Cost Analysis of Open Radical Cystectomy Versus Robot-assisted Radical Cystectomy

Bladder cancer is the fourth and ninth most common malignancy in males and females, respectively, in the U.S. and one of the most costly cancers to manage. With the current economic condition, physicians will need to become more aware of cost-effective therapies for the treatment of various malignancies. Robot-assisted radical cystectomy (RARC) is the latest minimally invasive surgical option for muscle-invasive bladder cancer. Current reports have shown less blood loss, a shorter hospital stay, and a lower morbidity with RARC, as compared with the traditional open radical cystectomy (ORC), although long-term oncologic results of RARC are still maturing. There are few studies that have assessed the cost outcomes of RARC as compared with ORC. Currently, ORC appears to offer a direct cost advantage due to the high purchase and maintenance cost of the robotic platform, although when the indirect costs of complications and extended hospital stay with ORC are considered, RARC may be less expensive than the traditional open procedure. In order to accurately evaluate the cost effectiveness of RARC versus ORC, prospective randomized trials between the two surgical techniques with long-term oncologic efficacy are needed.     

Safety and feasibility of concomitant surgery during holmium laser enucleation of the prostate (HoLEP)

Purpose

To determine the feasibility and outcomes associated with performing simultaneous surgical procedures during holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia and concomitant urologic conditions.

Methods

A retrospective review of patients that underwent a HoLEP was performed. Patients undergoing a concomitant procedure at the time of HoLEP were selected and stratified based on complexity of the secondary procedure (simple, intermediate, and complex) and matched based on age and prostate volume to patients undergoing only a HoLEP. Baseline characteristics, preoperative, operative, and postoperative outcomes were collected.

Results

A total of 372 HoLEPs were performed. Thirty-eight (10.2 %) patients underwent concomitant procedures at the time of HoLEP. Compared to the simple and intermediate secondary surgical procedures, the matched control group that underwent a HoLEP alone did not demonstrate statistically significant differences in the preoperative, operative, or postoperative outcomes. Patients with a complex secondary surgical procedure at the time of HoLEP had statistically significant differences in operative time (221 vs. 65 min, p = 0.007), estimated blood loss (92 vs. 33 mL, p = 0.012), catheter time (8.5 vs. 1 day, p = 0.041), and length of hospitalization (2 vs. 1 day, p = 0.032) compared to the control group.

Conclusions

Obstructive voiding symptoms secondary to BPH are common in older patients and may coincide with other concomitant lower urinary tract pathology that may require surgical intervention. Rather than staging surgical interventions, it appears that definitive treatment for BPH with HoLEP is safe and efficacious in those patients that also require secondary procedures.     

Community perceptions of childbearing and use of safer conception strategies among HIV-discordant couples in Kisumu,Kenya

Introduction

Safer conception strategies (SCS) have the potential to decrease HIV transmission among HIV-discordant couples who desire children. Community perceptions of SCS may influence the scale-up and uptake of these services, but little is known about how communities will react to these strategies. Without community support for SCS, their success as an HIV prevention tool may be limited. The objective of this study is to characterize community perceptions of SCS for HIV-discordant couples in Kisumu, Kenya, to inform ongoing and future safer conception intervention studies in low-resource settings.

Methods

We conducted six focus group discussions and 11 in-depth-interviews in Kisumu, Kenya, among a diverse group (N=59) of community members, including men, women, youth (age 19–25), community health workers and local leaders. An iterative qualitative analysis using a grounded theory approach was employed.

Results and discussion

All participants emphasized the importance of childbearing in their society and the right to have children, regardless of an individual''s HIV status. While most participants believed that HIV-discordant couples should be allowed to have children, they discussed several barriers to the uptake of SCS such as HIV-related stigma, fear of HIV transmission to the uninfected partner and child, fear of unfamiliar medical procedures and lack of information among community members and health care providers about HIV prevention interventions that allow safer conception. Access to information, community experiences with successful safer conception interventions, healthcare provider training, male engagement and community mobilization may help overcome these barriers. Though assisted reproduction strategies generated the most negative reactions from participants, our results suggest that with education and explanation of these services, participants express interest in these strategies and want them to be offered in their community.

Conclusions

Many community members noted a need and desire for safer conception education and services in Kisumu. However, community barriers such as fear, stigma and lack of information should be addressed before safer conception interventions can be successfully implemented and delivered. Further research focused on community education, male engagement and healthcare provider training is a crucial next step in delivering safer conception in this region.     

Robotic-assisted laparoscopic bladder diverticulectomy and concomitant ureteral re-implantation: initial clinical experience

We present our initial clinical experience with robotic-assisted laparoscopic bladder diverticulectomy with associated ureteral re-implantation. A 75-year-old man was referred to us for recurrent urinary tract infections and lower urinary tract symptoms. On computed tomography of abdomen and pelvis the patient was found to have a 13 × 14 × 6 cm diverticulum in the left posterior bladder wall. The patient elected to undergo robotic-assisted laparoscopic removal of the diverticulum. The patient’s preparation, draping, and trocar placement was performed as per standard fashion of robotic-assisted laparoscopic radical prostatectomy. The bladder was mobilized and diverticulum was identified and removed. The left ureter was transected secondary to its passage through the diverticulum, and required re-implantation. After hemostasis was achieved, the repair was tested and confirmed. The operation was completed in 207 min without any complications. Estimated blood loss was 150 cc. On postoperative day 1, the patient was placed on oral analgesic and discharged home. Our initial report of robotic-assisted laparoscopic bladder diverticulectomy and ureteral re-implantation illustrates that this minimally invasive technique is an effective method of treatment of bladder diverticulum. Proximity of the ureter to the diverticulum should not be a deterrent for this approach of repair.     

Oncologic outcomes for lymph node-positive urothelial carcinoma patients treated with robot assisted radical cystectomy: With mean follow-up of 3.5 years

PurposePrevious studies have shown robot assisted radical cystectomy (RARC) to have comparable perioperative outcomes to open radical cystectomy. There are few reports that have examined the oncologic results of RARC, specifically with respect to lymph node-positive patients. We report the outcomes of pathologic node-positive patients who have undergone RARC with medium-term follow-up.Materials and methodsA total of 275 patients underwent RARC at 2 institutions for invasive bladder cancer between April 2005 and June 2009. We examined the 50 patients with lymph node-positive disease. Oncologic outcomes, overall, and recurrence-free survival were analyzed and compared with the open literature.ResultsMean (median) clinical follow-up in this cohort was 42 (39.5) months (range 16–75 months). The mean (median) number of lymph nodes (LN) removed was 18 (17.5) (range 5–35), and mean (median) number of positive LN was 3 (2) (range 1–12). Mean lymph node density was 18%. Seventeen (34%) patients had ≤ pT₂ disease and 33 (66%) pT₃/T₄ disease. At this follow-up, 29 patients have recurred, and 22 patients have died of disease. Mean (median) time to recurrence was 10 (9) months. The estimated overall survival at 36 and 60 months was 55%, and 45%, respectively. The recurrence-free survival at 36 and 60 months was 43%, and 39%, respectively. Thirty-three (66%) patients had an LN density <20%. The estimated overall survival at 36 months of patients with a lymph node density of <20% was higher than those with a lymph node density >20%, though the difference was not statistically significant. A total of 58% of patients received chemotherapy in this cohort. The use of chemotherapy was associated with a statistically significant (P = 0.033) improvement in overall survival, with an overall survival of 68% at 36 months compared with 36% for the patients who did not receive any chemotherapy.ConclusionsThe oncologic outcomes of patients with lymph node-positive bladder cancer treated with robot assisted radical cystectomy (RARC) compare favorably to previous published studies of open radical cystectomy at medium-term (mean follow-up of 42 months). As our follow-up increases, we expect to continue to accurately define the long-term clinical suitability and oncologic success of this procedure in this high-risk population.