Vattikuti Institute Prostatectomy: Technique (2023)

During robotic-assisted radical prostatectomy (RARP), the use of electrocautery near the neurovascular bundles (NVBs) frequently results in thermal injury to the cavernous nerves. The cut and “touch” monopolar cautery technique has been suggested to reduce desiccating thermal injury caused by bipolar energy when vessels are sealed.

To compare potency outcomes between an athermal technique (AT) and touch cautery (TC) to transect the prostatic vascular pedicles (PVPs) and dissect the NVBs.

A retrospective concomitant nonrandomized study of AT versus TC was performed in 733 men. A total of 323 undergoing AT had “thin” pedicles, easily suitable for suture ligation. TC was based on “thick” pedicles (n=230) difficult to suture ligate. Men were excluded for an International Index of Erectile Function (IIEF-5) score of <15 or adjuvant therapies (n=180).

Single-surgeon RARP.

Patient-reported outcomes with erectile function (EF) recovery defined as two affirmative answers to erections sufficient for intercourse (ESI; “are erections firm enough for penetration?” and “are the erections satisfactory?”), IIEF-5 scores 15–25, and a novel percent fullness score comparing pre- versus postoperative erection fullness. Logistic regression models assessed the correlation between cautery technique, covariates, and EF recovery.

In an unadjusted analysis, preoperative IIEF-5, age, body mass index (BMI), and prostate weight were significant predictors of potency recovery. Follow-up was similar (AT 52.7 mo vs TC 54.6 mo, p=0.534). In logistic regression, preoperative IIEF-5, age, and BMI were significant predictors of EF recovery, defined as IIEF-5 scores 15–25, ESI, and percent fullness >75%. Results were similar when IIEF-5 and percent fullness were assessed continuously.

During transection of the PVPs and dissection of the NVBs, TC did not impact EF recovery significantly, compared with an AT.

Electrocautery can be applied safely, with similar outcomes to those of an athermal technique.

We compared the learning curve and pathologic and functional outcomes of retropubic radical prostatectomy (RRP) and robotic-assisted radical prostatectomy (RARP) performed during the same time period by a novice to identify how the two surgical types affect each other.

We retrospectively reviewed 480 men who underwent RRP or RARP for prostate cancer between January 2008 and December 2012. Operation time, estimated blood loss (EBL), positive surgical margin (PSM) rate, urinary continence and potency recovery, and complications were compared. Scatter-graphs were drawn using locally weighted scatterplot smoothing (LOWESS).

Operation time reached the lowest point in the 90th case in RRP and the 200th case in RARP. EBL showed a similar pattern, reaching the lowest point in the 95th case in RRP and the 230th case in RARP. The lowest points for both operation time and EBL took about 3 years to reach for both surgical types. PSM rate was not significantly different (P=0.807). No pads were required at 6 and 12 months in 55.6% and 66.9% of patients in RRP, respectively, but in 79.6% and 88.4% of patients in RARP. The potency recovery rates were 59.1% in RRP and 70.9% in RARP at 12 months.

When RRP and RARP were begun contemporaneously by a novice, they showed similar learning curve patterns. The direct tactile feedback in RRP and the magnified field of view and detailed techniques in RARP help improve surgical skills complementarily to attain proficiency in both surgical types.

To examine variation in the open market cost of a radical prostatectomy (RP) procedure in the US hospitals for an uninsured patient, as many proposals for health care reform highlight the importance of individuals actively participating in selecting care. However, reports suggest that obtaining procedure prices remains challenging and highly variable.

We used 2011-2012 US News and World Report rankings to identify a cohort of 100 hospitals making an effort to include an equal distribution of both academic and private centers, city size, and geographic region. Each hospital was called and the essence of the script included a caller stating he was a healthy, uninsured 55-year-old man recently diagnosed with Gleason 3+ 4 prostatic adenocarcinoma with no metastases. Facility, surgeon, and anesthesia fees were solicited.

Seventy hospitals provided facility prices. Facility estimates averaged $34,720 (±20,335; range, $10,100-$135,000), which was statistically higher at academics centers. No significant differences were seen by region, population, or hospital ranking. Surgeon and anesthesia fees were provided by 10%, averaging $8280 (±$4282; range, $4028-$18,720). Thirty-three hospitals provided discounted fees for prompt payment averaging 34% (±16%; range, 10%-80%).

There is wide variation in pricing for RP, with higher rates found in academic centers. Wide variation in facility costs were observed, and nearly all were unable to provide surgeon and/or anesthesia fees. Currently, it appears to be unacceptably difficult for men with prostate cancer without insurance to obtain prices for an RP procedure.

Single-port (SP) robot-assisted laparoscopic prostatectomy (RALP) appears to be a safe and feasible approach for radical prostatectomy, but no prior studies have compared SP-RALP to a multiport (MP) platform. Using retrospective data from a single-center tertiary institution we compare 50 consecutive SP-RALP patients (da Vinci SP) to a contemporary cohort of 113 patients who underwent MP-RALP (da Vinci Xi). We found no significant differences in surgical or total operating room time. Pain scores were measured on a scale from 0 to 10. There were more pain-free patients on postoperative day 1 (18% difference, 95% confidence interval [CI] 9.9–27%) and there were shorter hospital stays (−1 d, 95% CI −1.0 to 0) in favor of SP. There were no significant differences in inpatient total morphine equivalents used, complication rates, or stress incontinence determined at a minimum of 90 d. These findings show that the learning curve for SP-RALP is relatively short for an experienced robotic surgeon and may favor better pain control and shorter hospitalization.

We analyzed the differences in robotic surgery for localized prostate cancer using a single-port robotic platform compared to the traditional multiport robotic platform. We did not find significant differences in operative times, but significantly more patients were pain-free on the first postoperative day and had shorter hospital stays.

Understanding factors associated with variation in hospital charges may help identify means to increase savings. The aim of the present study was to define potential variation in hospital charges associated with hepatopancreatobiliary(HPB) surgery.

Patients who underwent an HPB procedure between 2009–2013 were identified. Total hospital charges were tabulated for room and board, surgical/anaesthesia services, medications, laboratory/radiology services and other miscellaneous charges.

Approximately 2545 patients underwent either a pancreas (66.8%) or liver/biliary (33.2%) resection. The mean total charges for all patients were $42357±33745 (pancreas: $46352± 34932 versus the liver: $34303±29639; P'<0.001). Morbidity (pancreas, range: 7–18%; liver, range: 9–18%) and observed:expected (O:E) length of stay (LOS)(pancreas, range: 0.67–1.64; liver, range: 1.06–3.35) varied among providers (both P<0.001). While a peri‐operative complication resulted in increased total hospital charges (complication: $66401±55124 versus no complication: $39668±29250; P<0.001), total charges remained variable even among patients who did not experience a complication (P<0.001). Surgeons within the lowest quartile of O:E LOS had lower total charges ($33879±$27398) versus surgeons in the highest quartile ($49498±40971) (P<0.001). Surgeons with the highest O:E LOS had higher across‐the‐board charges (operating room, highest quartile: $10514±$4496 versus lowest quartile: $7842±$3706; medication, highest quartile: $1796 ± $3799 versus lowest quartile: $925±$2211; radiology, highest quartile: $2494±$4683 versus lowest quartile: $1424±$3247; P=0.001; laboratory, highest quartile: $4236±$5991 versus lowest quartile: $3028±$3804; all P<0.001).

After accounting for in‐hospital complications, the total mean hospital charges for HPB surgery remained variable by case type and provider. While the variation in charges was associated with LOS, provider‐level differences in across‐the‐board charges were also noted.

To evaluate the stability of physician-specific episode payments for prostatectomy, nephrectomy, and cystectomy in the context of value-based purchasing programs, such as the merit-based incentive payment system.

We utilized Surveillance, Epidemiology and End Results-Medicare data to identify patients aged 66-99 who underwent a prostatectomy, nephrectomy, or cystectomy from 2008 to 2012. We calculated each surgeon's average 90-day episode payment by procedure. Next, we examined payment differences between the most and least expensive quartile providers. For the most expensive quartile of physicians in 2010, we examined their spending quartile in 2011. Finally, we evaluated the correlation in spending over time and across procedures.

We identified 14,585 patients who underwent surgery by one of 1895 unique clinicians. Differences in payments between the highest and lowest quartiles were $5881, $17,714, and $40,288 for prostatectomy, nephrectomy, and cystectomy, respectively. Only 39%, 16%, and 13% of physicians that were in the highest spending quartile for prostatectomy, nephrectomy, and cystectomy in 2010 were also in the most expensive quartile in 2011. Although we observed weak correlation in year-to-year spending for prostatectomy (0.108, P = .033 to .270, P < .001), annual payments for nephrectomy and cystectomy were not significantly correlated. Finally, there was minimal correlation in surgeon spending across procedures.

There is wide variation in physician-specific episode payments for prostatectomy, nephrectomy, and cystectomy. However, physician spending patterns are not stable over time or across procedures, raising concerns about the ability of the cost-based measures in merit-based incentive payment system to change physician behavior and reliably distinguish those providing less efficient or lower quality care.