a high impedance process, bipolar cutting electrodes do not perform as intended with typical bipolar generators. Therefore, bipolar cutting electrodes should be employed with a monopolar generator or a generator designed specifically for their use.

Endourological treatment of ureteroenteric anastomotic strictures: long-term followup.

In 1987 we reported our initial experience with an endosurgical incisional approach to ureteroenteric anastomotic strictures (that is endoureterotomy). We have extended that initial report to encompass 15 patients with 19 ureteroenteric strictures followed for an average of 2.5 years. In all cases an endosurgical approach was well tolerated, blood loss was less than 50 cc and hospital stay averaged 3.5 days. A 16 to 22F external stent was left in place for 4 to 6 weeks postoperatively in 14 strictures. A permanent external 12F catheter was left in 5 strictures due to the presence of metastatic disease (4) and a complete dense stricture (1). The only major complication was a ureteroenteric fistula that healed over a ureteral stent without any open surgical intervention. Among 14 ureteroenteric strictures in which the stent was removed, the ureteroenteric area has remained patent in 8 (57%) with an average followup of 28.6 months (range 9 to 57 months). Failures were associated with metastatic disease in 2 cases, generalized debility in 2 and unexplained in 2. In this series an endosurgical approach to ureteroenteric strictures provided long-term satisfactory management of the problem in the majority of patients with benign and malignant disease. By current standards, only 1 patient (7%) would have been considered a candidate for open surgical repair.

Direct-current potentials created by arcing during monopolar radiofrequency electrosurgery.

Muscle and nerve stimulation during radiofrequency electrosurgery has been a well-known phenomenon for over 50 years. However, as electrosurgery expands into new procedures, such as tissue ablation in the heart, the mechanism of the potentially deleterious stimulation becomes more important. This article presents data showing that large DC currents are generated during electrosurgery and that these potentials increase with increasing sparking at the active electrode. The data also show DC potentials generated by various generators, different operation modes (cut, coagulation, fulguration), and operations on tissues of various impedances.

Use of 5F bipolar electrosurgical probe in endoscopic urological procedures.

Experimental data have shown bipolar electrodes to function in saline solution with less volume and depth of tissue destruction compared to similar sized monopolar electrodes. We applied the same bipolar generator and electrodes used in laboratory testing in 41 procedures on 36 patients to determine if the bipolar electrode will provide clinically adequate hemostasis. The bipolar electrode was used for bladder fulguration in 37 procedures and ureteral fulguration in 4. The procedures were performed by 7 urological surgeons and in normal saline solution. The bipolar electrode was believed to perform as well as the standard monopolar probe in 39 procedures. The 2 failures included 1 bladder tumor fulguration and 1 electroincision of a ureterointestinal anastomotic stricture. There were no episodes of recurrent bleeding after any procedure. The bipolar system has the added advantage of not requiring a return electrode (ground pad), thereby eliminating the possibility of skin burns.

In vivo effect of 5 French bipolar and monopolar electrosurgical probes on the porcine bladder.

Previous in vitro studies have indicated bipolar electrosurgical probes would electrodesiccate tissue in a normal saline solution. This study applies similar sized monopolar and bipolar electrosurgical probes to porcine bladder in order to compare each probe's effect in vivo. The power delivered by each probe was calculated; the width and depth of the porcine bladder damage was measured and the volume of the damage calculated. The animals were sacrificed at 24, 48 and 96 h post-procedure so that the amount of tissue destruction could be quantitated relative to the bladder's natural tissue reaction. The data shows the power (watts) delivered by the monopolar probe to be approximately six times that of the bipolar probe. Likewise, the area of bladder wall damage was larger with monopolar at all time periods sampled and showed significant differences at 24 and 48 h. These studies indicate that in viable bladder, tissue bipolar probes will electrodessicate at a lower power and with less shortterm tissue damage.

Magnetic resonance imaging in the diagnosis and followup of idiopathic retroperitoneal fibrosis.

Four cases of idiopathic retroperitoneal fibrosis are reported. Magnetic resonance and computerized tomographic images were obtained for diagnosis in each case, and followup scans were obtained at various intervals after therapy. In all 4 cases magnetic resonance imaging was equal or superior to computerized tomography in the diagnosis of retroperitoneal fibrosis, outlining the extent of involvement, preoperative planning and assessing response to medical or surgical therapy.

A comparison of urologic application of bipolar versus monopolar five French electrosurgical probes.

Urologic endoscopic procedures often involve electrosurgery. Recently bipolar probes have become commercially available. This study compares monopolar and bipolar electrosurgical probes in relation to power losses in urologic endoscopic instruments with the infusion of sterile water and saline, and the power transmitted by probes to tissue correlated to tissue destruction in each fluid. The power losses through each instrument in both solutions were minimal. The bipolar electrode functioned at a much lower power output than did the monopolar electrode. The bipolar probe was also more effective in saline than sterile water. The depth, width and volume of tissue damage for both electrodes were found to vary with generator power output. The data shows the burns had similar diameters for both probes but the bipolar probe caused significantly less burn depth than the monopolar probe. These initial studies indicate that bipolar electrodes can function in normal saline with less depth damage compared to the monopolar probe.

Management of benign ureteral structures: open surgical repair or endoscopic dilation?

We reviewed 20 cases of ureteral strictures, 15 of which were secondary to ureteral trauma. Of the patients 6 were managed initially by open repair and 14 underwent endoscopic manipulation. All 6 open repairs were successful, compared to 9 of the 14 patients who underwent endoscopic dilation of the ureteral stricture. Of the 5 failures 3 were due to the inability to cannulate the strictured ureter with a guide wire and 2 failed to respond to balloon dilation. Of these 5 patients 4 were treated successfully by an open operation. There were no serious intraoperative or postoperative complications. The average hospitalization was less for the endoscopic group (2.1 days) compared to the open surgical group (8.3 days). Followup ranged from 6 to 48 months.

Invasive adenocarcinoma of bladder response to cisplatinum, methotrexate, and vinblastine chemotherapy.

Primary invasive adenocarcinoma of the bladder was diagnosed in a fifty-two-year-old male with a two-month history of irritative voiding symptoms. He was treated with three courses of cisplatinum, methotrexate, and vinblastine with marked regression of tumor shown radiographically and cystoscopically. Subsequent prostatocystectomy and ileal loop diversion revealed invasive tumor through the bladder wall to regional lymph nodes. The patient had two postoperative courses of the same chemotherapeutic regimen and is without evidence of disease recurrence at one year.

A simple and inexpensive method for measuring electrosurgical variables.

A simple circuit that demodulates the high-frequency output of an electrosurgical generator to proportional DC values can be employed to monitor generator voltage and electrosurgical current. An example of the use of the circuit in a urologic application is given. Employing this monitoring circuit, quantitative comparisons of electrosurgical equipment and performances can be made.

Advances in endosurgery. Treatment of ureteral-enteric anastomotic strictures.

The described endourologic technique of incision and dilation of a ureteral-intestinal stricture is effective in most patients. Indeed, with the outlined treatment regimen, less than 30 per cent of patients with ureteral-intestinal anastomotic strictures will eventually require open surgical revision. Further advances in the use of lasers or the endourologic positioning of free tissue grafts may further improve the success rate of the endoscopic approach.

Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair.

The established treatment for ureterointestinal anastomotic strictures is open surgical revision. In an effort to evaluate the efficacy of endourological surgery for this problem, we compared 7 patients (9 strictures) who underwent open revision to 6 patients (7 strictures) who underwent endoscopic incision and balloon dilation of the stricture. The success rate (that is patent ureter and no stent) was 89 per cent for the open revision group and 71 per cent (5 of 7) for the endoscopic group. All open revisions required use of general anesthesia, while 3 of the endoscopic procedures were performed with the patient under assisted local anesthesia. The endoscopic group had markedly shorter hospitalization, decreased blood loss, diminished patient discomfort and no postoperative complications. While the endoscopic procedure for ureteroileal anastomotic strictures is less successful than open revision, the lower morbidity, decreased cost and shorter hospital stay associated with the endourological approach favor its use over open revision. For elderly patients who fail initial endoscopic revision and for patients with metastatic transitional cell cancer, placement of an indwelling stent is a reasonable alternative. Given these guidelines, less than 30 per cent of the patients who suffer a ureteroileal anastomotic stricture will require open surgical revision.

The value of testosterone deprivation in stage D1 carcinoma of the prostate.

The question of whether hormonal manipulation is effective in the treatment of stage D1 carcinoma of the prostate has yet to be determined conclusively. To study this question a retrospective review was conducted of 68 patients with stage D1 disease. Of the patients 22 underwent immediate orchiectomy, 24 delayed orchiectomy and 11 exogenous antiandrogen treatment (8 immediate and 3 delayed treatment), and 11 had no androgen deprivation. The patients were placed into 2 groups consisting of those receiving immediate hormonal deprivation (30) and those having treatment at the time of bone metastasis or who are as yet untreated (38). The minimum followup was 60 months. The median interval to progression to bone metastasis was 43 months in the delayed treatment group compared to 100 months in the immediate hormonal deprivation group. This difference was statistically significant (p equals 0.0087). Likewise, the median period from diagnosis to death was 90 months in the delayed treatment group and 150 months in the immediate treatment group. This difference was not significant (p equals 0.1110). Thus, orchiectomy or adequate androgen deprivation from our data significantly prolongs the interval to bone metastasis in patients with metastatic prostate cancer limited to the pelvic lymph nodes. The apparent increased length of survival of the immediate treatment group lacks statistical confirmation.