Thromboprophylaxis practice patterns in hip fracture surgery patients: experience in Perth, Western Australia

Background: International guidelines recommend that all patients undergoing hip fracture surgery receive specific thromboprophylaxis. The purpose of the present study was to examine current thromboprophylaxis practice patterns in patients undergoing hip fracture surgery at Royal Perth Hospital. Methods: A total of 129 consecutive patients admitted to Royal Perth Hospital between 4 February and 21 July 2002 for surgical repair of a fractured neck of femur, was studied. The primary outcome was the frequency, type, and duration of thromboprophylaxis use during hospitalization. Results: Mean patient age was 79.4 ± 13.4 years and 69.8% (90/129) were female. Seventy‐four patients (57.8%; 95% confidence interval (CI): 48.8?66.8%) received specific thromboprophylaxis during hospitalization, including 50 patients (39.1%; 95%CI: 30.6?48.1%) who received pharmacological prophylaxis only, three (2.3%; 95%CI: 0.5?6.7%) who received mechanical prophylaxis only, and 21 (16.4%; 95%CI: 10.5?24.0%) who received both mechanical and pharmacological prophylaxis. Of those receiving pharmacological prophylaxis, 35 (49.3%; 95%CI: 37.2?61.4%) received low‐molecular‐weight heparin, 26 (36.6%; 95%CI: 25.5?48.9%) received low‐dose unfractionated heparin, eight (11.3%; 95%CI: 5.0?21.0%) received warfarin, 35 (49.3%; 95%CI: 37.2?61.8%) received aspirin or clopidogrel, and 27 (38.0%; 95% CI: 26.8?50.3%) received combined anticoagulant and antiplatelet prophylaxis. The median duration of mechanical prophylaxis was 8 days (range: 6?12 days) and that of pharmacological prophylaxis was 12 days (range: 6?26 days). When the 32 patients already taking aspirin or warfarin at the time of admission were excluded, only 45 (46.9%; 95%CI: 36.6?57.3%) of the remaining 96 patients received specific thromboprophylaxis. Conclusion: Specific thromboprophylaxis remains under‐utilized in patients undergoing surgery for hip fracture at Royal Perth Hospital. These data should prompt the implementation of effective strategies to improve thromboprophylaxis practice patterns in high‐risk orthopaedic patients.     

Current use of artificial urinary sphincters in the United States

PURPOSE: Significant improvement and high patient satisfaction are seen after artificial urinary sphincter implantation for male stress urinary incontinence. However, only a small percent of men are treated with an artificial urinary sphincter nationally. We defined trends in current artificial urinary sphincter use in the United States, specifically focusing on regional differences in use. Current rates of radical prostatectomy and the regional distribution of urologists were analyzed as possible factors to explain these disparities. MATERIALS AND METHODS: Data provided by American Medical Systems, Minnetonka, Minnesota on the number of artificial urinary sphincter units sold were analyzed by state, regional and city distribution. American Urological Association data on the number of urologists were used to estimate urologist use of artificial urinary sphincters. The number of radical prostatectomies reported by the American College of Surgeons National Cancer Database were used to estimate artificial urinary sphincter use per radical prostatectomy. RESULTS: In the most populous states and cities generally the most artificial urinary sphincter units were purchased, the most urologists were reported and the most radical prostatectomies were performed. The proportional use of artificial urinary sphincters per radical prostatectomy by state varied from 1% to 10% (national average approximately 6%). The number of urologists per 100,000 men older than 50 years appeared uniform across states (national average 34). However, artificial urinary sphincter use by urologist appeared localized and concentrated. Nationally 1 artificial urinary sphincter unit was purchased for every 3 urologists in the United States. CONCLUSIONS: Artificial urinary sphincter use demonstrates considerable state and regional variation even when controlled for differences in the frequency of radical prostatectomy and the distribution of urologists. Overall the data suggest that artificial urinary sphincters may be underused in some areas of the country, particularly for post-prostatectomy incontinence.     

Anesthetic considerations for robotic prostatectomy: a review of the literature

Since the first robotic prostatectomy in 2000, the number of prostatectomies performed using robot-assisted laparoscopy has been increasing. As of 2009, 90,000 robotic radical prostatectomies were performed worldwide, and 80% of all radical prostatectomies performed in the United States were performed robotically. Robotic prostatectomy is becoming more common globally because of the many advantages offered to patients, primarily due to the minimally invasive nature of the procedure. Several new perioperative concerns and challenges for anesthesiologists and are described.     

Current practice regarding the use of fatty livers: A Trans-Atlantic survey

A strong association exists between the presence of steatosis in a donor liver for transplantation and the development of primary nonfunction in the recipient. Despite this, appraisal of the donor remains one of the least scientific aspects of the transplantation process, and many centers base their practice on subjective opinion, rather than objective data. We conducted this survey to illuminate controversial issues and highlight the variation of opinion and practice policies both between and within the United Kingdom and the United States. A simple, anonymous, one-page, 10-question survey with tick-box answers was sent to every practicing liver transplant surgeon in the United Kingdom. The same form was sent by E-mail to liver transplant surgeons in the United States with a current E-mail address listed in the American Society of Transplant Surgeons registry. In the United Kingdom, 16 of 19 surgeons polled responded (84.2%) and thus were considered representative. From the United States, there were 78 respondents from 52 centers, representing all 11 United Network for Organ Sharing regions. We found that current practice policies differ not only between nations, but also among centers in each country. US surgeons generally follow a more conservative approach, with greater emphasis on histological assessment. Dichotomous opinions exist on the significance of microvesicular steatosis in both countries. Most evident from this survey is that more research in the field is required to help answer these questions and allow for the safe use of all viable livers. (Liver Transpl 2002;8:545-549.)     

Marked Variation in Venous Thromboprophylaxis Management for Abdominal Aortic Aneurysm Repair; Results of Survey Amongst Vascular Surgeons in the United Kingdom

Objectives

We aimed to survey the current management of venous thromboprophylaxis in patients undergoing elective surgery for abdominal aortic aneurysm (AAA) by vascular surgeons in the United Kingdom.

Design

A questionnaire was designed to investigate anticoagulation strategies in the perioperative period of elective AAA repair, both open and endovascular. This included both chemical and mechanical prophylaxis. A total of 395 questionnaires was posted to the members of the Vascular Society of Great Britain and Ireland.

Results

One hundred and seventy-two (44%) valid responses were received. Half of the respondents administered pre-operative chemical prophylaxis at a mean of 13 h prior to AAA surgery. There was a high level of concordance in administration of heparin during surgery and in thromboprophylaxis post-operatively, with 97% giving some form of thromboprophylaxis. However there was a variation in the dose and timing, if administered, of chemical and mechanical prophylaxis.

Conclusion

The survey revealed diversity in perioperative thromboprophylaxis strategies among vascular surgeons. This suggests that standardisation of pre-operative and post-operative mechanical and chemical thromboprophylaxis may be required which could potentially improve the outcomes in elective management of AAA in the UK.     

Variation in surgical treatment patterns for patients with prostate cancer in the United States: Do patients in academic hospitals fare better?

Introduction

With prostate cancer (CaP) screening, overtreatment of low-risk CaP remains a concern. We investigated the patterns of radical prostatectomy (RP) for pathologic insignificant (iCaP) and significant CaP (sCaP) as well as variations between academic and nonacademic hospitals.

Erythropoeitin dose variation in different facilities in different countries and its relationship to drug resistance

BACKGROUND: The correction of anemia using erythropoeitin (EPO) is accorded high priority in the management of patients undergoing hemodialysis (HD). Target hemoglobin (Hb) levels have been established in many countries. Following an observation that the mean facility EPO dose in a chain of facilities in the United States varied by more than two-fold, an examination of the practice of anemia correction in other settings was carried out. METHODS: We reviewed demographic and laboratory parameters in prevalent HD patients in 50 United States facilities and in a single HD facility in Vicenza, Italy. The mean EPO dose profile of the United States facilities was compared with the profiles in 10 facilities in the eastern United Kingdom (UKER) and in 20 facilities reporting to the United Kingdom Renal Registry (UKRR). Analysis of the factors that correlate with EPO resistance was carried out using the United States and Italian data. RESULTS: The average EPO doses, by facility, in the 51 United States, the 10 UKER, and the 19 UKRR facilities were 19,569, 8,416, and 7,992 international units per week (IU/wk), respectively. While examination of the UKRR revealed a similar degree of inter-facility variation (2.6-fold), much larger doses of EPO were being administered in the United States patients, particularly in the low Hb group. Multivariate analysis of the United States data suggested that factors related to inflammation, including low albumin, the use of tunneled catheters for vascular access, and low protein catabolic rate (enPCR) correlated with low Hb and relative EPO resistance. CONCLUSION: Despite similar guidelines for anemia management, significant differences in practice are observed. While there seems to be a reluctance to administer large EPO doses to individual patients in Europe, this does not seem to apply in the United States, where more EPO is given. EPO resistance seems relative rather than absolute in many patients, allowing some to respond to the higher doses.     

Transition from open to robotic-assisted radical prostatectomy: 7 years experience at Hackensack University Medical Center

Background and objective Open radical prostatectomy (ORP) is the standard approach for the surgical management of localized prostate cancer. The steep learning curve for laparoscopic prostatectomy poses a challenge for surgeons with minimal laparoscopic experience. As robotic-assisted surgery becomes more prevalent in the urologic community, there appears to be an increasing interest in robotic-assisted radical prostatectomy (RARP) among urologists throughout the United States. We report on the impact of robotics on practice patterns in the treatment of localized prostate cancer at a single institution. Methods A retrospective review was conducted of radical prostatectomies performed between January 2000 and December 2006 at Hackensack University Medical Center (Hackensack, N.J.). Over this time period, our medical center acquired four da Vinci™ Surgical Systems. The trends for open and robotic-assisted prostatectomies were analyzed. Results Over a 7-year period (2000–2006), a total of 1252 radical prostatectomies were performed by 17 urologists: 469 (37%) ORPs and 783 (63%) RARPs. The total number of prostatectomies increased annually during this time period. The robotic-assisted procedure was predominantly performed by three (18%) urologists from 2001–2003, seven (41%) in 2004, nine (53%) in 2005, and 11 (65%) in 2006. As more urologists became trained in robotic-assisted surgery, the trend gradually shifted towards robotic-assisted prostatectomy. In 2001, only 9.6% of all radical prostatectomies at our institution were performed with robotic assistance; in 2006, this had risen to 92.8%. Conclusion The acquisition of the da Vinci™ Surgical System has allowed robotic-assisted surgery to be an available alternative to open surgery at a single institution. The implementation of robotic technology has led to the gradual adoption of robotic-assisted radical prostatectomy by many of the urologists that surgically treat prostate cancer. As a result, the percentage of open prostatectomies has steadily decreased over time, while trends in robotic-assisted prostatectomies have increased. The impact of robotics also appears to have had an influential effect on the total number of prostatectomies performed annually.     

Hirudo Medicinalis and the plastic surgeon.

Medicinal leech therapy is an ancient craft that dates back to ancient Egypt and the beginnings of civilisation. The popularity of Hirudo Medicinalis has varied throughout history, reaching such a peak in Europe in the early 19th century that supplies were exhausted. During the latter half of the 19th century, their use fell out of favour, as they did not fit in with the emerging concepts of modern medicine. Leeches have enjoyed a renaissance in the world of reconstructive microsurgery during recent years, and their first reported use in alleviating venous engorgement following flap surgery was reported in this journal [M Derganc, F Zdravic, Venous congestion of flaps treated by application of leeches, Br J Plast Surg 13 (1960) 187]. Contemporary plastic and reconstructive surgeons in units throughout the United Kingdom and Ireland continue to use leeches to aid salvage of failing flaps. We carried out a survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland to assess the current extent of use, and to investigate current practice. We have shown that the majority of plastic surgery units in the UK and Ireland use leeches post-operatively and that the average number of patients requiring leech therapy was 10 cases per unit per year. Almost all units use antibiotic prophylaxis, but the type of antibiotic and combination used is variable. We outline current practice and suggest a protocol for the use of leeches. Whilst the use of leeches is widespread, the plastic surgery community has progressed little in defining indications for their use or in achieving an accepted protocol for their application in units throughout the UK and Ireland.     

Thromboprophylaxis following cast immobilisation for lower limb injuries--survey of current practice in United Kingdom

The risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) is well documented in patients following cast immobilisation for injuries of lower extremities. There are no generally accepted approaches to preventing this complication and hence there remains substantial practice variation amongst surgeons regarding the use of anticoagulation measures. The present survey was conducted to investigate the current chemothromboprophylaxis practice among UK orthopaedic departments for patients immobilised with plasters for lower extremity injuries and establish any variations in practice. A telephone questionnaire survey was conducted on junior doctors (Senior House Officers and Registrars) in orthopaedic departments of 70 randomly selected hospitals in United Kingdom. This survey assessed the thromboprophylaxis practice for lower limb injuries in plaster casts. Our results show substantial variation amongst British orthopaedic surgeons in the use of chemothromboprophylaxis measures. Sixty-two percent of the departments do not use any DVT prophylaxis in this group of trauma. Furthermore, only 11.4% of the departments performed risk stratification on their patients. Ninety-nine percent of the respondents were unaware of any existing guidelines in this regard. Although the incidence of DVT in patients in plaster for lower extremity injuries is low compared to the Hip/Knee arthroplasty group, this is not insignificant. Both over and under treatment with thromboprophylaxis can have implications in terms of side effects and costs. One possible solution is to use risk stratification to identify individuals who are likely to benefit from prophylaxis. There is a substantial variation and inconsistency in practice among orthopaedic departments in United Kingdom due to a lack of clinical guidelines in this group of trauma and it remains underused even in high-risk group.     

Practice Trends in the Use of Extracorporeal Treatments for Poisoning in Four Countries

Extracorporeal treatments (ECTRs) such as hemodialysis (HD), enhance the elimination of a small number of toxins. Changes in overdose trends, prescribing practices, antidotes, and dialysis techniques may alter the indications and rates of ECTR use over time. This study analyzed trends in ECTR for poisonings in four countries. A retrospective study of national poison center databases from the United States, Denmark, United Kingdom, and five regional databases within Canada was performed. All cases of patients receiving an ECTR were included. ECTR cases were totalled annually and reported as annual rates per 100,000 exposures with stratification per types of ECTR and toxins. The data collection varied by countries. United States, 1985–2014; United Kingdom, 2011–2013; Denmark, 2005–2014, and regions of Canada as follows: Alberta, 1991–2015; Saskatchewan, 2001–2015; Nova Scotia‐PEI, 2006–2015; Quebec, 2008–2014; Ontario‐Manitoba, 2009–2015; British Columbia, 2012–2015. During the study period, the total number of ECTRs and rates per 100,000 exposures, respectively, were: United States, 40,258 and 65.7; United Kingdom, 343 and 232.6; Denmark, 616 and 305.5; Canada, 2709 and 177.5; case rates increased over time for the United States, Denmark, and Canada, but decreased in the United Kingdom. Across the United States and Denmark, HD was the preferred modality used. Toxins for which ECTR was most often used were: United States, ethylene glycol; Canada, methanol; United Kingdom, ethylene glycol; Denmark, salicylates. A high number of ECTRs were performed for atypical toxins such as acetaminophen and benzodiazepines. These data demonstrate a growing use of HD for poisoning with significant regional variations in the overall rates and indications.     

Tumour volume is an independent predictor of prostate-specific antigen recurrence in patients undergoing radical prostatectomy for clinically localized prostate cancer

Authors from the USA sought to establish the relationship between tumour volume, pathological stage and outcomes after radical prostatectomy. In a large series of patients they found that tumour volume was correlated directly with pathological stage, and that it was independently correlated with PSA recurrence. The authors suggested that tumour volume had a potential use for prognostication in patients undergoing radical prostatectomy. Two papers, one from the USA and one from Germany, advise a re-staging TUR in patients with superficial bladder cancer who are at high risk of early tumour progression. In a large series of patients they found that residual tumour after initial resection was commoner than might be expected, and that the second resection indicated the way to earlier radical treatment and a better prognosis. OBJECTIVE: To establish the relationship between tumour volume (TV), pathological stage and outcome after radical prostatectomy (RP), as TV is theoretically an important variable in prostate cancer pathology, but to date it has not been routinely reported and its independent prognostic significance is not well defined. PATIENTS AND METHODS: The study included 431 consecutive patients undergoing RP for clinically localized cancer, from January 2000 to January 2002, who had a pathological examination of totally submitted whole-mount processed RP specimens. In addition to Gleason grade, tumour stage and margin assessment by standard techniques, TV was determined by digital planimetry. The total TV or index TV, for cases with obvious discrete separate tumours, were correlated with pathological stage and prostate-specific antigen (PSA) recurrence. RESULTS: The mean (range) follow-up was 25.4 (6-51) months, and the mean TV for all patients was 3.28 (0.4-38.8) mL. There was a direct correlation between TV and pathological stage (P < 0.001). The TV for organ-confined and extraprostatic disease was 2.09 and 6.02 mL, respectively (P < 0.001). In a multivariate analysis, TV was an independent predictor of PSA recurrence (P = 0.04). The mean TV for patients with PSA recurrence vs no recurrence was 6.8 and 2.6 mL, respectively (P < 0.001). CONCLUSION: TV correlates directly with pathological stage in RP specimens; furthermore, it is independently correlated with PSA recurrence. TV has potential use for prognostication in patients undergoing RP, and may be combined with other well established clinical variables to aid in predicting outcomes.     

Survey of arrangements for anaesthesia for interventional neuroradiology for aneurysmal subarachnoid haemorrhage

The management of patients with subarachnoid haemorrhage following rupture of an intracranial aneurysm is changing. The recent introduction of endovascular occlusion of the aneurysm using detachable coils offers an alternative to craniotomy and clipping of the aneurysm for the prevention of recurrent aneurysmal haemorrhage. The aim of this survey was to evaluate the current provision of peri-operative care for patients with an aneurysmal subarachnoid haemorrhage in the United Kingdom and Republic of Ireland. A survey was conducted of the 34 neuroscience centres which provide an adult neurosurgery service in the United Kingdom and Republic of Ireland. Most centres reported an increasing role for coiling, and a decreasing role for clipping in the management of aneurysmal subarachnoid haemorrhage. The provision of peri-operative care for patients undergoing interventional neuroradiology procedures varied greatly between centres. Neurovascular services in the UK are being reorganised and adequate staff and facilities should be available for the peri-operative care of patients undergoing interventional neuroradiology procedures.     

Thoracic epidural anaesthesia and analgesia: United Kingdom practice

BACKGROUND: Thoracic epidural analgesia has become increasingly practised in recent years. Complications are rare but potentially serious and, consequently, careful evaluation is required before undertaking this technique. The practice surrounding this procedure varies widely amongst anaesthetists. METHODS: A postal survey to examine the practice of thoracic epidural analgesia was sent to all Royal College of Anaesthetists tutors in the United Kingdom. RESULTS: Responses were received from 240 tutors, representing a return rate of 83%. When obtaining consent for thoracic epidural cannulation, 42% of respondents mentioned risk of a dural tap complication and 11% mentioned neurological damage. Fifty percent of respondents performed epidural cannulation following induction of general anaesthesia. The practice of epidural insertion in patients with abnormal coagulation varied, although over 80% of respondents did not consider concurrent treatment with either aspirin or non-steroidal anti-inflammatory drugs a contraindication. Sterile precautions for epidural insertion also varied between anaesthetists. Postoperatively, 95% of respondents used an opioid-based bupivacaine solution for epidural infusions, and these were most commonly nursed on general surgical wards (63%). Seventy-eight percent of hospitals provided an acute pain team to review epidural analgesia. CONCLUSION: In the United Kingdom, there is little consensus in the practice of thoracic epidural analgesia relating to the issues of informed consent, epidural cannulation in patients with deranged clotting and the sterile precautions taken prior to performing epidural insertion. Most respondents use an opioid-based bupivacaine solution to provide postoperative epidural analgesia. Most hospitals in the UK now provide an acute pain service for thoracic epidural follow-up.     

Thromboprophylaxis in trauma: a review of methods, evidence and guidelines

Venous thromboembolism is a common cause of morbidity and mortality in trauma patients. Mechanical and pharmacological methods of thromboprophylaxis are available and guidelines relating to thromboprophylaxis in trauma include those published by the American College of Chest Physicians, the UK-based National Institute of Clinical Excellence, the Scottish Intercollegiate Guidelines Network and US-based Eastern Association for the Surgery of Trauma. All four guidelines have in common a recommendation for the use of low-molecular-weight heparin except where contraindicated. However, there is little consensus between guidelines relating to which mechanical methods should be used. Given the risk of thromboembolism in trauma patients and increasing interest in this condition clinicians should be aware of local and national guidelines relating to venous thromboembolism prevention in trauma patients. This paper reviews methods of thromboprophylaxis and compares guidelines relating to their use in trauma patients.     

Online marketing strategies of plastic surgeons and clinics: a comparative study of the United Kingdom and the United States

The cosmetic surgery market is a rapidly growing sector of healthcare, and the use of marketing strategies is now an integral part of any cosmetic surgery practice. In this study, the authors review 50 Web sites from practitioners in London and New York to quantify the utilization of online marketing, comparing results between the United Kingdom and the United States.     

Long-term surveillance of bladder tumours: current practice in the United Kingdom and Ireland

INTRODUCTION: Surveillance of transitional cell carcinoma of the bladder forms a major part of the workload of many urology units. Unfortunately, the policy for long-term surveillance of these cancers is neither clear nor agreed upon in the absence of evidence base. Our study was performed to provide current national practice data, and begin the debate on consensus guidelines. MATERIALS AND METHODS: A questionnaire was sent to Consultant Urologists (CUs) in the UK and Ireland (n=501) asking about their policy on the long-term surveillance of different bladder tumours once patients are free of recurrence. RESULTS: A 73% response rate was observed (365/501). Views varied considerably. They ranged from life long cystoscopic surveillance for low-stage low-grade tumours (pTaG1) to discharge after 5 years (or less) of a recurrence-free period for pT1G3 tumour. Once long-term surveillance with cystoscopy had been discontinued, 55% of CUs felt no role was indicated for urine cytology in further follow up, whereas 17% would use it for all tumour types and 28% are selective. CONCLUSION: Our study has shown the complete lack of consensus regarding the long-term surveillance of bladder cancer in the UK and Ireland. This has major implications for policy making, resources allocation and cancer survival. We highlight the need for national guidelines in this area for optimal surveillance of bladder cancer, as a good prospective evidence-based data will not be available for many years. We believe our study might form the basis for discussion on such guidelines.     

Radical prostatectomy in Britain and Ireland at the millennium

OBJECTIVE: To report a national questionnaire survey of all consultant urologists, providing a 'snapshot' of attitudes, current practice and referral patterns for radical prostatectomy (RP) in Britain and Ireland at the millennium. METHODS: During 1999/2000 a simple questionnaire about RP was sent to the 487 urologists registered as full BAUS members. From 418 (86%) returns nine were excluded, to leave a study group of 409 urologists. RESULTS: In all, 157 (38%) consultants were undertaking RP, whilst 252 (62%) were not; 29 (18.5%) performed > 20 operations/year, 44 (28%) undertook 11-20, but 84 (53.5%) carried out < or= 10. During the survey period, 741 (51%) RPs were conducted in teaching hospitals and 724 (49%) in district general hospitals. Of the 252 not undertaking RP, 23 (9%) stated they wished to learn the technique. CONCLUSIONS: This questionnaire suggests that the number of urologists undertaking RP in the UK and Ireland has stabilized but confirms that over half perform < or = 10/year; outcome data are now required. Any change towards concentrating cases will have significant consequences for patient distribution and resources.     

Discrepancies in Gleason scoring of prostate biopsies and radical prostatectomy specimens and the effects of multiple needle biopsies on scoring accuracy. A regional experience in Tamworth, Australia

BACKGROUND: The aim of this study was to review the discrepancies in Gleason scores (GS) of prostate biopsies and radical prostatectomy specimens and the effects of multiple-needle biopsies on scoring accuracy. METHODS: One hundred patients who had undergone consecutive radical prostatectomies (RP) between January 2004 and May 2006 were reviewed retrospectively. Patient information including age, prebiopsy prostate-specific antigen levels, biopsy GS, RP GS and pathology details were recorded and compared. RESULTS: The concordance rate of biopsy GS and RP GS was found to be at 43%, with 46% of biopsy specimens being undergraded. Eleven per cent of the specimens were overgraded. The accuracy was fairly similar when specimens were reported by the same or different pathologists, at 42 and 44%, respectively. The accuracy of biopsy GS improved with increasing number of biopsies taken. CONCLUSION: There are significant discrepancies in Gleason scoring of biopsy and RP specimens, with a concordance rate of 43% and undergrading rate of 46%. Increasing the number of biopsies helps improve scoring accuracy. Clinicians and patients need to be mindful when deciding cancer treatment options, in view of these discrepancies.     

Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes

PURPOSE: The technique of laparoscopic radical prostatectomy is difficult to master and is associated with a steep learning curve. We hypothesized that a structured approach to establishing a laparoscopic prostatectomy program would diminish complications during the learning process and that robotic technology would be useful in learning the operation. MATERIALS AND METHODS: A structured laparoscopic radical prostatectomy program was introduced at the Vattikuti Urology Institute on October 23, 2000. One of 2 surgeons with a combined experience of more than 500 laparoscopic radical prostatectomies performed or supervised the first prostatectomies, training a third surgeon with extensive "open" surgical skills but no laparoscopic experience. The "trained" surgeon then started performing the operation independently with robotic assistance. The results of this approach were analyzed at the end of 12 months. RESULTS: We performed 48 laparoscopic radical prostatectomies and 50 robot assisted prostatectomies within the 12-month period. The preoperative and intraoperative demographical variables were comparable in both groups as were the operative times, changes in hemoglobin concentrations, durations of hospitalization, positive margin rates and overall complication rates. All measured parameters were comparable to the "best-in-class" values for laparoscopic radical prostatectomy reported in the literature. CONCLUSIONS: A structured approach minimizes complications during the establishment of laparoscopic radical prostatectomy program. Robotic assistance helps skilled "open" surgeons learn the technique of laparoscopic radical prostatectomy.