Perioperative Outcomes, Health Care Costs, and Survival After Robotic-assisted Versus Open Radical Cystectomy: A National Comparative Effectiveness Study.

Journal European Urology
Authors Hu, Jim C; Chughtai, Bilal; O’Malley, Padraic; Halpern, Joshua A; Mao, Jialin; Scherr, Douglas S; Hershman, Dawn L; Wright, Jason D; Sedrakyan, Art
Year Published 2016
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Abstract

BACKGROUND: Radical cystectomy is the gold-standard management for muscle-invasive bladder cancer, and there is debate concerning the comparative effectiveness of robotic-assisted (RARC) versus open radical cystectomy (ORC).

OBJECTIVE: To compare utilization, perioperative, cost, and survival outcomes of RARC versus ORC.

DESIGN, SETTING, AND PARTICIPANTS: We identified bladder urothelial carcinoma treated with RARC (n=439) or ORC (n=7308) during 2002-2012 using the Surveillance, Epidemiology, and End Results Program-Medicare linked data.

INTERVENTION: Comparison of RARC versus ORC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We used propensity score matching to compare perioperative and survival outcomes, including lymph node yield, perioperative complications, and healthcare costs.

RESULTS AND LIMITATIONS: Utilization of RARC increased from 0.7% of radical cystectomies in 2002 to 18.5% in 2012 (p<0.001). Women comprised 13.9% versus 18.1% (p=0.007) of RARC versus ORC, respectively. RARC was associated with greater lymph node yield with 41.5% versus 34.9% having ≥10 lymph nodes removed (relative risk 1.1, 95% confidence interval [CI] 1.01-1.22, p=0.03) and shorter mean length of hospitalization at 10.1 (± standard deviation 7.1) d versus 11.2 (± 8.6) d (p=0.004). While inpatient costs were similar, RARC was associated with increased home healthcare utilization (relative risk 1.14, 95% CI 1.04-1.26, p=0.009) and higher 30-d (p<0.01) and 90-d (p<0.01) costs. With a median follow-up of 44 mo (interquartile range 16-78), overall survival (hazard ratio 0.88, 95% CI 0.74-1.05) and cancer-specific survival (hazard ratio 0.91, 95% CI 0.66-1.26) were similar. CONCLUSIONS: RARC provides equivalent perioperative and intermediate term outcomes to ORC. Additional long-term and randomized studies are needed for continued comparative effectiveness assessment of RARC versus ORC.

PATIENT SUMMARY: Our population-based US study demonstrates that robotic-assisted radical cystectomy has similar perioperative and survival outcomes albeit at higher costs.

Use and risks of surgical mesh for pelvic organ prolapse surgery in women in New York state: population based cohort study

Journal BMJ
Authors Chughtai, Bilal; Mao, Jialin; Buck, Jessica; Kaplan, Steven; Sedrakyan, Art
Year Published 2015
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Abstract

OBJECTIVE: To assess the use of mesh in pelvic organ prolapse surgery, and compare short term outcomes between procedures using and not using mesh.

DESIGN: All inclusive, population based cohort study.

SETTING: Statewide surgical care captured in the New York Statewide Planning and Research Cooperative System.

PARTICIPANTS: Women who underwent prolapse repair procedures in New York state from 2008 to 2011.

MAIN OUTCOMES MEASURES: 90 day safety events and reinterventions within one year, after propensity score matching. Categorical, time to event, and subgroup analyses (<65 and ≥65 year age groups) were conducted.

RESULTS: Of 27 991 patients in total, 7338 and 20 653 underwent prolapse repair procedures with and without mesh, respectively. Mesh use increased by 44.7%, from 1461 procedures in 2008 to 2114 procedures in 2011. Most patients in the cohort were younger than 65 years (62.3% (n=17 424/27 991)). However, more patients were aged 65 years and older in the mesh group than in the non-mesh group (44.3% (n=3249) v 35.4% (n=7318)). Complications after surgery were not common, irrespective of the use or non-use of mesh. After propensity score matching, patients who received the surgery with mesh had a higher chance of having a reintervention within one year (mesh 3.3% v no mesh 2.2%, hazard ratio 1.47 (95% confidence interval 1.21 to 1.79)) and were more likely to have urinary retention within 90 days (mesh 7.5% v no mesh 5.6%, risk ratio 1.33 (95% confidence interval 1.18 to 1.51)), compared with those who received surgery without mesh. In subgroup analyses based on age, mesh use was associated with an increased risk of reintervention within one year in patients under age 65 years, and increased risk of urinary retention in patients aged 65 years and over.

CONCLUSIONS: Despite multiple warnings released by the US Food and Drug Administration since 2008, use of mesh in pelvic organ prolapse surgery continues to grow. In this statewide comprehensive study, mesh procedures were associated with an increased risk of reinterventions within one year and urinary retention after surgery.

Mesh use in surgery for pelvic organ prolapse

Journal BMJ
Authors Barber, Matthew D
Year Published 2015
Link to article

Introduction

By age 80 years, one in eight women will undergo surgery for pelvic organ prolapse (POP), a condition where the pelvic organs descend into or through the vaginal canal. In the United States, about 80% of procedures are performed transvaginally. Building on the experience of general surgeons and the treatment of abdominal hernias, pelvic surgeons began using synthetic mesh to augment prolapse repairs to reduce prolapse recurrence seen frequently after native tissue (non-mesh) repairs. However, use of synthetic mesh also results in increased adverse events, in some cases with serious consequences

Trends and Utilization of Laser Prostatectomy in Ambulatory Surgical Procedures for the Treatment of Benign Prostatic Hyperplasia in New York State (2000-2011).

Journal Journal of Endourology
Authors
Chughtai Bilal I., Simma-Chiang Vannita, Lee Richard, Isaacs Abby, Te Alexis E., Kaplan Steven A., and Sedrakyan Art.
Year Published 2014
Link to Publication

Abstract Introduction: There has been a significant change in surgical treatment of benign prostatic hypertrophy (BPH) over the last two decades. Most importantly, laser surgery (coagulation, vaporization, or enucleation) has been growing in popularity as an alternative to standard transurethral prostatectomy (TURP) or other procedures. Our goal was to analyze the trends of BPH surgeries and compare outcomes of laser surgery to TURP, the two most common alternative surgeries. Materials and Methods: We used the New York Statewide Planning and Research Cooperation System (SPARCS) data to identify patients diagnosed as having BPH who underwent BPH-related surgery from October 2000 to December 2011. Age, insurance, individual comorbidities, and average hospital volumes were assessed. Bivariate and multivariate regression models were used to analyze predictors of laser use. In-hospital outcomes were then compared between laser and TURP in a balanced propensity-matched cohort. Results: Ninety thousand six hundred seventy patients underwent BPH surgery. Laser surgery usage increased from 6.4% to 44.5% over 10 years (p<0.0001). TURP declined significantly from 72.2% to 48.3% (p<0.0001). Patients with Medicaid were less likely to undergo laser therapy than those with private insurance (odds ratio [OR]: 0.58, 95% confidence interval [CI]: 0.48, 0.69). Mid- and high-volume institutions were more likely to use laser treatment than low-volume centers (OR: 2.26, 95% CI: 1.22, 4.2; OR: 4.07, 95% CI: 1.75, 9.46, respectively). In the matched cohort, both laser and TURP patients had similar complication rates with more frequent electrolyte disorders in TURP patients (2.9% vs 2.3%, p=0.001). Conclusions: TURP remains the most common procedure. However, the rate of use has declined over time. In contrast, laser use has significantly increased. Laser treatment was utilized more in younger patients, in those privately insured, in hospitals with high volumes of BPH procedures, and in patients with fewer comorbid conditions. Both surgeries are safe with no differences in terms of occurrences of morbidity and complications.