Tag Archive for: surgery

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Should we abandon live surgery: reflections after Semi-Live 2017

Prokar_v2Ever since 2002, I have performed live surgery almost every year where it is transmitted to an audience eager to learn. This year I was invited by Markus Hohenfellner to the unique conference, Semi Live 2017 in Heidelberg. To say that it was an eye opener is perhaps stating the obvious. One look at the program will show you that the worlds most respected Urological surgeons had been invited to participate, but with a difference. There was no live surgery. Instead videos of operations – open, laparoscopic and robotic were shared with the attendees “warts and all” as a learning experience. These were not videos designed to show the best parts of an operation. There were plenty of difficult moments, do’s and don’ts and troubleshooting, but all this was achieved without causing harm or potential harm to a single patient.

My highlights were laparoscopic sacrocolpopexy (Gaston), robotic IVC thrombectomy up to the right atrium (Zhang) and reconstructive surgery for the buried penis (Santucci). The event takes place every 2 years and the videos are all available on the meeting app which can be downloaded here and is an outstanding educational resource.

We were treated to a heritage session which included the superstars Walsh, Hautmann, Clayman, Mundy, Schroder and Ghoneim. This was followed by our host Markus Hohenfellner comparing and contrasting the art of Cystectomy and reconstruction by Ghoneim, Stenzl and Studer.

 

Open surgery is certainly not dead yet. The session ended with Seven Pillars of Wisdom from Egypt which turned out to be a big hit on Twitter.

capture

The editor’s choice session, a new innovation for 2017, allowed me to showcase the Best of BJUI Step by Step, a section that has now replaced Surgery Illustrated with fully indexed and citable HD videos and short papers.

Has live surgery had its day?

Many on Twitter seemed to agree that in 20 years time we might look back and say that it was not the right thing to do.

1-1

1-2

Surgeons do not operate “live” every day. Most doctors in a survey, would not subject themselves or their families to be patients during live surgery. Talk about hypocrisy!! Why should it be any different for our patients? Live surgery is NOT a blood sport practised in Roman times….

The counterpoint is that patients often have the services of the best surgeons during live surgery, recorded, edited videos are not quite the same and that the whole affair has become safer thanks to patient advocates and strict guidelines from some organisations like the EAU. Others have banned the practice for good reason. While the debate continues, I for one came away feeling that Semi-Live was as educational, less stressful and much safer for our patients.

 

Prokar Dasgupta @prokarurol
Editor-in-Chief, BJUI 

 

Infographic: nephron-sparing surgery across a nation

BAUS 2012 national partial nephrectomy audit infographic

Read the full article

See more infographics

Randomised Controlled Trials in Robotic Surgery

PDGSep16It has been nearly 15 years since one of the first ever randomised controlled trials (RCT) in robotic surgery was conducted in 2002. The STAR-TRAK compared telerobotic percutaneous nephrolithotomy (PCNL) to standard PCNL and showed that the robot was slower but more accurate than the human hand [1].

In the 24 h since the much anticipated RCT of open vs robot-assisted radical prostatectomy was published in The Lancet [2], our BJUI blog from @declangmurphy was viewed >2500 times, receiving >40 comments, making it one of our most read and interactive blogs ever. It is a negative trial showing no differences in early functional outcomes between the two approaches.

And it is not the only negative trial of its kind as a number of others have matured and reported recently. The RCT of open vs robot-assisted radical cystectomy and extracorporeal urinary diversion showed no differences in the two arms [3], and likewise a comparison of the two approaches to cystectomy as a prelude to the RAZOR (randomised open vs robotic cystectomy) trial showed no differences in quality of life at 3-monthly time points up to a year [4]. The only RCT comparing open, laparoscopic and robotic cystectomy, the CORAL, took a long time to recruit and yet again showed no differences in 90-day complication rates between the three techniques [5].

In all likelihood, despite the level 1 evidence provided in The Lancet paper showing no superiority of the robotic over the open approach, the Brisbane study may not change the current dominance of robotic prostatectomy in those countries who can afford this technology. Why is this? Apart from the inherent limitations that the BJUI blog identifies, there are other factors to consider. In particular, as observed previously in a memorable article ‘Why don’t Mercedes Benz publish randomised trials?’ [6], there may be reasons why surgical technique is not always suited to the RCT format.

A few additional reflections are perhaps appropriate at this time:

  1. Despite the best statistical input many of these and future studies are perhaps underpowered.
  2. Many have argued that the RCTs have shown robotics to be as good, although not better than open surgery, even in the hands of less experienced surgeons.
  3. Patient reported quality of life should perhaps become the primary outcome measure because that in the end that is what truly matters.
  4. Cost-effectiveness ratios should feature prominently, as otherwise there is much speculation by the lay press without any hard data.
  5. Industry has a role to play here in keeping costs manageable, so that these ratios can become more palatable to payers.
  6. Surgery is more of an art than a science. The best surgeons armed with the best technology that they are comfortable with will achieve the best outcomes for their patients.

While this debate will continue and influence national healthcare providers and decision makers, the message looks much clearer when it comes to training the next generation of robotic surgeons. A cognitive- and performance-based RCT using a device to simulate vesico-urethral anastomosis after robot-assisted radical prostatectomy (RARP) showed a clear advantage in favour of such structured training [7]. In this months’ issue of the BJUI, we present the first predictive validity of robotic simulation showing better clinical performance of RARP in patients [8]. This is a major step forward in patient safety and would reassure policy makers that investment in simulation of robotic technology rather than the traditional unstructured training is the way forward.

Most of our patients are knowledgeable, extensively research their options on ‘Dr Google’ and decide what is good for them. It is for this reason that many did not agree to randomisation in other robotic vs open surgery RCTs, like LopeRA (RCT of laparoscopic, open and robot assisted prostatectomy as treatment for organ-confined prostate cancer) and BOLERO (Bladder cancer: Open vs Lapararoscopic or RObotic cystectomy). Many of them continue to choose robotic surgery without necessarily paying heed to the best scientific evidence. Perhaps what patients will now do is select an experienced surgeon whom they can trust to use their best technology to deliver the best clinical outcomes.

Prokar Dasgupta @prokarurol
Editor-in-Chief, BJUI 

@declangmurphy

Associate Editor BJUI

References

2 Yaxley JW, Coughlin GD, Chambe rs SK et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet 2016 [Epub ahead of print]. doi: 10.1016/S0140-6736(16)30592-X
3 Bochner BH, Sjoberg DD, Laudone VP, Memorial Sloan Kettering Cancer Center Bladder Cancer Surgical Trials Group. A randomized trial of robot-assisted laparoscopic radical cystectomy. N Engl J Med 2014; 371:38990

4

Messer JC, Punnen S , Fitzgerald J et al. Health-related quality of life from a

6 OBrien T, Viney R , Doherty A, Thomas K. Why dont Mercedes Benz publish
randomised trials? BJU Int 2010; 105 : 2935
8 Aghazadeh MA, Mercado MA, Pan MM , Miles BJ, Goh AC. Performance of

 

Article of the Week: NSS Across a Nation

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Archie Fernando and Tim O’Brien, discussing their paper.

If you only have time to read one article this week, it should be this one.

Nephron-sparing surgery across a nation – outcomes from the British Association of Urological Surgeons 2012 national partial nephrectomy audit

Archie Fernando*, Sarah Fowler* and Tim OBrien*, on behalf of the British
Association of Urological Surgeons (BAUS) 

 

*BAUS, The Royal College of Surgeons of England, and The Urology Centre, Guys and St Thomas NHS Foundation Trust, London, UK

 

Read the full article
BAUS-2012-national-partial-nephrectomy-audit-infographic-clipped

 

Click on image for full size infographic

 

Objective

To determine the scope and outcomes of nephron-sparing surgery (NSS), i.e. partial nephrectomy, across the UK and in so doing set a realistic benchmark and identify fresh contemporary challenges in NSS.

Patients and Methods

In 2012 reporting of outcomes of all types of nephrectomy became mandatory in the UK. In all, 148 surgeons in 86 centres prospectively entered data on 6 042 nephrectomies undertaken in 2012. This study is a retrospective analysis of the NSS procedures in the dataset.

Results

A total of 1 044 NSS procedures were recorded and the median (range) surgical volume was 4 (1–39) per consultant and 8 (1–59) per centre. In all, 36 surgeons and 10 centres reported on only one NSS. The indications for NSS were: elective with a tumour of ≤4.5 cm in 59%, elective with a tumour of >4.5 cm in 10%, relative in 7%, imperative in 12%, Von Hippel–Lindau in 1%, and unknown in 11%. The median (range) tumour size was 3.4 (0.8–30) cm. The technique used was minimally invasive surgery in 42%, open in 58%, with conversions in 4%. The histology results were: malignant in 80%, benign in 18%, and unknown in 2%. In patients aged <40 years 36% (36/101) had benign histology vs 17% (151/874) of those aged ≥40 years (P < 0.01). In patients with tumours of <2.5 cm 29% (69/238) had benign histology vs 14% (57/410) with tumours of 2.5–4 cm vs 8% (16/194) with tumours of ≥4 cm (P = 0.02). In patients aged <40 years with of tumours of <2.5 cm 44% (15/34) were benign. The 30-day mortality was 0.1% (1/1 044). There were major complications (Clavien–Dindo grade of ≥IIIa) in 5% (53/1 044). There was an increased risk of complications after extended elective NSS of 19% (19/101) vs elective at 12% (76/621) (relative risk [RR] 1.54; P < 0.01). Margins were recorded in 68% (709/1 044) of the patients, with positive margins identified in 7% (51/709). Positive surgical margins after NSS for pathological T3 (pT3) tumours were found in 47.8% (11/23) vs 6.1% (32/523) for pT1a, tumours (RR 5.61; P < 0.01). In all, 14% (894/6 042) of the patients underwent surgery for T1a tumours: 55% (488/894) by NSS, 42% (377/894) by radical nephrectomy (RN), and in 3% (29/894) the procedure used was unknown. Major complications after occurred in 4.9% (24/488) of NSS vs 1.3% (5/377) of RN (P < 0.01). Limitations included poor reporting of renal function data and no data on tumour complexity.

Conclusions

In its first year, mandatory national reporting has provided several challenging contemporary insights into NSS.

Read more articles of the week

Editorial: SRMs – Where is the Wisdom We Have Lost in Knowledge?

The perceived wisdom that a small enhancing mass in the kidney represents a surgical lesion that automatically requires excision without the need for a preoperative biopsy has been challenged by Fernando et al. [1] in this issue of BJUI.

The authors are to be congratulated in bringing these data to publication to provoke debate on the treatment paradigm for small renal masses (SRMs) by reviewing nationally collected data on the main therapeutic surgical option: nephron-sparing surgery. As anyone who has attended a renal multidisciplinary meeting can testify, the predominant presentation of renal cancer is the incidentally detected SRM, often in elderly patients with significant comorbidity.

As the authors emphasize, these data are unique in representing a national picture encompassing both high- and low-volume centres, as opposed to the majority of the studies in the literature, which report data from high-volume tertiary referral centres.

Drawing conclusions from data requires a clear understanding of the source and quality. Most importantly, as these data only refer to patients undergoing nephron-sparing surgery, we need to be cautious about extrapolating to infer information on the management of SRMs in general.

For instance, a striking finding of the present study is the high incidence of benign lesions in the younger age groups. We have no knowledge of the numbers of patients with SRMs within the study period who had biopsy-proven benign disease and thus avoided surgery. It is probable that the true incidence of benign disease would be even higher if these cases had been recorded and included in the analysis.

An inherent difficulty with self-reported data is the issue of compliance, and this is clearly evident in the present study, with, for example, almost a third of cases missing data on surgical margin results. It would perhaps be helpful for future audits if the BAUS dataset had a clear definition of positive surgical margin in recognition of the surgical drift to enucleation rather than excision with a margin of renal parenchyma.

The variation in caseload between reporting centres raises important questions, as does the finding that two fifths of patients with T1a tumours underwent radical nephrectomies. As the authors concede, with the numbers involved and the absence of any measure of tumour complexity, it is difficult to draw firm conclusions; however, the study does highlight the need to examine this issue in future analyses and to consider including some form of renal scoring system in future audits.

Where do we go from here and what can we do with this information? First, we need to rethink our discussion with patients with SRMs. Can we justify performing major surgery with a one in 20 chance of a significant complication for a possible benign lesion without at least a pragmatic discussion of the role of renal biopsy with the patient? Indeed, one may argue, could it really be an ‘informed’ decision without it?

Second, we need to improve the quality of the data by encouraging robust data reporting, increasing the completion rate and considering adding data fields which will allow us to draw clearer conclusions on surgical margin and surgical outcome and volume relationships.

Third, we need to recognize that nephron-sparing surgery is only one component of the management of SRMs, which represents a major contemporary challenge in terms of health resources and, most importantly, in deciding the best treatment paradigm for our patients. If BAUS can carry out this audit, could we not extend this to all patients with SRMs, whether they have surgery, ablation or surveillance, and establish greater clarity on these treatment methods?

Read the full article
Michael Aitchison, Consultant Urological Surgeon and Maxine Tran, Senior Lecturer in Renal Cancer Surgery and Honorary Consultant Urological Surgeon

 

Renal Cancer Service, Royal Free NHS Foundation Trust, London, UK

 

Reference

 

Video: Nephron-Sparing Surgery Across the UK

Nephron-sparing surgery across a nation – outcomes from the British Association of Urological Surgeons 2012 national partial nephrectomy audit

Archie Fernando*, Sarah Fowler* and Tim OBrien*, on behalf of the British
Association of Urological Surgeons (BAUS) 

 

*BAUS, The Royal College of Surgeons of England, and The Urology Centre, Guys and St Thomas NHS Foundation Trust, London, UK

 

Read the full article

Objective

To determine the scope and outcomes of nephron-sparing surgery (NSS), i.e. partial nephrectomy, across the UK and in so doing set a realistic benchmark and identify fresh contemporary challenges in NSS.

Patients and Methods

In 2012 reporting of outcomes of all types of nephrectomy became mandatory in the UK. In all, 148 surgeons in 86 centres prospectively entered data on 6 042 nephrectomies undertaken in 2012. This study is a retrospective analysis of the NSS procedures in the dataset.

Jun AOTW Results Image 4

Results

A total of 1 044 NSS procedures were recorded and the median (range) surgical volume was 4 (1–39) per consultant and 8 (1–59) per centre. In all, 36 surgeons and 10 centres reported on only one NSS. The indications for NSS were: elective with a tumour of ≤4.5 cm in 59%, elective with a tumour of >4.5 cm in 10%, relative in 7%, imperative in 12%, Von Hippel–Lindau in 1%, and unknown in 11%. The median (range) tumour size was 3.4 (0.8–30) cm. The technique used was minimally invasive surgery in 42%, open in 58%, with conversions in 4%. The histology results were: malignant in 80%, benign in 18%, and unknown in 2%. In patients aged <40 years 36% (36/101) had benign histology vs 17% (151/874) of those aged ≥40 years (P < 0.01). In patients with tumours of <2.5 cm 29% (69/238) had benign histology vs 14% (57/410) with tumours of 2.5–4 cm vs 8% (16/194) with tumours of ≥4 cm (P = 0.02). In patients aged <40 years with of tumours of <2.5 cm 44% (15/34) were benign. The 30-day mortality was 0.1% (1/1 044). There were major complications (Clavien–Dindo grade of ≥IIIa) in 5% (53/1 044). There was an increased risk of complications after extended elective NSS of 19% (19/101) vs elective at 12% (76/621) (relative risk [RR] 1.54; P < 0.01). Margins were recorded in 68% (709/1 044) of the patients, with positive margins identified in 7% (51/709). Positive surgical margins after NSS for pathological T3 (pT3) tumours were found in 47.8% (11/23) vs 6.1% (32/523) for pT1a, tumours (RR 5.61; P < 0.01). In all, 14% (894/6 042) of the patients underwent surgery for T1a tumours: 55% (488/894) by NSS, 42% (377/894) by radical nephrectomy (RN), and in 3% (29/894) the procedure used was unknown. Major complications after occurred in 4.9% (24/488) of NSS vs 1.3% (5/377) of RN (P < 0.01). Limitations included poor reporting of renal function data and no data on tumour complexity.

Conclusions

In its first year, mandatory national reporting has provided several challenging contemporary insights into NSS.

Read more articles of the week

Article of the Week: Evaluating health resource use and secondary care costs for RP and partial nephrectomy

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Mr. Jim Adshead, discussing his paper.

If you only have time to read one article this week, it should be this one.

Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques in oncology: analysis of English secondary care data for radical prostatectomy and partial nephrectomy

David Hughes*, Charlotte Camp*, Jamie OHara*† and Jim Adshead

 

*HCD Economics, Daresbury, Faculty of Health and Social Care, University of Chester, Chester, and Hertfordshire and South Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK

 

Read the full article

Objectives

To evaluate postoperative health resource utilisation and secondary care costs for radical prostatectomy and partial nephrectomy in National Health Service (NHS) hospitals in England, via a comparison of robot-assisted, conventional laparoscopic and open surgical approaches.

Patients and Methods

We retrospectively analysed the secondary care records of 23 735 patients who underwent robot-assisted (RARP, n = 8 016), laparoscopic (LRP, n = 6 776) or open radical prostatectomy (ORP, n = 8 943). We further analysed 2 173 patients who underwent robot-assisted (RAPN,n = 365), laparoscopic (LPN, n = 792) or open partial nephrectomy (OPN, n = 1 016). Postoperative inpatient admissions, hospital bed-days, excess bed-days and outpatient appointments at 360 and 1 080 days after surgery were reviewed.

JUnAOTW2FI

Results

Patients in the RARP group required significantly fewer inpatient admissions, hospital bed-days and excess bed-days at 360 and 1 080 days than patients undergoing ORP. Patients undergoing ORP had a significantly higher number of outpatient appointments at 1 080 days. The corresponding total costs were significantly lower for patients in the RARP group at 360 days (£1679 vs £2031 for ORP; P < 0.001) and at 1 080 days (£3461 vs £4208 for ORP; P < 0.001). In partial nephrectomy, Patients in the RAPN group required significantly fewer inpatient admissions and hospital bed-days at 360 days compared with those in the OPN group; no significant differences were observed in outcomes at 1 080 days. The corresponding total costs were lower for patients in the RAPN group at 360 days (£779 vs £1242 for OPN,P = 0.843) and at 1 080 days (£2122 vs £2889 for ORP; P = 0.570). For both procedure types, resource utilisation and costs for laparoscopic surgeries lay at the approximate midpoint of those for robot-assisted and open surgeries.

Conclusion

Our analysis provides compelling evidence to suggest that RARP leads to reduced long-term health resource utilisation and downstream cost savings compared with traditional open and laparoscopic approaches. Furthermore, despite the limitations that arise from the inclusion of a small sample, these results also suggest that robot-assisted surgery may represent a cost-saving alternative to existing surgical options in partial nephrectomy. Further exploration of clinical cost drivers, as well as an extension of the analysis into subsequent years, could lend support to the wider commissioning of robot-assisted surgery within the NHS.

Read more articles of the week

Editorial: Cost-effectiveness of robotic surgery; what do we know?

The introduction of the daVinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) has led to a continuous discussion about the cost-effectiveness of its use. The capital costs and extra costs per procedure for robot-assisted procedures are well known, but there are limited data on healthcare consumption in the longer term. In this issue of BJUI, a retrospective study investigated the NHS-registered, relevant care activities up to three years after surgery comparing robot-assisted, conventional laparoscopic, and open surgical approaches to radical prostatectomy and partial nephrectomy [1].

The robotic system is particularly useful in difficult to perform laparoscopic surgeries, which are easier to perform with the daVinci system due to improved three-dimensional vision, ergonomics, and additional dexterity of the instruments. Because the use of the robotic system is more costly, to justify its use the outcomes for patients should be improved. Therefore, more detailed information about the clinical and oncological outcomes, as well as the incidence of complications after surgery with the daVinci system, is needed.

Lower rates of positive surgical margins for robot-assisted radical prostatectomy (RARP) vs open and laparoscopic RP have been reported [2]. There also is evidence of an earlier recovery of functional outcomes, such as continence. RARP is associated with improved surgical margin status compared with open RP and reduced use of androgen-deprivation therapy and radiotherapy after RP, which has important implications for quality of life and costs. Ramsay et al. [3] reported that RARP could be cost-effective in the UK with a minimum volume of 100–150 cases per year per robotic system.

Centralisation of complex procedures will not only result in better outcomes, but also facilitate optimal economical usage of expensive medical devices. Furthermore, the skills learned to perform the RARP procedure can be used during other procedures, such as robot-assisted partial nephrectomy (RAPN) and radical cystectomy (RARC). The recent report by Buse et al. [4] confirms that RAPN is cost-effective in preventing perioperative complications in a high-volume centre, when compared with the open procedure. Minimally invasive techniques for complex procedures, such as a RC, take more time to perform, but result in less blood loss. A systematic review by Novara et al. [5] showed a longer operation time for RARC, but fewer transfusions and fewer complications compared with open surgery. However, there is no solid evidence about the cost-effectiveness of this technique to date. The RAZOR trial (randomised trial of open versus robot assisted radical cystectomy, DOI: 10.1111/bju.12699) is likely to provide some answers about differences in cost, complications, and quality of life when the results of the study become available later this year.

Additionally, the robotic system has been shown to shorten the learning curve of complex laparoscopic procedures in simulation models [6]. Recently, a newly structured curriculum to teach RARP has been validated by the European Association of Urology-Robotic Urology Section [7]. The effect of the shorter learning curve on the cost of the procedures has not yet been well studied for cost-effectiveness. However, due to the shorter learning curves, patients have lower risks of complications, which from the patients’ perspective is more important than any increased costs.

The study reported in this issue [1]; however, does not include the ‘out of pocket’ expenses of patients, it does not report on the differences in patient and tumour characteristics, and outcomes such as complications and oncological safety. These issues are all challenges to be addressed in a thorough prospective (randomised) trial on the cost-effectiveness of the use of robot-assisted surgery, including quality-of-life measurements and complications of the surgical procedures. In the Netherlands the RACE trial (comparative effectiveness study open RC vs RARC, www.racestudie.nl) started in 2015 and the results are expected in 2018–2019.

Read the full article
Carl J. Wijburg
Department of Urology, Robotic Surgery , Rijnstate HospitalArnhem, The Netherlands

 

References

 

 

2 HuJC, Gandaglia G, Karakiewicz PI et al. Comparative effectiveness of robot-assisted versus open radical prostatectomy. Eur Urol 2014; 66: 66672

 

 

4 Buse S, Hach CE, Klumpen P et al. Cost-effectiveness of robot-assisted partial nephrectomy for the prevention of perioperative complications. World J Urol 2015; [Epub ahead of print]. DOI:10.1007/s00345-015-1742-x

 

 

6 Moore LJ, Wilson MR, Waine E, Masters RS, McGrath JS, Vine SJRobotic technology results in faster and more robust surgical skill acquisition than traditional laparoscopy. J Robot Surg 2015; 9: 6773

 

 

Video: Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques

Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques in oncology: analysis of English secondary care data for radical prostatectomy and partial nephrectomy

David Hughes*† ,Charlotte Camp*, Jamie OHara*† and Jim Adshead

 

*HCD Economics, Daresbury, Faculty of Health and Social Care, University of Chester, Chester, and Hertfordshire and South Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK

 

Read the full article

Objectives

To evaluate postoperative health resource utilisation and secondary care costs for radical prostatectomy and partial nephrectomy in National Health Service (NHS) hospitals in England, via a comparison of robot-assisted, conventional laparoscopic and open surgical approaches.

Patients and Methods

We retrospectively analysed the secondary care records of 23 735 patients who underwent robot-assisted (RARP, n = 8 016), laparoscopic (LRP, n = 6 776) or open radical prostatectomy (ORP, n = 8 943). We further analysed 2 173 patients who underwent robot-assisted (RAPN,n = 365), laparoscopic (LPN, n = 792) or open partial nephrectomy (OPN, n = 1 016). Postoperative inpatient admissions, hospital bed-days, excess bed-days and outpatient appointments at 360 and 1 080 days after surgery were reviewed.

JUnAOTW2FI

Results

Patients in the RARP group required significantly fewer inpatient admissions, hospital bed-days and excess bed-days at 360 and 1 080 days than patients undergoing ORP. Patients undergoing ORP had a significantly higher number of outpatient appointments at 1 080 days. The corresponding total costs were significantly lower for patients in the RARP group at 360 days (£1679 vs £2031 for ORP; P < 0.001) and at 1 080 days (£3461 vs £4208 for ORP; P < 0.001). In partial nephrectomy, Patients in the RAPN group required significantly fewer inpatient admissions and hospital bed-days at 360 days compared with those in the OPN group; no significant differences were observed in outcomes at 1 080 days. The corresponding total costs were lower for patients in the RAPN group at 360 days (£779 vs £1242 for OPN,P = 0.843) and at 1 080 days (£2122 vs £2889 for ORP; P = 0.570). For both procedure types, resource utilisation and costs for laparoscopic surgeries lay at the approximate midpoint of those for robot-assisted and open surgeries.

Conclusion

Our analysis provides compelling evidence to suggest that RARP leads to reduced long-term health resource utilisation and downstream cost savings compared with traditional open and laparoscopic approaches. Furthermore, despite the limitations that arise from the inclusion of a small sample, these results also suggest that robot-assisted surgery may represent a cost-saving alternative to existing surgical options in partial nephrectomy. Further exploration of clinical cost drivers, as well as an extension of the analysis into subsequent years, could lend support to the wider commissioning of robot-assisted surgery within the NHS.

Read more articles of the week

April #UROJC: The Surgeon Scorecard – Merits of Publicly Reported Surgical Outcomes

The April 2016 International Urology Journal Club on Twitter (#urojc) hosted a discussion on our paper, “Comparing Publicly Reported Surgical Outcomes with Quality Measures from a Statewide Improvement Collaborative”. Published in JAMA Surgery on March 16, 2016, the paper was authored by Gregory Auffenberg MD, David Miller MD, Khurshid Ghani, Zaojun Ye, Apoorv Dhir, Yoquing Gao. I contributed as a member of MUSIC.

It was an honor to have the paper selected for a #urojc discussion, and the authors would like to thank JAMA Surgery for providing open access during the discussion period. This post serves as an overview, and the entire #urojc transcript is available for reading courtesy of Symplur

For those not familiar, the #urojc Twitter chat is a 48-hour asynchronous conversation amongst urologists around the world on Twitter on a selected journal paper, taking place on the first Sunday/Monday of every month.

 

The ProPublica Surgeon Scorecard

The subject of our research centered on the online U.S. surgeon ratings compiled for ProPublica’s Surgeon Scorecard. ProPublica is an investigative journalism organization that was given exclusive access to U.S. Medicare data for the years 2009 to 2013.

“Reporters Olga Pierce and Marshall Allen studied almost 75 million hospital visits billed to Medicare looking for eight common, elective surgeries. They then looked to see whether the same person returned to the hospital for what appeared to be complications from the surgery. Their full methodology is spelled out here.

 

The Michigan Urological Surgery Improvement Collective

Specifically, our research paper looked at ProPublica’s ratings for only one procedure – results on radical prostatectomy (RP) for prostate cancer – and correlation to reporting by MUSIC, the Michigan Urological Surgery Improvement Collaborative. MUSIC is a state-specific quality initiative in the U.S. in which I am a participating surgeon. Participation in MUSIC is voluntary, over 85 percent of urologists in the State of Michigan participate in the collaborative.

 

 

April #UROJC

As our paper states, the recent release of the Surgeon Scorecard accelerated debate around the merits of publicly reporting surgical outcomes. Surgical outcomes assessment is not a new concept, even dating back to 1860 as this tweet by @mattbultitude surfaced.


What does our community of urologists think about public reporting? Does greater transparency correlate with better outcomes? What are the benefits of a collaborative method like MUSIC? What methods are used in other parts of the world?

 

The #urojc discussion found that many urologists outside the U.S. were not familiar with the ProPublica ratings or debate. Some were not surprised that we did not find a correlation between our MUSIC outcomes data and the ProPublica data, thereby validating the need for quality outcomes data.

 

 

If the Surgeon Scorecard is flawed, what needs to be done to create an acceptable public reporting system?

 

Is public reporting of surgical outcomes taking place in Australia, UK, Canada & elsewhere?

 

 

How are ‘outliers’ identified by this study handled by MUSIC?

 

Do ratings lead to cherry-picking of patients?

 

According to New York cardiologist, Sandeep Jauhar, MD via Medscape, 63 percent of cardiac surgeons acknowledged accepting only relatively healthy patients for heart bypass surgery owing to report cards in New York State.

 

Moving Surgical Outcomes Forward 

On behalf of the authors of the paper and the entire MUSIC collaborative, I would like to thank our #urojc colleagues around the world for their thoughts, insights, criticisms and questions about the paper.

The ProPublica Surgeon Scorecard has generated significant and serious discussion in the U.S. about the challenges and merits of the public reporting of surgical outcomes. In an increasingly connected world, it’s difficult to imagine how this can remain simply an American debate.

Urologists by their very nature are leaders. Personally, I see this debate as yet another opportunity for us to develop and implement systems and strategies that reassure the public and advance patient care.

MUSIC JAMA Paper

 

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