Robotic prostatectomy usage increasing for BPH

Boston-The use of robot-assisted simple prostatectomy (RASP) is increasing for the management of BPH in the United States. Patients were nearly seven times more likely to undergo RASP in 2011-2015 compared to 2003-2006, after adjusting for confounders.

“The robotic approach has gained steady traction across the years, from 1.5% in 2003 to over 10% in 2015, overtaking pure laparoscopy as the main [minimally invasive surgical] method of performing simple prostatectomy in the United States in 2010,” said Jeffrey Leow, MBBS, MPH, at the AUA annual meeting in Boston.

The analysis found that “there was also a decreasing trend in number and proportion of open simple prostatectomies” said Dr. Leow, urology resident at Tan Tock Seng Hospital, Singapore, and research fellow at the Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, working with Jesse Sammon, DO, and co-authors.

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The growing popularity of holmium laser enucleation of the prostate (HoLEP) probably explains the stable rate of total simple prostatectomies over the study period. Guidelines from the AUA in 2014 and the European Association of Urology in 2017 for men with symptomatic BPH recommend simple prostatectomy or HoLEP, especially for prostate volumes >80 grams.

The effect of the advent of robotics on the use of simple prostatectomy in an era of growing popularity of enucleation was assessed by data extraction from the Premier Healthcare Database.

A total of 43,731 men who underwent simple prostatectomy for BPH at 414 U.S. hospitals between the first quarter of 2003 through the third quarter of 2015 formed the study population. Men diagnosed with prostate cancer were excluded. Using a combination of ICD-9 codes and a detailed review of the billing codes, procedures were identified as robotic or laparoscopic. Prostatectomy was performed via open procedure in 40,995 cases, via laparoscopic approaches in 1,348 cases, and via robotic technique in 1,388. The primary outcome of interest was the use of RASP over the study period.

Potential confounders were adjusted for and accounted for clustering by hospitals and survey weighting to ensure nationally representative estimates.

Next - RASP predictors: Hospital size, region

RASP predictors: Hospital size, region

On multivariable logistic regression, predictors of performing RASP were larger hospital size, hospital region, higher annual surgeon volume, and the period during which the procedure was performed.

Among the findings:

• The odds ratio (OR) for robotic simple prostatectomy at hospitals with ≥500 beds was 3.43 (p=.010) compared with hospitals with <300 beds. RASP was also more likely to be performed at hospitals with 300 to 499 beds compared with <300 beds (OR: 2.72, p=.036).

• RASP was more likely to be performed at hospitals in the Northeast (OR: 5.55, p=.007) and South (OR: 4.47, p=.013) than in the Midwest.

• The OR for RASP with higher annual surgical volume was 1.20 (p=.047).

• RASP was almost seven times as likely (OR 6.98, p<.001) when simple prostatectomy was performed in 2011 to 2015 compared with 2003 to 2006.

• The OR for RASP in a teaching hospital was 4.44 (p<.0001) compared with a non-teaching hospital.

In addition to examining trends in the use of RASP, 90-day rates of mortality, complications, and readmissions; receipt of blood transfusions; postoperative use of vasopressors, and postoperative intensive care unit stay were also examined.

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“The outcomes were pretty equivalent across the procedures, but in terms of postoperative ICU stay, the proportion of patients who underwent RASP was only 2.7% compared with 5% for the open group (p=.20). In addition, the receipt of blood transfusion was much less in the robotic group (14.6% vs. 24.4%, p=.01). This underscores what we know that open simple prostatectomy is traditionally a bloody procedure and such morbidity can potentially be overcome by the robotic platform,” Dr. Leow said.

Median costs were about 15% higher in the groups undergoing laparoscopic simple prostatectomy or RASP compared with open simple prostatectomy.

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