The perioperative charge equivalence of radical prostatectomy with 1-year follow up since the diagnosis of prostate cancer

We assessed the 1-year charges in the group of patients undergoing radical prostatectomy and the changes in hospital costs and resource use following implementation of a clinical care path. A total of 69 consecutive men treated with radical prostatectomy for clinically localized prostate cancer were enrolled in the study. Hospital and outpatient records were analyzed for each patient in regard to preoperative, operative and postoperative charges of a 12-month period. Parameters included number of encounters, diagnostic and therapeutic interventions, hospitalization and operative charges, and follow-up visits, diagnostic tests and interventions for 1 year. The mean first-year cost of treatment with radical prostatectomy for localized prostate cancer was 144 x 10(4) yen. The increases in the first-year cost with higher prostate specific antigen (PSA) level for the diagnosis level appeared to primarily be associated with increased inpatient resource use and greater use of hormonal therapy. Length of the stay in a hospital significantly influenced the first-year cost. After implementation of the radical prostatectomy care path hospital costs decreased by 30% (66 x 10(4) yen vs 46 x 10(4) yen), total costs decreased 40% (190 x 10(4) yen vs 113 x 10(4) yen) and length of hospital stay decreased by 56% (37.0 vs 16.6). The first-year costs with radical prostatectomy are influenced greatly by the hormonal therapy and the number of hospital days. By standardizing preoperative and postoperative management for patients undergoing radical prostatectomy, significant savings can be achieved toward shorter hospital stays and lower hospital costs.     

Use of the Transurethral Prostatectomy Clinical Path to Monitor Health Outcomes

Purpose

We evaluated the effect on cost and medical care quality of use of the transurethral prostatectomy clinical path.

Materials and Methods

Results in 100 patients treated when the transurethral prostatectomy clinical path was used were compared to those of 100 treated by the same physicians before implementation of this path.

Results

After implementation of the transurethral prostatectomy clinical path the length of hospital stay was significantly decreased from 5.9 to 5.0 days (p <0.01) and Foley catheterization time was significantly decreased from 3.13 to 2.84 days (p <0.01). Antibiotics were routinely used from the day before surgery to the day of hospital discharge as required by patient conditions. Therefore, a shorter hospital stay will significantly decrease the use of antibiotics. After implementation of the clinical path the average admission charges were decreased significantly by 17% (p <0.01). Although some results from use of this path will not significantly affect costs, they will reflect some quality improvement. The effect of clinical path implementation on length of hospital stay between patients treated by junior and senior attending physicians was not significant. However, there was a statistically significant difference (p <0.01) between results obtained by junior and senior attending physicians regarding average admission charges.

Conclusions

Implementation of the transurethral prostatectomy clinical path can improve health care outcome by decreasing length of stay and admission charges, and improving quality of medical care, particularly for patients treated by junior attending physicians.     

A cost containment strategy for radical retropubic prostatectomy: Results from implementation of a clinical pathway program

Health care costs from the management of prostate cancer are estimated at $1.5 billion per year. As the number of radical prostatectomies being performed increases, a simultaneous rise in these costs can be expected. However, diminishing resources and the expanding managed care environment necessitate measures to curtail and even reduce these inflationary trends in health care expenditure. With this in mind, we established a collaborative clinical pathway for patients undergoing radical retropubic prostatectomy at our institution. The goals of the pathway were to reduce patient costs and hospital stay and to promote efficient use of resources for the procedure. We studied 71 patients who underwent radical retropubic prostatectomy and were managed according to the pathway during the first year of its implementation (July 1994 through July 1995). Outcome variables for these patients were compared with those of a group of 65 patients who underwent an identical procedure during the previous year (July 1993 through June 1994) before implementation of the pathway. Outcome parameters that were compared included hospital charges, length of stay (LOS), operating room (OR) time, units of packed red cells transfused, morbidity, and mortality. The overall hospital charges since implementation of the pathway decreased by 17.2% when corrected for inflation (p ≤ 0.006). LOS also decreased from a mean of 6.4 days to 5.2 days. There was no significant change in OR time. Overall complications remained unaffected (12.3% vs 12.6%). Based on these results, we conclude that establishment of an individualized, procedure-oriented clinical pathway for patients undergoing radical retropubic prostatectomy can result in significant reduction in patient costs without appreciable effect on morbidity and mortality.     

A direct comparison of robotic assisted versus pure laparoscopic radical prostatectomy: a single institution experience

PURPOSE: We compared a single institution experience with radical prostatectomy using a pure laparoscopic technique vs a robotically assisted technique with regard to preoperative, intraoperative or postoperative parameters. MATERIALS AND METHODS: From May 2003 to May 2005 we reviewed 133 consecutive patients who underwent extraperitoneal robot assisted radical prostatectomy and compared them to 133 match-paired patients treated with a pure extraperitoneal laparoscopic approach. The patients were matched for age, body mass index, previous abdominopelvic surgery, American Society of Anesthesiologists score, prostate specific antigen, pathological stage and Gleason score. Preoperative, perioperative and postoperative data, including complications and oncological results, were analyzed between the 2 groups. RESULTS: The 2 groups were statistically similar with respect to age, body mass index, prostate specific antigen, Gleason score and clinical stage. No statistical differences were observed regarding operative time, estimated blood loss, hospital stay or bladder catheterization between the 2 groups. The transfusion rate was 3% and 9.8% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.03). Conversion from robotic assisted laparoscopic prostatectomy to laparoscopic radical prostatectomy was necessary in 4 cases. None of the laparoscopic radical prostatectomy cases required conversion to an open technique. The percentage of major complications was 6.0% vs 6.8%, respectively (p = 0.80). The overall positive margin rate was 15.8% vs 19.5% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.43). CONCLUSIONS: We demonstrated that the laparoscopic extraperitoneal radical prostatectomy is equivalent to the robotic assisted laparoscopic prostatectomy in the hands of skilled laparoscopic urological surgeons at our institution with respect to operative time, operative blood loss, hospital stay, length of bladder catheterization and positive margin rate.     

Local cost structures and the economics of robot assisted radical prostatectomy

PURPOSE: Robot assisted prostatectomy (RAP) is more costly than traditional radical retropubic prostatectomy (RRP) under the cost structures at certain hospitals. However, this finding may not be the case in all care settings. We investigated the sensitivity of RAP and RRP inpatient costs to variations in length of stay (LOS), local hospitalization costs and robotic case volume in the specialist and generalist settings. MATERIALS AND METHODS: We developed a model of RAP vs RRP costs in the specialist and generalist settings using published data on operative time and LOS, and cost data from our academic medical center. All inpatient cost centers were included, namely surgery costs, professional fees, postoperative care, robotic equipment and service. Extensive 1 and 2-way sensitivity analyses were performed. RESULTS: Our base case model demonstrated a cost premium for RAP vs RRP of USD $783 and $195 in the specialist and generalist settings, respectively. Sensitivity analysis of our model assumptions demonstrated that RAP could achieve cost equivalence with RRP at a surgical volume of 10 cases weekly. If case volume increased to 14 cases weekly, RAP would be less expensive than RRP in some practice settings in which RAP LOS was less than 1.5 days. CONCLUSIONS: The inpatient costs of robotic assisted prostatectomy are volume dependent and cost equivalence with generalist radical retropubic prostatectomy is possible at higher volume RAP specialty centers. While RAP may be cost competitive with RRP at high cost hospitals or high volume RAP specialist centers, this procedure would exist at a cost premium to RRP in other practice settings.     

Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy

PURPOSE: Minimally invasive surgery has been shown to decrease postoperative morbidity and length of stay for a number of surgical procedures. Furthermore, length of stay after open radical prostatectomy has decreased dramatically during the last decade. We examined differences in length of stay between a prospectively evaluated cohort of patients who underwent radical retropubic prostatectomy and robot assisted laparoscopic prostatectomy. MATERIALS AND METHODS: Between January 2003 and March 2006, 1,003 radical prostatectomies were performed at our hospital. Data were collected in prospective fashion and a comparison was made between 374 patients who underwent radical retropubic prostatectomy and 629 who underwent robot assisted laparoscopic prostatectomy. Length of stay, factors influencing length of stay, readmission rates and unscheduled clinic or emergency room visits were evaluated. Patients in the 2 groups were treated using the same clinical care pathway. RESULTS: Overall 94.3% of patients in the radical retropubic prostatectomy group and 97.5% in the robot assisted laparoscopic prostatectomy group were discharged home on or before postoperative day 1. Mean length of stay in the radical retropubic and robot assisted laparoscopic prostatectomy groups was 1.25 (median 1.09) and 1.17 days (median 1.03), which was similar and not statistically different (p=0.27). Readmission rates were similar in robot assisted laparoscopic and radical retropubic prostatectomy patients (7% and 5%, respectively, p=0.12). Unscheduled clinic or emergency room visits were the same in the robot assisted laparoscopic and radical retropubic prostatectomy groups (10%, p=0.95). CONCLUSIONS: Patients who underwent radical retropubic prostatectomy or robot assisted laparoscopic prostatectomy can be treated on the same clinical pathway. A targeted hospital discharge date of postoperative day 1 can be achieved in the majority of patients who underwent radical prostatectomy. Readmission rates or unscheduled hospital visits are necessary in a small percent of patients treated with an early discharge program, of which the majority are caused by ileus.     

Charge and length of hospital stay analysis of radical retropubic prostatectomy and transperineal prostate brachytherapy

PURPOSE: For the treatment of clinically localized prostate cancer radical retropubic prostatectomy with its attendant hospital stay should be associated with higher charges than transperineal prostate brachytherapy. We report a comparative case series to determine patient charges and length of hospitalization of 2 modalities of monotherapy for localized prostate cancer. MATERIALS AND METHODS: A total of 35 consecutive patients with clinically localized prostate cancer underwent radical retropubic prostatectomy (16) or transperineal prostate brachytherapy (19) at the Arthur James Cancer Hospital and Research Institute. Complete charge and length of hospital stay data were collected for each patient. Total charges were calculated and the 2 modalities were compared. RESULTS: Charge data were available in 33 cases. Average total charges in the prostatectomy and brachytherapy groups were $15,097 and $21,025, respectively ($5,928 difference, p <0.0001). The difference increased further when outliers were excluded from study. Average length of hospital stay and average charge in the prostatectomy group were 3.8 days and $1,897. The higher charges for transperineal prostatic brachytherapy were due to dosimetry calculations, radioactive seeds and seed implantation. CONCLUSIONS: At our institution the average total charges for transperineal prostate brachytherapy are significantly higher than those for radical retropubic prostatectomy.     

Surgical outcomes for men undergoing laparoscopic radical prostatectomy after transurethral resection of the prostate

PURPOSE: We reviewed outcomes for men with a history of transurethral prostate resection who underwent laparoscopic radical prostatectomy for prostate cancer. MATERIALS AND METHODS: Between January 26, 1998 and December 2006, 3,061 men underwent laparoscopic radical prostatectomy at our institution. A retrospective review showed that 119 had a history of transurethral prostate resection. These men were compared to randomized matched controls with regard to operative and postoperative outcomes. The matching criteria used to randomly select patients were clinical stage, preoperative prostate specific antigen and biopsy Gleason score. RESULTS: Mean +/- SD age in the groups with and without transurethral prostate resection was 66.2 +/- 5.6 and 60.7 +/- 7.0 years, respectively (p <0.01). Mean estimated blood loss, transfusion rate, pathological prostate volume and reoperation rate were statistically similar between the groups. Mean length of stay for the groups with and without transurethral prostate resection was 6.5 +/- 3.0 and 5.29 +/- 2.3 days, respectively (p <0.01). Mean operative time for the groups with and without transurethral prostate resection was 179 +/- 44 and 171 +/- 38 minutes, respectively (p = 0.02). Positive margins were seen in 21.8% and 12.6% of the patients with and without transurethral prostate resection, respectively (p = 0.02). A total of 64 complications were seen in patients with a history of transurethral prostate resection compared to 34 in those without such a history (p <0.01). CONCLUSIONS: We report that patients with a history of transurethral prostate resection who undergo laparoscopic radical prostatectomy have worse outcomes with respect to operative time, length of stay, positive margin rate and overall complication rate. This subset of patients should be made aware of these potential risks before undergoing laparoscopic radical prostatectomy.     

Implementation of a clinical pathway decreases length of stay and cost for bowel resection

OBJECTIVE: To examine the effect of a clinical pathway for small and large bowel resection on cost and length of hospital stay. SUMMARY BACKGROUND DATA: Clinical pathways are designed to streamline patient care delivery and maximize efficiency while minimizing cost. Theoretically, they should be most effective in commonly performed procedures, in which volume and familiarity are high. METHODS: A clinical pathway to assist in the management of patients undergoing bowel resection was developed by a multidisciplinary team and implemented. Data about length of stay and cost was collected for all patients undergoing bowel resection 1 year before and 1 year after pathway implementation. Three groups were compared: patients undergoing bowel resection in the year prior to pathway implementation (prepathway), patients in the year after pathway implementation but not included on the pathway (nonpathway), and patients included in the pathway (pathway). RESULTS: The mean cost per hospital stay was $19,997.35 +/- 1244.61 for patients in the prepathway group, $20,835.28 +/- 2286.26 for those in the nonpathway group, and $13,908.53 +/- 1113.01 for those in the pathway group (p < 0.05 vs. other groups). Mean postoperative length of stay was 9.98 +/- 0.62 days (prepathway), 9.68 +/- 0.88 days for (nonpathway), and 7.71 +/- 0.37 days (pathway) (p < 0.05 vs. other groups). CONCLUSIONS: Implementation of the pathway produced significant decreases in length of stay and cost in the pathway group as compared to the prepathway group. These results support the further development of clinical pathways for general surgical procedures.     

Consequences of endoscopic inguinal hernioplasty with mesh on subsequent open radical prostatectomy

AIM: To determine the effect of prior endoscopic hernia repair with prosthetic mesh on subsequent open radical prostatectomy. METHODS: A retrospective study from 1990 to 2004 identified nine patients with preperitoneal mesh placement followed by open radical prostatectomy. Case controls (n = 26) were matched for age, type of operation, year of surgery and pathologic stage of prostatic adenocarcinoma. Outcome variables of operating time, number of pelvic lymph nodes excised, duration of hospital stay, duration of urinary catheterization, recurrence rates, and incidence of complications were compared. Data analysis was performed using Wilcoxon's rank sums test. RESULTS: Intraoperatively, subjective difficulty in dissection was documented in all cases by the performing urologist. Duration of hospital stay was significantly increased by 1.3 days (p < 0.05), as compared to the control group. However, no statistically significant increase in mean operating time (173 vs. 172 min, p = 0.925), number of lymph nodes sampled (4.4 vs. 6.6, p = 0.147), duration of urinary catheterization (22 vs. 19 days, p = 0.925), oncologic recurrence (11 vs. 11% at 6.1 and 4.8 years follow-up), or complications was found. CONCLUSIONS: Prior TEP/TAPP did not increase the morbidity or mortality of subsequent prostate surgery. Despite some subjective operative difficulty, open prostatectomy was safe and feasible in all cases with a comparable oncologic outcome. Mesh-associated inflammation may preclude adequate nodal sampling. While endoscopic hernia repair remains an excellent option to fix unilateral, bilateral, and recurrent herniae, consideration of future prostate surgery is important. Inserting less "inflammatory" mesh or using an open, anterior approach may be prudent in some men at high risk for needing subsequent prostate surgery.     

Robotic assisted laparoscopic radical prostatectomy versus retropubic radical prostatectomy: a prospective assessment of postoperative pain

PURPOSE: Laparoscopic prostatectomy, whether or not coupled with robotic assistance, is often considered less invasive than open radical retropubic prostatectomy (RRP). Minimal postoperative pain has been reported following robot assisted laparoscopic prostatectomy (RALP) but there have been few comparative studies with RRP. We compared perioperative narcotic use and patient reported pain in a prospective patient series. MATERIALS AND METHODS: Between June 2003 and May 2004, 314 patients underwent radical prostatectomy at our institution, including RALP in 159, RRP in 154 and conversion in 1. All patients were treated on a postoperative clinical pathway that included 30 mg ketorolac intravenously immediately postoperatively, followed by 15 mg intravenously every 6 hours. No regional anesthesia (epidural/spinal) narcotics or patient controlled analgesic pumps were used. All narcotic use was converted to morphine sulfate equivalents for purpose of analysis. A Likert scale of 0 to 10 was used to assess pain on the day of surgery, and on postoperative days 1 and 14. RESULTS: The total mean morphine sulfate equivalent +/- SD in patients in the RALP and RRP groups was low and, when corrected for length of stay, it was not statistically different (22.41 +/- 1.13 vs 23.01 +/- 1.16 mg, p = 0.72). Mean Likert pain perception scores were low at all time points in the RALP and RRP groups but statistically lower on the day of surgery in the RALP cohort (2.05 +/- 1.99 vs 2.60 +/- 2.25, p = 0.027). Patient reported mean pain scores were almost identical for RALP vs RRP on postoperative days 1 (1.76 +/- 1.87 vs 1.73 +/- 1.77, p = 0.880) and 14 (2.51 +/- 1.91 vs 2.42 +/- 1.84, p = 0.722). CONCLUSIONS: Perioperative narcotic use and patient reported pain are low regardless of the surgical approach used for radical prostatectomy. RALP did not provide a clinically meaningful decrease in pain compared with RRP, primarily because of the low pain scores reported in each group. Outcomes other than pain will ultimately determine the role of laparoscopic radical prostatectomy and RALP.     

Impact of age on clinical care pathway length of stay after complex head and neck resection

OBJECTIVE: This article investigates the effect of patient age on postoperative pathway length of stay (LOS) for head and neck surgery. Aggregate clinical results for 43 patients, enrolled in the CCP from June 1996-July 1997, are described. Patient age, comorbid status, and postoperative complications are analyzed with respect to impact on LOS. SETTING: Tertiary level academic medical center with an operative otorhinolaryngology volume of approximately 1200 cases per year. PATIENTS: Forty-three patients undergoing head and neck resection with primary closure, local flap, or free flap closure were enrolled on CCP from June 1996-July 1997. Length of stay, frequency of selected aggregated comorbidities, and frequencies of complications are analyzed with nonparametric statistics. A pre-pathway group of 87 consecutive patients is used for comparison. MAIN OUTCOME MEASURES: Length of stay and age. RESULTS: Median actual LOS post-pathway for the patients enrolled in the first year of the pathway was 8 days. This met the CCP target and improved on pre-pathway LOS by 5 days (p <.001). The average LOS increased 25% from 8 days to 10 days for patients older than 65 years of age (p =.036, Mann-Whitney U test). Presence of a comorbidity and a complication concomitantly was statistically associated with increased LOS though not with advancing age (p =.003). CONCLUSIONS: The CCP-reported performance improvement achieved by this pathway suggests improved resource use, and improved patient outcomes are achieved for postoperative care of head and neck surgery patients. Our experience suggests that advancing age creates a clinically significant increase in resource use represented by our finding of increasing LOS. This finding warrants further investigation.     

Preserved postoperative penile size correlates well with maintained erectile function after bilateral nerve-sparing radical retropubic prostatectomy

OBJECTIVES: Controversial data on penile length after radical retropubic prostatectomy are available. We hypothesised that postoperative penile size correlates to erectile function following bilateral nerve-sparing radical retropubic prostatectomy (BNSRRP). METHODS: Thirty-three consecutive patients with a preoperative erectile function domain of the International Index of Erectile Function (IIEF-EF) score indicating full potency (> or = 26) were prospectively enrolled. All patients underwent BNSRRP performed by one high-volume surgeon. All patients were preoperatively evaluated by IIEF-EF, analysis of comorbidities, physical examination, and penile power colour Doppler ultrasound using intracavernosal injection of prostaglandin E(1) (PGE(1)) 20 microg plus audiovisual and manual genital stimulation. Penile length and circumference were measured in flaccidity and at maximum erection. Six months postoperative, patients were assessed with the same protocol plus general assessment questions investigating penile structure and function. Statistical analysis was performed with an independent sample t test. RESULTS: Mean patient age was 56.5 yr. We found no difference between the preoperative and the 6-mo postoperative mean IIEF-EF domain score (27.2 vs, 26.7, respectively; p = 0.35). No difference was found in penile colour Doppler evaluation between the preoperative and postoperative periods (all p values > or = 0.3). We found no differences in penile length and circumference between the preoperative and postoperative evaluation either in the flaccid or in the erect state. Mean flaccid penile length (cm; preop vs. postop): 13.2 vs. 13 (p = 0.6). Mean flaccid penile circumference (cm; preop vs. postop): 11.1 vs. 11 (p = 0.7). Mean erect penile length (cm; preop vs. postop): 16.8 vs. 16.5 (p = 0.08). Mean erect penile circumference (cm; preop vs. postop): 15.6 vs. 15.3 (p = 0.2). CONCLUSIONS: This is the first report on penile changes in flaccidity and at maximum erection after BNSRRP in patients treated by one high-volume surgeon. The postoperative preservation of erectile function positively correlated with the maintenance of penile length following surgery. We found no change in penile size after surgery.     

Impact of clinical pathways on hospital costs and early outcome after major vascular surgery

Purpose: The purpose of this study was to determine whether major vascular surgery could be performed safely and with significant hospital cost savings by decreasing length of stay and implementation of vascular clinical pathways.Methods: Morbidity, mortality, readmission rates, same-day admissions, length of stay, and hospital costs were compared between patients who were electively admitted between September 1, 1992, and August 30, 1993 (group 1), and January 1 to December 31, 1994 (group 2), for extracranial, infrarenal abdominal aortic, and lower extremity arterial surgery. For group 2 patients, vascular critical pathways were instituted, a dedicated vascular ward was established, and outpatient preoperative arteriography and anesthesiology-cardiology evaluations were performed. Length-of-stay goals were 1 day for extracranial, 5 days for aortic, and 2 to 5 days for lower extremity surgery. Emergency admissions, inpatients referred for vascular surgery, patients transferred from other hospitals, and patients who required prolonged preoperative treatment were excluded.Results: With this strategy same-day admissions were significantly increased (80% [145/177] vs 6.2% [9/145]) (p < 0.0001), and average length of stay was significantly decreased (3.8 vs 8.8 days) (p < 0.0001) in group 2 versus group 1, respectively. There were no significant differences between group 1 and group 2 in terms of overall mortality rate (2.1% [3/145] vs 2.3% [4/177]), cardiac (3.4% [5/145] vs 4.0% [7/177]), pulmonary (4.1% [6/145] vs 1.7% [3/177]), or neurologic (1.4% [2/145] vs 0% [0/177]) complications, or readmission within 30 days (11.3% [16/142] vs 9.2% [16/173]) (p > 0.05). There were also no differences in morbidity or mortality rates when each type of surgery was compared. Annual hospital cost savings totalled $1,267,445.Conclusion: Same-day admission and early hospital discharge for patients undergoing elective major vascular surgery can result in significant hospital cost savings without apparent increase in morbidity or mortality rates. (J VASC SURG 1995;22:649-60.)     

The effect of hospital volume on mortality and resource use after radical prostatectomy

PURPOSE: The value of radical prostatectomy for patients with prostate cancer depends on low morbidity and mortality. We assessed whether patient outcome is associated with how many of these procedures are performed at hospitals yearly. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample, which is a stratified probability sample of American hospitals, we identified 66,693 men who underwent radical prostatectomy between 1989 and 1995. Cases were categorized into volume groups according to hospital annual rate of radical prostatectomies performed, including low-fewer than 25, medium-25 to 54 and high-greater than 54. We performed multivariate logistic regression to control for patient characteristics when assessing the associations of hospital volume, in-hospital mortality and resource use. RESULTS: Overall adjusted in-hospital mortality after radical prostatectomy was relatively low (0.25%). However, patients at low volume centers were 78% more likely to have in-hospital mortality than those at high volume centers (adjusted odds ratio 1.78, 95% confidence interval 1.7 to 2.6). Overall length of stay decreased at all hospitals between 1989 and 1995. However, average length of stay was longer and total hospital charges were higher at low than at high volume centers (7.3 versus 6.1 days, p<0.0001, and $15,600 versus $13,500, p<0.0001, respectively). CONCLUSIONS: Hospital volumes inversely related to in-hospital mortality, length of stay and total hospital charges after radical prostatectomy. Further study is necessary to examine the association of hospital volume with other important outcomes, including incontinence, impotence and long-term patient survival after radical prostatectomy.     

Can single dose preoperative intrathecal morphine sulfate provide cost-effective postoperative analgesia and patient satisfaction during radical prostatectomy in the current era of cost containment?

We retrospectively analyzed the analgesic efficacy and surgical outcomes of a single preoperative intrathecal long-acting morphine sulfate injection (0.25-0.5 mg) and postoperative intravenous (i.v.) ketorolac in 62 patients who underwent radical retropubic prostatectomy (RRP). Total postoperative analgesic requirement was documented along with assessment of length of hospital stay, pain control and time for resumption of normal activity. Postoperatively, 45% of patients required only nonsteroidal agents (ketorolac), whereas 55% needed a mean of 13.3 mg of supplemental i.v. morphine sulfate. Mean hospital stay was 2.3+/-0.3 days. Eighty-two per cent of patients felt the length of hospital stay adequate. Ninety-seven per cent of patients were satisfied with anesthesia selected and 95% of patients considered pain control on postoperative days 1 and 2 as effective. All patients resumed to full physical activity by 5.3+/-0.4 weeks after surgery. We conclude that a single preoperative injection of intrathecal morphine sulfate combined with i.v. ketorolac postoperatively results in effective analgesia, diminished supplemental narcotic requirement and high patient satisfaction during radical retropubic prostatectomy.     

The cost of radical prostatectomy: retrospective comparison of open, laparoscopic, and robot-assisted approaches

New technologies are regularly being used for surgical treatment of prostate cancer, however the cost associated is often a secondary issue. We assessed the operative costs incurred by using the daVinci robot assisted prostatectomy (RAP) method compared to pure laparoscopic radical prostatectomy (LRP) and open radical prostatectomy (ORP). We retrospectively analyzed three techniques of radical prostatectomies: ORP, LRP, and RAP (n = 70, 57, 106, respectively). The mean patient age was 53.6, 57.6, and 60 with a mean preoperative prostate specific antigen (PSA) of 7.2, 8.4, and 6.6, respectively. The mean Gleason score was 6. Operative cost was measured for each patient. Charts were reviewed to assess individual patients postoperative requirements, and hospital length of stay (LOS). Intraoperative data show costs to be higher with the RAP and LRP compared to open surgery. Average total operating room (OR) costs per case were $5410, $3876, and $1870 for RAP, LRP, and open prostatectomy, respectively. However when comparisons are made in the postoperative period with regard to LOS, there is a significant advantage of the RAP and LRP groups over open surgery (P < 0.05). Intraoperative costs are highest for RAP. Both LRP and RAP are associated with a shorter hospital stay.     

Multimodal analgesia for radical prostatectomy provides better analgesia and shortens hospital stay

STUDY OBJECTIVE: To assess the clinical impact of paravertebral blocks (PVBs) on the immediate outcome of patients undergoing radical prostatectomy. DESIGN: Retrospective review. SETTING: Urology ward of a university medical center. MEASUREMENTS: Records of 100 consecutive patients who underwent a radical prostatectomy by the same surgeon were examined. In the first 50 patients (group 1), at surgical closure, the wound was infiltrated with 30 mL bupivacaine 0.25% and ketorolac 30 mg administered intravenously (IV). Postoperatively, patients received 15 mg ketorolac IV every 6 hours for 48 hours. Opioid (IV) patient-controlled analgesia was given overnight and thereafter, opioids were given orally as needed. The remaining 50 patients (group 2) received, in addition to the cited medication, a single preoperative oral dose of valdecoxib (40 mg) and preoperative bilateral PVBs at T10-T11-T12 using ropivacaine 0.5% (5 mL per level). Pain scores, opioid consumption, and hospital length of stay (LOS) were recorded. MAIN RESULTS: Addition of preoperative valdecoxib and bilateral PVBs was associated with significantly lower pain scores and opioid consumption. Hospital LOS was reduced from an average of 56 hours in group 1 to 47 hours in group 2. CONCLUSIONS: Preoperative bilateral PVBs and a single dose of a COX-2 inhibitor may improve immediate outcome and shorten hospital LOS after radical retropubic prostatectomy.     

Making ends meet: a cost comparison of laparoscopic and open radical retropubic prostatectomy

PURPOSE: We compared the perioperative costs of laparoscopic radical prostatectomy (LRP) and open radical retropubic prostatectomy (RRP) at a metropolitan hospital by developing a detailed computer model. MATERIALS AND METHODS: Our predictive model incorporates institutional cost centers for operative time, operating room consumables, professional fees, hospital room and board, oral analgesics, autologous blood banking, blood transfusion and cystography. Versions with and without pelvic lymphadenectomy (PLND) were evaluated using 1 and 2-way sensitivity analyses. Operative times, lengths of stay and transfusion rates were derived from published series. We also reviewed individual hospital charges for 172 consecutive prostatectomy cases for comparison and validation of model predictions. RESULTS: The model predicted cost premiums for LRP of 14.4% (without PLND) and 17.5% (with PLND). The actual hospital charge premium for LRP and PLND was 18.4%, which differed from the predicted cost premium by less than 1%. The most significant cost centers in order of importance were operative time, length of stay and consumables. To achieve cost equivalence with RRP, operative times would need to average 159 minutes (LRP and PLND) and 174 minutes (LRP alone) holding other factors constant. Cost equivalence could not be achieved by shortening hospital stay alone unless LRP were performed as an outpatient procedure. CONCLUSIONS: Our model predicts the perioperative costs of LRP to be greater than RRP by a factor of less than 1.2x. If disposable instruments and trocars are eliminated, and patients undergoing LRP and PLND are discharged on postoperative day 2, cost equivalence with RRP and PLND can be achieved with operative times of 3.4 hours.     

Comparison of early oncologic results of laparoscopic radical prostatectomy by extraperitoneal versus transperitoneal approach

PURPOSE: Compare the early oncological results of laparoscopic radical prostatectomy performed by either an extraperitoneal or a transperitoneal approach. METHODS: 330 consecutive men underwent laparoscopic radical prostatectomy for localized prostate cancer, the first 165 by transperitoneal approach, and the last 165 by extraperitoneal approach. Clinical stage, serum PSA, Gleason score of biopsy were recorded, as well as operating time, surgical and medical complications, blood loss, length of hospital stay and catheterization time. The weight of the specimen, pathological stage (1997 TNM classification) and status of the surgical margins were noted. The Fisher test as well as the chi2-test were used for statistical analysis. Differences were considered significant when p < 0.05. RESULTS: There were no significant differences between the two groups in terms of preoperative characteristics except for Gleason score of the biopsies which was higher in the extraperitoneal group (p < 0.0001). The operating time was longer with the transperitoneal approach (248.5 min vs. 220.0 min, p < 0.0001). There was no difference in transfusion rate (1.2% vs. 5.4%, transperitoneal vs. extraperitoneal, respectively, p = 0.6). There was no difference in hospital stay, medical and surgical complications. Respectively, in the transperitoneal and extraperitoneal groups, there were 108 and 88 pT2 tumors. There were no differences in terms of positive surgical margins between the two groups, 23% and 29.7% (p = 0.21) overall, 13.0% and 17.0% (p = 0.42) in pT2 tumors and 43.6% and 44.7% (p = 0.99) in pT3 tumors. CONCLUSIONS: Extraperitoneal approach offers the same early oncological results as transperitoneal approach with a shorter operative time.