Robotic radical prostatectomy raises surgical volume, lowers morbidity

Atlanta-Hospital adoption of robotic technology leads to an increase in overall volume of radical prostatectomy cases and has a positive impact on patient morbidity, according to research undertaken by urologists at Johns Hopkins University's James Brady Buchanan Urological Institute, Baltimore.

First author Jeffrey K. Mullins, MD, a urologic surgery resident at Johns Hopkins, reported the findings at the AUA annual meeting in Atlanta. The data used were derived from the Maryland Health Services Cost Review Commission (HSCRC), a state agency that prospectively collects data for 30 days after index admission for all inpatient discharges from nonfederal hospitals. The study included men who underwent radical prostatectomy between 2000 and 2011 at 28 hospitals, of which 14 acquired robotic technology during the study period and 14 did not. Excluded were data from one extremely high-volume hospital (Johns Hopkins, >100 RPs per year), 16 extremely low-volume hospitals (<1 RP per year), and others where no RP was performed.

For the 14 hospitals that acquired robotic technology during the study period, comparisons were made between the eight calendar quarters before acquisition and the most recent eight calendar quarters. The results showed a statistically significant increase in median quarterly RP volume (four to eight) and statistically significant decreases in the proportion of cases being performed by high-volume surgeons (32.8% to 14.3%) and at high-volume hospitals (64.9% to 60.0%).

The impact on patient outcomes was investigated by analyzing in-hospital mortality, intensive care unit admissions, length of stay, and 30-day readmissions, and the results showed statistically significant decreases from the pre- to post-robotic technology acquisition periods in both mean length of stay (2 to 1 day) and 30-day readmission rate (1.2% to 0.3%).

"We know that the introduction of robotic technology has been associated with nationwide increases in post-RP hospital discharges, and in this study, we have observed a similar trend in Maryland hospitals," said Dr. Mullins, who worked on the study with Brian Matlaga, MD, MPH, and colleagues.

"The impact of acquiring robotic technology on postsurgical morbidity has not been fully defined, and although the Maryland HSCRC lacks granular data on postoperative morbidity, our study shows reductions in length of stay and 30-day readmissions in men operated on at hospitals with robotic technology.

"These are important observations because men who get out of the hospital faster and stay out of the hospital are more likely to have a smooth and accelerated recovery after surgery. Furthermore, these endpoints have significant health care cost implications that may begin to justify the increased cost associated with performing a robotic prostatectomy," Dr. Mullins said.

A second analysis compared patient demographics and outcomes at robotic adopter and non-adopter hospitals, but only including data from procedures performed beginning in the last quarter of 2008, which is when the ICD-9 modifier for robotic surgery was first introduced. The results showed that compared to non-adopter hospitals, hospitals with robotic technology were more likely to be high-volume centers (63.8% vs. 0%) and had a higher proportion of high-volume surgeons (>40 cases per year, 25.3% vs. 0%).

Compared with the non-adopting hospitals, patients undergoing RP at hospitals with robotic technology were again found to have a significantly shorter length of stay (1 vs. 2 days) and significantly lower 30-day readmission rate (0.2 vs. 6%).

Analyses of quarterly case volumes throughout the study period also showed an increase at hospitals adopting robotic technology, from 8.9 to 10.7 cases (+20.5%), whereas there was a 52.8% decrease from three to 1.4 cases at hospitals that did not acquire a robot.