Trends in the Care of Radical Prostatectomy in the United States from 2003-2006
Aaron C. Weinberg, BS1, Jeremy Shelton, MD1, Nathanael D. Hevelone, MPH2, Stuart Lipsitz, PHD3, Jim C. Hu, MD, MPH1.
1Division of Urologic Surgery Brigham and Women’s Hospital, Boston, MA, USA, 2Division of Vascular Surgery, UCSF Medical Center, San Francisco, CA, USA, 3Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA.
BACKGROUND: While utilization of minimally invasive radical prostatectomy (MIRP) has diffused rapidly, few studies examine outcomes in community settings. We preformed a population-based study during 2003-2006 to determine whether MIRP outcomes improved over a period of rapid adoption compared to traditional approaches.
We identified 19,821 men undergoing MIRP, perineal (PRP), and retropubic radical prostatectomy (RRP) from MarketScan® Medstat, a nationally representative employer-based administrative database. We assessed for temporal trends by surgical approach in perioperative complications, use of postoperative cystography, anastomotic strictures, incontinence, and erectile dysfunction.
In 2006, MIRP utilization was 39.4% vs. 57% for RRP and 3.6% for PRP. Over the 4-year study period, MIRP length of stay decreased from 2.1 to 1.7 days, p<0.0001 and 30-day perioperative complications decreased from 13.4% to 10.7%, (p=0.02), driven by reductions in genitourinary (3.1% to 2.5%, p=0.0345) and miscellaneous surgical complications (3.8 to 2.9%, p=0.0148). Additionally, re-exploration rates (12.9% to 7.4%, p=<0.0001) and intestinal injury (1.4% to 0.1%, p=0.0008) decreased over the study period. RRP length of stay decreased from 3.2 to 2.9 days, (p=<0.0001) and 30-day complications decreased from 17.78% to 14.89%, (p=0.0008), due to reductions in both wound/bleeding complications, 2.1% to 1.2%, (p=0.0168) and heterologous blood transfusions, 9.1% to 6.6%, (p=<0.0001). Men undergoing MIRP vs. RRP experienced a reduced overall 30-day perioperative complication rate (12.34% vs. 17.22%, p<0.001), blood transfusions (1.5% vs. 8.7%, p<0.001), anastomotic strictures (6.2% vs. 12.4%, p<0.001), and shorter median lengths of stay (1 vs. 3 days, p<0.001). Additionally trends were observed indicating a reduction in length of stay, Heterologous blood transfusion and perioperative wound complications for RRP (3.2 days to 2.9 days p<0.0001, 17.78% to 14.89% p<0.0001, 2.08% to 1.06%).
Despite the increased in utilization of MIRP, there was a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation for men undergoing this procedure. Additionally MIRP was found to have less associated complications as compared to RRP Furthermore RRP was also associated with relatively favorable outcomes, however further study is needed to adjust for these perioperative complications, continence and potency as well as long term cancer control by tumor characteristics and surgeon volume. Temporal trends in MIRP Complications and Iatrogenic Injuries
|Length of Stay (Mean)||2.1||1.9||2.0||1.7||1.9||<0.0001|
|Length of Stay (Median)||2.0||1.0||1.0||1.0||1.0||-|
|Overall Perioperative Comp||13.38||13.32||14.06||10.71||12.34||0.0206|
|Re-exploration (0 days)||12.9||12.1||12.1||7.4||10.0||<0.0001|
|Re-exploration (1-7 days)||1.3||0.4||0.5||0.4||0.5||0.18|
|Incisional Hernia Repair||0.8||1.9||1.6||-||0.8||0.4753|
Temporal trends in RRP Complications and Iatrogenic Injuries
|Length of Stay (Mean)||3.2||3.1||3.1||2.9||3.1||<0.0001|
|Length of Stay (Median)||3.0||3.0||3.0||3.0||3.0||-|
|Overall Perioperative Comp||17.78||17.11||18.54||14.89||17.22||0.0008|
|Rectal Repair (6mo)||1.02||0.99||1.12||0.76||1.0||0.72|
|Re-exploration (0 days)||0.26||0.12||0.11||0.00||0.14||0.023|
|Re-exploration (1-7 days)||0.01||0.02||0.06||0.04||0.03||0.34|
|Incisional Hernia Repair (1yr)||0.69||0.66||1.12||-||1.0||0.11|