- Email: [email protected]
Patterns of Care for Radical Prostatectomy in the United States From 2003 to 2005
Patterns of Care for Radical Prostatectomy in the United States From 2003 to 2005 Jim C. Hu,* Nathanael D. Hevelone, Marcos D. Ferreira, Stuart R. Lipsitz, Toni K. Choueiri, Martin G. Sanda and Craig C. Earle From the Division of Urologic Surgery (JCH, MDF) and Center for Surgery and Public Health (JCH, SRL), Brigham and Women’s Hospital, Lank Center for Genitourinary Oncology (JCH, TKC) and Center for Outcomes and Policy Research, Dana Farber Cancer Institute (NDH, CCE) and Division of Urologic Surgery, Beth Israel Deaconess Hospital (MGS), Harvard Medical School, Boston, Massachusetts
Purpose: The demand for minimally invasive radical prostatectomy is increasing, although population based outcomes remain unclear. We assessed use and outcomes in American men undergoing radical prostatectomy. Materials and Methods: We identified 14,727 men undergoing minimally invasive, perineal and retropubic radical prostatectomy during 2003 to 2005 using nationally representative, employer based administrative data. We assessed the association between surgical approach and outcomes, adjusting for age, race, comorbidity and geographic region. Results: Minimally invasive radical prostatectomy use increased from 5.4% to 24.4%, while conversion to open surgery decreased from 28.6% to 4.5% in the 3-year study. Men undergoing minimally invasive and perineal radical prostatectomy vs retropubic radical prostatectomy experienced fewer 30-day complications (14.2% and 14.9% vs 17.5%, p ⫽ 0.001), blood transfusions (2.2% and 3.6% vs 9.1%, p ⬍0.001) and anastomotic strictures (6.8% and 8.5% vs 12.9%, p ⬍0.001), and shorter median length of stay (1 and 2 days, respectively, vs 4, p ⬍0.001). On adjusted analysis minimally invasive vs retropubic radical prostatectomy was associated with fewer 30-day complications (OR 0.78, 95% CI 0.66, 0.92), transfusions (OR 0.24, 95% CI 0.16, 0.34) and anastomotic strictures (OR 0.50, 95% CI 0.40, 0.62), and shorter length of stay (parameter estimate ⫺0.53, 95% CI ⫺0.58, ⫺0.49). Similarly perineal vs retropubic radical prostatectomy was associated with fewer transfusions (OR 0.50, 95% CI 0.31, 0.82) and anastomotic strictures (OR 0.65, 95% CI 0.47, 0.90), and shorter length of stay (parameter estimate ⫺0.53, 95% CI ⫺0.42, ⫺0.29). Conclusions: While the use of minimally invasive radical prostatectomy surged, men undergoing minimally invasive vs perineal radical prostatectomy experienced a lower risk of 30-day complications, blood transfusions and anastomotic strictures, and a shorter length of stay. Furthermore, perineal vs retropubic radical prostatectomy was also associated with relatively favorable outcomes. Further study is needed to assess continence, potency and cancer control. Key Words: prostate; prostatectomy; surgical procedures, minimally invasive; outcome assessment (health care); complications
n the United States 1 in 6 men will have prostate cancer in his lifetime and prostate cancer is the second leading cause of cancer mortality in men.1 Radical prostatectomy remains the most common treatment choice in the United States.2 However, men electing surgery must choose between open and minimally invasive radical prostatectomy with limited data demonstrating differences in outcomes. Although the use of minimally invasive radical prostatectomy has increased in recent years, sparse data are available about use and outcomes compared to the open procedures, that is retropubic and perineal radical prostatectomy. This is particularly relevant, given descriptions of steep learning curves3,4 and increased complications associated with the rapid adoption of minimally invasive surgical ap-
I
Submitted for publication March 6, 2008. Supported by a Lance Armstrong Young Investigator Award and a Dana Farber Harvard Cancer Center Career Development Award (JCH). * Correspondence: Division of Urologic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts (telephone: 617-7326907; FAX: 617-566-3475; e-mail: [email protected]).
0022-5347/08/1805-1969/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
proaches.5 Furthermore, most comparisons of minimally invasive and open radical prostatectomy are often retrospective, single center studies that may not reflect practice patterns and outcomes in community settings. To explore the use and outcomes of different surgical approaches to radical prostatectomy in the United States we performed a population based study of men diagnosed with prostate cancer in a 3-year period, drawn from a nationally representative, privately insured, employer based population, with a subset of men who also had Medicare supplemental coverage. In particular we examined whether perioperative outcomes were comparable by surgical approach. METHODS Study Population We identified 14,727 men diagnosed with prostate cancer by ICD-9 code 185.0 from the MarketScan® Commercial Claims and Encounters, and Medicare Supplemental and Coordination of Benefits database to longitudinally assess the inpatient and outpatient experience in men after surgery in 2003 to 2005. Men undergoing prostate cancer sur-
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Vol. 180, 1969-1974, November 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.07.054
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RADICAL PROSTATECTOMY PATTERNS OF CARE IN UNITED STATES these events typically present within 6 months of surgery.7 Heterologous blood transfusions were captured during the surgical hospital admission with ICD-9 codes 99.0, 99.01, 99.03 and 99.04, and CPT-4 code 36430. Hospital stay was defined as the number of days from admission to discharge. Conversion from minimally invasive to retropubic radical prostatectomy was identified by the corresponding ICD-9 diagnosis code v64.4x, a laparoscopic surgical procedure converted to an open procedure and a CPT code for minimally invasive plus retropubic radical prostatectomy on the same calendar day. Statistical Analysis Use rates of perineal, retropubic and minimally invasive radical prostatectomy were derived for the 3-year study period. We compared patient characteristics and outcomes of interest by the surgical approach using the chi-square test. Length of stay was compared with a robust 1-way ANOVA that accounts for length of stay nonnormality. Multivariate models were constructed to determine the effect of the surgical approach on outcomes of interest while adjusting for age, comorbidity and geographic region. Logistic regression was used for perioperative complications and anastomotic strictures. Length of stay was modeled as a linear function of covariates, including the type of radical prostatectomy. Ordinary least squares with a robust variance estimate were used to estimate the linear regression for length of stay. R2 and rank correlation index statistics are reported to provide the overall model predictive value of the linear and logistic models, respectively.
Approach to radical prostatectomy by year (Mantel-Haenszel chisquare test p⬍0.001). MIRP, minimally invasive radical prostatectomy. PRP, perineal radical prostatectomy. RRP, retropubic radical prostatectomy.
gery were identified by CPT-4 codes 55810, 55812 and 55815 for perineal, 55840, 55842 and 55845 for retropubic, and 55866 for minimally invasive radical prostatectomy. Independent Variables Information on patient age (younger than 55, 55 to 64, 65 to 74 and 75 years or older) was obtained from the enrollment file. Comorbidity was assessed using the Charlson index based on administrative claims during the year before surgery.6 Geographic region was classified according to United States Census Bureau regions as Northeast, Midwest, South or West.
RESULTS Minimally invasive radical prostatectomy use increased from 6.2% in 2003 to 21.6% in 2005, while retropubic and perineal radical prostatectomy use decreased from 86.6% to 72.8% and 5.2% to 4.1%, respectively (p ⬍0.001, see figure). In addition, the conversion rate from minimally invasive to retropubic radical prostatectomy decreased significantly from 28.6% in 2003 and 9.2% in 2004, to 4.5% in 2005 (p ⬍0.001). Finally, significant geographic variation in the surgical approach existed during the study period since almost half of perineal radical prostatectomies were performed in the South (table 1).
Dependent Variables Perioperative complications and anastomotic strictures were identified using relevant ICD-9 or CPT-4 diagnosis and procedure codes (see Appendix).7 Perioperative complications were ascertained in the 30 days after surgery, including potentially life threatening cardiac, respiratory or vascular events, the need for reoperation, bleeding and other events, such as renal failure and shock. Anastomotic strictures were identified up to 6 months after surgery because
TABLE 1. Study population demographic characteristics No. Radical Prostatectomy (%)
Age: Younger than 55 55–64 65–74 75 or Older Charlson comorbidity index: 0 1 2 3 Geographic region: Northeast Midwest South West
No. Pts
Minimally Invasive
Perineal
Retropubic
Conversion (minimally invasive to retropubic)
2,785 7,995 3,666 352
417 (19.6) 1,195 (56.2) 476 (22.4) 38 (1.8)
123 (18.7) 348 (52.2) 171 (25.6) 17 (2.6)
2,181 (18.5) 6,318 (53.6) 2,895 (25.3) 295 (2.5)
64 (27.4) 134 (57.3) 34 (14.5) 2 (0.9)
12,391 2,083 241 83
1,835 (86.3) 259 (12.2) 24 (1.1) 8 (2.4)
528 (80.1) 113 (17.2) 12 (1.8) 6 (0.9)
9,841 (83.4) 1,671 (14.2) 200 (1.7) 67 (0.6)
187 (79.9) 40 (17.1) 5 (2.1) 2 (0.9)
1,241 4,467 5,146 3,849
175 (8.2) 775 (36.4) 691 (32.5) 470 (22.1)
31 (4.7) 237 (35.9) 301 (45.7) 82 (12.4)
992 (8.4) 3,364 (28.6) 4,088 (34.7) 3,265 (27.7)
43 (18.4) 91 (38.9) 66 (28.2) 32 (13.7)
p Value (Mantel-Haenszel chi-square) ⬍0.001
0.009
⬍0.001
RADICAL PROSTATECTOMY PATTERNS OF CARE IN UNITED STATES
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TABLE 2. Unadjusted outcomes by radical prostatectomy approach Radical Prostatectomy
No. complications (%): Cardiac Respiratory Wounds Vascular Genitourinary Miscellaneous medical Miscellaneous surgical Overall* No. heterologous blood transfusion (%) No. anastomotic stricture (%) Mean/median hospital stay (days)
Minimally Invasive
Perineal
21 (1.0) 52 (2.5) 19 (0.09) 23 (1.1) 86 (4.0) 103 (4.8) 87 (4.1) 289 (13.6) 41 (1.9) 122 (5.7) 1.9/1
9 (1.4) 20 (3.0) 15 (2.3) 4 (0.6) 24 (3.6) 24 (3.6) 33 (5.0) 96 (14.6) 26 (3.9) 60 (9.1) 2.2/2
Retropubic
Conversion (minimally invasive to retropubic)
p Value (Mantel-Haenszel chi-square)
199 (1.7) 545 (4.6) 185 (1.6) 239 (2.0) 304 (2.6) 700 (5.6) 504 (4.3) 2,072 (17.6) 1,099 (9.3) 1,405 (11.9) 3.4/3
8 (3.4) 8 (3.4) 8 (3.4) 6 (2.6) 5 (2.1) 14 (6.0) 15 (6.4) 47 (20.1) 18 (7.7) 26 (11.1) 3.2/3
0.012 ⬍0.001 0.003 ⬍0.001 0.001 0.024 0.315 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
There may be more than 1 complication per patient.
The unadjusted overall perioperative complication rate was lowest for minimally invasive radical prostatectomy, followed by perineal and retropubic radical prostatectomy, while it was highest for conversions of minimally invasive to retropubic radical prostatectomy (14.2%, 14.9% and 17.5%, respectively, vs 19.4%, p ⫽ 0.001, table 2). In addition, cardiac, respiratory and wound complication rates were lowest for the minimally invasive vs open surgical approaches. However, genitourinary complication rates were highest for minimally invasive radical prostatectomy (p ⫽ 0.001). Men requiring conversion from minimally invasive to retropubic radical prostatectomy experienced the highest rates in complication subcategories except respiratory, genitourinary and miscellaneous surgical complications. Transfusion rates were lowest for minimally invasive radical prostatectomy, followed by perineal radical prostatectomy, conversions of minimally invasive to retropubic radical prostatectomy and retropubic radical prostatectomy (2.2%, 3.6%, 5.6% and 9.1%, respectively, p ⬍0.001). Furthermore, mean and median length of stay was shortest for minimally invasive radical prostatectomy, followed by perineal and retropubic radical prostatectomy, and conversions from minimally invasive to retropubic radical prostatectomy (p ⬍0.001). More-
over, anastomotic stricture rates were lowest for minimally invasive radical prostatectomy, followed by perineal radical prostatectomy, retropubic radical prostatectomy and conversions of minimally invasive to retropubic radical prostatectomy (6.8%, 8.5%, 12.9% and 13.3%, respectively, p ⬍0.001). On adjusted analysis men undergoing minimally invasive vs retropubic radical prostatectomy were less likely to experience 30-day complications (OR 0.78, 95% CI 0.66, 0.92) or receive blood transfusions (OR 0.24, 95% CI 0.16, 0.34), and they experienced a shorter length of stay (parameter estimate ⫺0.53, 95% CI ⫺0.58, ⫺0.49, table 3). Furthermore, men undergoing minimally invasive vs retropubic radical prostatectomy were less likely to have anastomotic strictures (OR 0.50, 95% CI 0.40, 0.62). Similarly men undergoing perineal vs retropubic radical prostatectomy were less likely to receive blood transfusions (OR 0.50, 95% CI 0.31, 0.82) or have anastomotic strictures (OR 0.65, 95% CI 0.47, 0.90) and they experienced shorter length of stay (parameter estimate ⫺0.35, 95% CI ⫺0.42, ⫺0.29). Few to no vs multiple comorbidities and young vs old age were significantly associated with fewer perioperative complications and a shorter length of stay (p ⬍0.05). Finally, significant geographic variation existed
TABLE 3. Adjusted analysis OR (95% CI)
Radical prostatectomy approach (referent retropubic): Perineal* Minimally invasive* Conversion (minimally invasive to retropubic) Age (referent 75 or older): Younger than 55 55–64 65–74 Charlson score (referent 3): 0 1 2 Region (referent West): Midwest Northeast South * p ⬍0.05.
30-Day Complications
Transfusion
Anastomotic Stricture
Hospital Stay Parameter Estimate (95% CI)
0.79 (0.63, 0.99) 0.76 (0.66, 0.87) 1.18 (0.81, 1.72)
0.52 (0.35, 0.78) 0.21 (0.15, 0.28) 0.93 (0.56, 1.53)
0.65 (0.47, 0.90) 0.50 (0.40, 0.62) 1.06 (0.69, 1.64)
⫺0.35 (⫺0.42, ⫺0.29) ⫺0.53 (⫺0.58, ⫺0.49) 0.01 (0.07, 0.09)
0.99 (0.88, 1.12) 1.54 (0.83, 2.87) 2.92 (1.51, 5.65)*
1.03 (0.88, 1.22) 2.76 (0.98, 7.75) 3.06 (1.01, 9.26)
1.03 (0.68, 1.57) 1.10 (0.74, 1.65) 1.24 (0.82, 1.86)
⫺0.39 (⫺0.47, ⫺0.32)* ⫺0.37 (⫺0.44, ⫺0.3)* ⫺0.31 (⫺0.38, ⫺0.24)*
0.23 (0.15, 0.36)* 0.35 (0.22, 0.55)* 0.89 (0.53, 1.47)
0.46 (0.25, 0.85)* 0.58 (0.32, 1.08) 0.57 (0.27, 1.21)
0.99 (0.42, 2.36) 1.09 (0.46, 2.63) 0.74 (0.26, 2.07)
⫺0.60 (⫺0.74, ⫺0.47)* ⫺0.43 (⫺0.57, ⫺0.30)* ⫺0.13 (⫺0.28, 0.03)
0.99 (0.87, 1.13) 0.87 (0.70, 1.07) 0.86 (0.75, 0.98)*
0.16 (0.13, 0.19)* 0.56 (0.46, 0.69)* 0.29 (0.26, 0.35)*
0.88 (0.76, 1.03) 0.96 (0.77, 1.21) 0.81 (0.69, 0.94)*
0.02 0.01 ⫺0.00
(⫺0.01, 0.05) (⫺0.03, 0.06) (⫺0.03, 0.03)
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RADICAL PROSTATECTOMY PATTERNS OF CARE IN UNITED STATES
for 30-day complications, transfusions and anastomotic strictures. DISCUSSION For many disease processes minimally invasive surgery offers distinct, consistently reproducible advantages over open approaches, including a shorter hospital stay, fewer inpatient procedures and lower cost. However, open radical prostatectomy is performed through a relatively small incision that is infrequently associated with significant pain and length of stay is relatively short at an average of 1 to 3 days at high volume referral centers.8 –10 Nevertheless, many patients intuitively perceive that minimally invasive approaches decrease complications compared with conventional open operations and prefer them due to smaller incisions requiring less analgesia and a shorter hospital stay, even at greater cost.11 Some studies suggest that minimally invasive vs retropubic radical prostatectomy results in significantly less blood loss, lower transfusion rates, less postoperative analgesic use and more rapid convalescence.9,12,13 However, distinguishing hype from reality may be difficult for novel procedures such as minimally invasive radical prostatectomy. In the absence of randomized, controlled trials observational, population based studies may be used to compare the outcomes of different treatments. Our study has several important findings. 1) Minimally invasive radical prostatectomy has been rapidly adopted since the initial suggestion of potential advantages over open radical prostatectomy in 2000.14 The trend in the diffusion of minimally invasive radical prostatectomy is more rapid than that of laparoscopic nephrectomy for donation or cancer control, which comprised less than 10% of all cases 5 years after its initial description.15 However, adoption is less pervasive than that of laparoscopic cholecystectomy, which accounted for at least 40% of all cases 5 years after its initial description.15 Nevertheless, minimally invasive radical prostatectomy is in widespread and rapidly expanding use with a correspondingly sharp decrease in the need for conversion to open surgery. To our knowledge our study is the first to illustrate the surging nationwide adoption of minimally invasive radical prostatectomy and the decreasing conversion rate to open surgery. Conversely the use of perineal radical prostatectomy was relatively low and it decreased during the study period. 2) Men undergoing minimally invasive vs retropubic radical prostatectomy experienced fewer 30-day complications and required fewer blood transfusions. In contrast, single center studies have suggested similar rates of perioperative complications by surgical approach.16 Furthermore, comparison of outcomes among reported series and different health settings is imprecise due to differences in patient selection, and methods of data collection and reporting,13 and using administrative data may offset these potential biases. In contrast, in our 3-year population based study we examined men undergoing surgery at community as well as academic settings in the United States. The lower 30-day complication rates that we observed for minimally invasive radical prostatectomy may be related to procedural blood loss and transfusion rates, which are consistently lower for the minimally invasive vs the open surgical approach due in part to the carbon dioxide insufflation pressure used during laparoscopy.9,12,13 Less blood loss low-
ers the risk of cardiac ischemia and the resultant cardiovascular complications as well as renal insufficiency. It also lessens the risk of respiratory complications that may result from aggressive, compensatory volume expansion. Similarly intraoperative blood loss is a strong predictor of major complications following general and vascular surgery.17 3) Men undergoing minimally invasive and perineal vs retropubic radical prostatectomy were less likely to have anastomotic strictures. Anastomotic strictures are one of the most common complications of retropubic radical prostatectomy with rates as high as 25% in the late 1990s.7 The challenge of directly visualizing the anastomosis during the retropubic approach may contribute to the higher anastomotic stricture rate. 4) Median length of stay was shortest for minimally invasive radical prostatectomy at 1 day, followed by perineal and retropubic radical prostatectomy at 2 and 3 days, respectively. While individual physician practice patterns contribute to the length of stay, the duration of the hospital stay is the primary determinant of hospital costs associated with radical prostatectomy in the United States.8 In addition to the lower transfusion rates, the shorter hospital stay of minimally invasive vs retropubic radical prostatectomy9,12 may offset the higher intraoperative costs secondary to the use of disposable materials and longer operative time.8 Our use of MarketScan data has certain limitations. 1) Administrative data are designed primarily to provide billing information and not detailed clinical information. In addition, we could not adjust for tumor characteristics such as grade or stage, although differences in tumor characteristics are unlikely to influence perioperative complications, anastomotic strictures or length of stay. 2) We did not examine rates of impotence and incontinence because they are poorly ascertained by administrative data. Moreover, the recovery of urinary and sexual function plateaus 18 to 24 months after prostatectomy,18 limiting our ability to detect significant differences in most patients during the 3-year study period. 3) While men undergoing retropubic radical prostatectomy performed by high volume surgeons have fewer complications and shorter length of stay,7 MarketScan comprises multiple health plans, of which each has unique, encrypted identifiers that preclude aggregation to determine surgeon volume. Thus, we were unable to assess the influence of surgeon volume on our outcomes of interest. 4) Minimally invasive radical prostatectomy included procedures performed with and without robotic assistance since these procedures share a common CPT code. Therefore, we were unable to discern whether the robot was used for assistance during minimally invasive radical prostatectomy. However, the intraoperative strategy is similar. Several reports suggest that robotic assistance may shorten the learning curve for minimally invasive radical prostatectomy19,20 but additional research is necessary to determine whether differences in outcomes exist between minimally invasive radical prostatectomy with and without robotic assistance. Despite these limitations our national, cross-sectional, longitudinal analysis demonstrates recent practice patterns and the outcomes of varying surgical approaches for prostate cancer. Furthermore, in contrast to population based studies of Medicare beneficiaries restricted to older men 65 years or older, our study includes men of all ages.
RADICAL PROSTATECTOMY PATTERNS OF CARE IN UNITED STATES CONCLUSIONS Minimally invasive radical prostatectomy diffused rapidly during the study period, while the conversion rate to open surgery decreased. In addition, minimally invasive vs retropubic radical prostatectomy was associated with shorter length of stay and a lower risk of perioperative complications, blood transfusions and anastomotic strictures. However, physician practice
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patterns may influence length of stay. While the use of perineal radical prostatectomy decreased, men undergoing perineal vs retropubic radical prostatectomy also experienced a shorter length of stay and were less likely to receive transfusion or have anastomotic strictures. Prospective studies are needed to determine variations in cancer control, and urinary and sexual function by surgical approach.
APPENDIX Radical prostatectomy complications Diagnosis Codes Perioperative complications (0–30 days): Cardiac Respiratory Vascular Wound or bleeding
Procedure Codes
410.x, 402.01, 402.11, 402.91, 428.x, 427.5, 997.1 518.0, 514, 518.4, 466.x, 480.x, 481, 482.x, 483.x, 485, 486, 518.5, 518.81, 581.82, 799.1, 997.3 415.1, 451.1x, 451.2, 451.81, 451.9, 453.8, 453.9, 997.2, 999.2, 444.22, 444.81, 433.x, 434.x, 436, 437.x 567.x, 998.3, 998.5x, 998.6
Genitourinary
595.89, 590.1x, 590.2, 590.8x, 590.9, 591, 997.5, 596.1, 596.2, 596.6, 593.3, 593.4, 593.5, 593.81, 593.82
Miscellaneous medical
584.x, 586, 785.5x, 995.0, 995.4, 998.0, 999.4, 999.5, 999.6, 999.7, 999.8, 457.8, 560.1, 560.8x, 560.9, 997.4, 353.0, 354.2, 723.4, 955.1, 955.3, 955.7, 955.8, 955.9, 593.4, 531.1, 531.2, 531.3, 531.4, 531.5, 531.6, 531.9, 532.1, 532.2, 532.3, 532.4, 532.5, 532.6, 532.9, 533.1, 533.2, 533.3, 533.4, 533.5, 533.6, 533.9, 782.4, 573.8 599.1, 596.1, 596.2, 596.6, 565.1, 569.3, 569.83, 569.4, 569.4x, 998.1x, 998.83, 998.9, 998.2, 998.4, 998.7, 604.0, E870.0, E870.4, E870.7, E870.8, E870.9, E871.0, E873.0, E876.0, 956.0, 956.1, 956.4, 956.5, 956.8, 956.9, 902.50, 902.51, 902.52, 902.53, 902.54, 902.59 596.0, 598.0, 598.1, 598.2, 598.8, 598.9
Miscellaneous surgical
Anastomotic stricture (0–180 days)
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8.
1.
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13.
ICD-9: 54.61, 54.91, 54.0, 54.19, 59.19 Healthcare Common Procedure Coding System: 26990, 45020, 49060, 51080 ICD-9: 55.02, 55.03, 55.12, 55.93, 55.94, 59.93, 97.61, 97.62, 56.1, 56.41, 56.74, 56.75, 56.81, 56.84, 56.86, 56.89, 56.91 Healthcare Common Procedure Coding System: 50040, 50120, 50125, 50395, 50398, 50605, 52290, 52332, 52334, 50600, 50700, 50715, 50760, 50770, 50780, 50782, 50783, 50785, 50800, 50810, 50815, 50820, 50825, 50840, 50900, 50940
ICD-9: 46.03, 46.04, 46.10, 46.11, 46.14, 48.4x, 48.5, 48.6x, 48.7x, 48.9x
ICD-9: 57.0, 57.1x, (except 57.11), 57.2x, 57.92, 58.6, 57.4x, 57.85, 57.91, 58.0, 58.1, 58.3x, 58.44, 58.5 Healthcare Common Procedure Coding System: 51010, 51040, 52510, 52281, 52283, 53600, 53601, 53605, 53620, 53621, 53640, 51800, 51820, 52275, 52276, 52310, 52500, 52620, 52640, 53000, 53010, 53020, 53400, 53405, 53410, 53415, 53420, 53425
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18.
Litwin MS, Melmed GY and Nakazon T: Life after radical prostatectomy: a longitudinal study. J Urol 2001; 166: 587. 19. Menon M, Shrivastava A, Tewari A, Sarle R, Hemal A, Peabody JO et al: Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol 2002; 168: 945. 20. Ahlering TE, Skarecky D, Lee D and Clayman RV: Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J Urol 2003; 170: 1738.
Purpose: The demand for minimally invasive radical prostatectomy is increasing, although population based outcomes remain unclear. We assessed use and outcomes in American men undergoing radical prostatectomy. Materials and Methods: We identified 14,727 men undergoing minimally invasive, perineal and retropubic radical prostatectomy during 2003 to 2005 using nationally representative, employer based administrative data. We assessed the association between surgical approach and outcomes, adjusting for age, race, comorbidity and geographic region. Results: Minimally invasive radical prostatectomy use increased from 5.4% to 24.4%, while conversion to open surgery decreased from 28.6% to 4.5% in the 3-year study. Men undergoing minimally invasive and perineal radical prostatectomy vs retropubic radical prostatectomy experienced fewer 30-day complications (14.2% and 14.9% vs 17.5%, p ⫽ 0.001), blood transfusions (2.2% and 3.6% vs 9.1%, p ⬍0.001) and anastomotic strictures (6.8% and 8.5% vs 12.9%, p ⬍0.001), and shorter median length of stay (1 and 2 days, respectively, vs 4, p ⬍0.001). On adjusted analysis minimally invasive vs retropubic radical prostatectomy was associated with fewer 30-day complications (OR 0.78, 95% CI 0.66, 0.92), transfusions (OR 0.24, 95% CI 0.16, 0.34) and anastomotic strictures (OR 0.50, 95% CI 0.40, 0.62), and shorter length of stay (parameter estimate ⫺0.53, 95% CI ⫺0.58, ⫺0.49). Similarly perineal vs retropubic radical prostatectomy was associated with fewer transfusions (OR 0.50, 95% CI 0.31, 0.82) and anastomotic strictures (OR 0.65, 95% CI 0.47, 0.90), and shorter length of stay (parameter estimate ⫺0.53, 95% CI ⫺0.42, ⫺0.29). Conclusions: While the use of minimally invasive radical prostatectomy surged, men undergoing minimally invasive vs perineal radical prostatectomy experienced a lower risk of 30-day complications, blood transfusions and anastomotic strictures, and a shorter length of stay. Furthermore, perineal vs retropubic radical prostatectomy was also associated with relatively favorable outcomes. Further study is needed to assess continence, potency and cancer control. Key Words: prostate; prostatectomy; surgical procedures, minimally invasive; outcome assessment (health care); complications
n the United States 1 in 6 men will have prostate cancer in his lifetime and prostate cancer is the second leading cause of cancer mortality in men.1 Radical prostatectomy remains the most common treatment choice in the United States.2 However, men electing surgery must choose between open and minimally invasive radical prostatectomy with limited data demonstrating differences in outcomes. Although the use of minimally invasive radical prostatectomy has increased in recent years, sparse data are available about use and outcomes compared to the open procedures, that is retropubic and perineal radical prostatectomy. This is particularly relevant, given descriptions of steep learning curves3,4 and increased complications associated with the rapid adoption of minimally invasive surgical ap-
I
Submitted for publication March 6, 2008. Supported by a Lance Armstrong Young Investigator Award and a Dana Farber Harvard Cancer Center Career Development Award (JCH). * Correspondence: Division of Urologic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts (telephone: 617-7326907; FAX: 617-566-3475; e-mail: [email protected]).
0022-5347/08/1805-1969/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
proaches.5 Furthermore, most comparisons of minimally invasive and open radical prostatectomy are often retrospective, single center studies that may not reflect practice patterns and outcomes in community settings. To explore the use and outcomes of different surgical approaches to radical prostatectomy in the United States we performed a population based study of men diagnosed with prostate cancer in a 3-year period, drawn from a nationally representative, privately insured, employer based population, with a subset of men who also had Medicare supplemental coverage. In particular we examined whether perioperative outcomes were comparable by surgical approach. METHODS Study Population We identified 14,727 men diagnosed with prostate cancer by ICD-9 code 185.0 from the MarketScan® Commercial Claims and Encounters, and Medicare Supplemental and Coordination of Benefits database to longitudinally assess the inpatient and outpatient experience in men after surgery in 2003 to 2005. Men undergoing prostate cancer sur-
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Vol. 180, 1969-1974, November 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.07.054
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RADICAL PROSTATECTOMY PATTERNS OF CARE IN UNITED STATES these events typically present within 6 months of surgery.7 Heterologous blood transfusions were captured during the surgical hospital admission with ICD-9 codes 99.0, 99.01, 99.03 and 99.04, and CPT-4 code 36430. Hospital stay was defined as the number of days from admission to discharge. Conversion from minimally invasive to retropubic radical prostatectomy was identified by the corresponding ICD-9 diagnosis code v64.4x, a laparoscopic surgical procedure converted to an open procedure and a CPT code for minimally invasive plus retropubic radical prostatectomy on the same calendar day. Statistical Analysis Use rates of perineal, retropubic and minimally invasive radical prostatectomy were derived for the 3-year study period. We compared patient characteristics and outcomes of interest by the surgical approach using the chi-square test. Length of stay was compared with a robust 1-way ANOVA that accounts for length of stay nonnormality. Multivariate models were constructed to determine the effect of the surgical approach on outcomes of interest while adjusting for age, comorbidity and geographic region. Logistic regression was used for perioperative complications and anastomotic strictures. Length of stay was modeled as a linear function of covariates, including the type of radical prostatectomy. Ordinary least squares with a robust variance estimate were used to estimate the linear regression for length of stay. R2 and rank correlation index statistics are reported to provide the overall model predictive value of the linear and logistic models, respectively.
Approach to radical prostatectomy by year (Mantel-Haenszel chisquare test p⬍0.001). MIRP, minimally invasive radical prostatectomy. PRP, perineal radical prostatectomy. RRP, retropubic radical prostatectomy.
gery were identified by CPT-4 codes 55810, 55812 and 55815 for perineal, 55840, 55842 and 55845 for retropubic, and 55866 for minimally invasive radical prostatectomy. Independent Variables Information on patient age (younger than 55, 55 to 64, 65 to 74 and 75 years or older) was obtained from the enrollment file. Comorbidity was assessed using the Charlson index based on administrative claims during the year before surgery.6 Geographic region was classified according to United States Census Bureau regions as Northeast, Midwest, South or West.
RESULTS Minimally invasive radical prostatectomy use increased from 6.2% in 2003 to 21.6% in 2005, while retropubic and perineal radical prostatectomy use decreased from 86.6% to 72.8% and 5.2% to 4.1%, respectively (p ⬍0.001, see figure). In addition, the conversion rate from minimally invasive to retropubic radical prostatectomy decreased significantly from 28.6% in 2003 and 9.2% in 2004, to 4.5% in 2005 (p ⬍0.001). Finally, significant geographic variation in the surgical approach existed during the study period since almost half of perineal radical prostatectomies were performed in the South (table 1).
Dependent Variables Perioperative complications and anastomotic strictures were identified using relevant ICD-9 or CPT-4 diagnosis and procedure codes (see Appendix).7 Perioperative complications were ascertained in the 30 days after surgery, including potentially life threatening cardiac, respiratory or vascular events, the need for reoperation, bleeding and other events, such as renal failure and shock. Anastomotic strictures were identified up to 6 months after surgery because
TABLE 1. Study population demographic characteristics No. Radical Prostatectomy (%)
Age: Younger than 55 55–64 65–74 75 or Older Charlson comorbidity index: 0 1 2 3 Geographic region: Northeast Midwest South West
No. Pts
Minimally Invasive
Perineal
Retropubic
Conversion (minimally invasive to retropubic)
2,785 7,995 3,666 352
417 (19.6) 1,195 (56.2) 476 (22.4) 38 (1.8)
123 (18.7) 348 (52.2) 171 (25.6) 17 (2.6)
2,181 (18.5) 6,318 (53.6) 2,895 (25.3) 295 (2.5)
64 (27.4) 134 (57.3) 34 (14.5) 2 (0.9)
12,391 2,083 241 83
1,835 (86.3) 259 (12.2) 24 (1.1) 8 (2.4)
528 (80.1) 113 (17.2) 12 (1.8) 6 (0.9)
9,841 (83.4) 1,671 (14.2) 200 (1.7) 67 (0.6)
187 (79.9) 40 (17.1) 5 (2.1) 2 (0.9)
1,241 4,467 5,146 3,849
175 (8.2) 775 (36.4) 691 (32.5) 470 (22.1)
31 (4.7) 237 (35.9) 301 (45.7) 82 (12.4)
992 (8.4) 3,364 (28.6) 4,088 (34.7) 3,265 (27.7)
43 (18.4) 91 (38.9) 66 (28.2) 32 (13.7)
p Value (Mantel-Haenszel chi-square) ⬍0.001
0.009
⬍0.001
RADICAL PROSTATECTOMY PATTERNS OF CARE IN UNITED STATES
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TABLE 2. Unadjusted outcomes by radical prostatectomy approach Radical Prostatectomy
No. complications (%): Cardiac Respiratory Wounds Vascular Genitourinary Miscellaneous medical Miscellaneous surgical Overall* No. heterologous blood transfusion (%) No. anastomotic stricture (%) Mean/median hospital stay (days)
Minimally Invasive
Perineal
21 (1.0) 52 (2.5) 19 (0.09) 23 (1.1) 86 (4.0) 103 (4.8) 87 (4.1) 289 (13.6) 41 (1.9) 122 (5.7) 1.9/1
9 (1.4) 20 (3.0) 15 (2.3) 4 (0.6) 24 (3.6) 24 (3.6) 33 (5.0) 96 (14.6) 26 (3.9) 60 (9.1) 2.2/2
Retropubic
Conversion (minimally invasive to retropubic)
p Value (Mantel-Haenszel chi-square)
199 (1.7) 545 (4.6) 185 (1.6) 239 (2.0) 304 (2.6) 700 (5.6) 504 (4.3) 2,072 (17.6) 1,099 (9.3) 1,405 (11.9) 3.4/3
8 (3.4) 8 (3.4) 8 (3.4) 6 (2.6) 5 (2.1) 14 (6.0) 15 (6.4) 47 (20.1) 18 (7.7) 26 (11.1) 3.2/3
0.012 ⬍0.001 0.003 ⬍0.001 0.001 0.024 0.315 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
There may be more than 1 complication per patient.
The unadjusted overall perioperative complication rate was lowest for minimally invasive radical prostatectomy, followed by perineal and retropubic radical prostatectomy, while it was highest for conversions of minimally invasive to retropubic radical prostatectomy (14.2%, 14.9% and 17.5%, respectively, vs 19.4%, p ⫽ 0.001, table 2). In addition, cardiac, respiratory and wound complication rates were lowest for the minimally invasive vs open surgical approaches. However, genitourinary complication rates were highest for minimally invasive radical prostatectomy (p ⫽ 0.001). Men requiring conversion from minimally invasive to retropubic radical prostatectomy experienced the highest rates in complication subcategories except respiratory, genitourinary and miscellaneous surgical complications. Transfusion rates were lowest for minimally invasive radical prostatectomy, followed by perineal radical prostatectomy, conversions of minimally invasive to retropubic radical prostatectomy and retropubic radical prostatectomy (2.2%, 3.6%, 5.6% and 9.1%, respectively, p ⬍0.001). Furthermore, mean and median length of stay was shortest for minimally invasive radical prostatectomy, followed by perineal and retropubic radical prostatectomy, and conversions from minimally invasive to retropubic radical prostatectomy (p ⬍0.001). More-
over, anastomotic stricture rates were lowest for minimally invasive radical prostatectomy, followed by perineal radical prostatectomy, retropubic radical prostatectomy and conversions of minimally invasive to retropubic radical prostatectomy (6.8%, 8.5%, 12.9% and 13.3%, respectively, p ⬍0.001). On adjusted analysis men undergoing minimally invasive vs retropubic radical prostatectomy were less likely to experience 30-day complications (OR 0.78, 95% CI 0.66, 0.92) or receive blood transfusions (OR 0.24, 95% CI 0.16, 0.34), and they experienced a shorter length of stay (parameter estimate ⫺0.53, 95% CI ⫺0.58, ⫺0.49, table 3). Furthermore, men undergoing minimally invasive vs retropubic radical prostatectomy were less likely to have anastomotic strictures (OR 0.50, 95% CI 0.40, 0.62). Similarly men undergoing perineal vs retropubic radical prostatectomy were less likely to receive blood transfusions (OR 0.50, 95% CI 0.31, 0.82) or have anastomotic strictures (OR 0.65, 95% CI 0.47, 0.90) and they experienced shorter length of stay (parameter estimate ⫺0.35, 95% CI ⫺0.42, ⫺0.29). Few to no vs multiple comorbidities and young vs old age were significantly associated with fewer perioperative complications and a shorter length of stay (p ⬍0.05). Finally, significant geographic variation existed
TABLE 3. Adjusted analysis OR (95% CI)
Radical prostatectomy approach (referent retropubic): Perineal* Minimally invasive* Conversion (minimally invasive to retropubic) Age (referent 75 or older): Younger than 55 55–64 65–74 Charlson score (referent 3): 0 1 2 Region (referent West): Midwest Northeast South * p ⬍0.05.
30-Day Complications
Transfusion
Anastomotic Stricture
Hospital Stay Parameter Estimate (95% CI)
0.79 (0.63, 0.99) 0.76 (0.66, 0.87) 1.18 (0.81, 1.72)
0.52 (0.35, 0.78) 0.21 (0.15, 0.28) 0.93 (0.56, 1.53)
0.65 (0.47, 0.90) 0.50 (0.40, 0.62) 1.06 (0.69, 1.64)
⫺0.35 (⫺0.42, ⫺0.29) ⫺0.53 (⫺0.58, ⫺0.49) 0.01 (0.07, 0.09)
0.99 (0.88, 1.12) 1.54 (0.83, 2.87) 2.92 (1.51, 5.65)*
1.03 (0.88, 1.22) 2.76 (0.98, 7.75) 3.06 (1.01, 9.26)
1.03 (0.68, 1.57) 1.10 (0.74, 1.65) 1.24 (0.82, 1.86)
⫺0.39 (⫺0.47, ⫺0.32)* ⫺0.37 (⫺0.44, ⫺0.3)* ⫺0.31 (⫺0.38, ⫺0.24)*
0.23 (0.15, 0.36)* 0.35 (0.22, 0.55)* 0.89 (0.53, 1.47)
0.46 (0.25, 0.85)* 0.58 (0.32, 1.08) 0.57 (0.27, 1.21)
0.99 (0.42, 2.36) 1.09 (0.46, 2.63) 0.74 (0.26, 2.07)
⫺0.60 (⫺0.74, ⫺0.47)* ⫺0.43 (⫺0.57, ⫺0.30)* ⫺0.13 (⫺0.28, 0.03)
0.99 (0.87, 1.13) 0.87 (0.70, 1.07) 0.86 (0.75, 0.98)*
0.16 (0.13, 0.19)* 0.56 (0.46, 0.69)* 0.29 (0.26, 0.35)*
0.88 (0.76, 1.03) 0.96 (0.77, 1.21) 0.81 (0.69, 0.94)*
0.02 0.01 ⫺0.00
(⫺0.01, 0.05) (⫺0.03, 0.06) (⫺0.03, 0.03)
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RADICAL PROSTATECTOMY PATTERNS OF CARE IN UNITED STATES
for 30-day complications, transfusions and anastomotic strictures. DISCUSSION For many disease processes minimally invasive surgery offers distinct, consistently reproducible advantages over open approaches, including a shorter hospital stay, fewer inpatient procedures and lower cost. However, open radical prostatectomy is performed through a relatively small incision that is infrequently associated with significant pain and length of stay is relatively short at an average of 1 to 3 days at high volume referral centers.8 –10 Nevertheless, many patients intuitively perceive that minimally invasive approaches decrease complications compared with conventional open operations and prefer them due to smaller incisions requiring less analgesia and a shorter hospital stay, even at greater cost.11 Some studies suggest that minimally invasive vs retropubic radical prostatectomy results in significantly less blood loss, lower transfusion rates, less postoperative analgesic use and more rapid convalescence.9,12,13 However, distinguishing hype from reality may be difficult for novel procedures such as minimally invasive radical prostatectomy. In the absence of randomized, controlled trials observational, population based studies may be used to compare the outcomes of different treatments. Our study has several important findings. 1) Minimally invasive radical prostatectomy has been rapidly adopted since the initial suggestion of potential advantages over open radical prostatectomy in 2000.14 The trend in the diffusion of minimally invasive radical prostatectomy is more rapid than that of laparoscopic nephrectomy for donation or cancer control, which comprised less than 10% of all cases 5 years after its initial description.15 However, adoption is less pervasive than that of laparoscopic cholecystectomy, which accounted for at least 40% of all cases 5 years after its initial description.15 Nevertheless, minimally invasive radical prostatectomy is in widespread and rapidly expanding use with a correspondingly sharp decrease in the need for conversion to open surgery. To our knowledge our study is the first to illustrate the surging nationwide adoption of minimally invasive radical prostatectomy and the decreasing conversion rate to open surgery. Conversely the use of perineal radical prostatectomy was relatively low and it decreased during the study period. 2) Men undergoing minimally invasive vs retropubic radical prostatectomy experienced fewer 30-day complications and required fewer blood transfusions. In contrast, single center studies have suggested similar rates of perioperative complications by surgical approach.16 Furthermore, comparison of outcomes among reported series and different health settings is imprecise due to differences in patient selection, and methods of data collection and reporting,13 and using administrative data may offset these potential biases. In contrast, in our 3-year population based study we examined men undergoing surgery at community as well as academic settings in the United States. The lower 30-day complication rates that we observed for minimally invasive radical prostatectomy may be related to procedural blood loss and transfusion rates, which are consistently lower for the minimally invasive vs the open surgical approach due in part to the carbon dioxide insufflation pressure used during laparoscopy.9,12,13 Less blood loss low-
ers the risk of cardiac ischemia and the resultant cardiovascular complications as well as renal insufficiency. It also lessens the risk of respiratory complications that may result from aggressive, compensatory volume expansion. Similarly intraoperative blood loss is a strong predictor of major complications following general and vascular surgery.17 3) Men undergoing minimally invasive and perineal vs retropubic radical prostatectomy were less likely to have anastomotic strictures. Anastomotic strictures are one of the most common complications of retropubic radical prostatectomy with rates as high as 25% in the late 1990s.7 The challenge of directly visualizing the anastomosis during the retropubic approach may contribute to the higher anastomotic stricture rate. 4) Median length of stay was shortest for minimally invasive radical prostatectomy at 1 day, followed by perineal and retropubic radical prostatectomy at 2 and 3 days, respectively. While individual physician practice patterns contribute to the length of stay, the duration of the hospital stay is the primary determinant of hospital costs associated with radical prostatectomy in the United States.8 In addition to the lower transfusion rates, the shorter hospital stay of minimally invasive vs retropubic radical prostatectomy9,12 may offset the higher intraoperative costs secondary to the use of disposable materials and longer operative time.8 Our use of MarketScan data has certain limitations. 1) Administrative data are designed primarily to provide billing information and not detailed clinical information. In addition, we could not adjust for tumor characteristics such as grade or stage, although differences in tumor characteristics are unlikely to influence perioperative complications, anastomotic strictures or length of stay. 2) We did not examine rates of impotence and incontinence because they are poorly ascertained by administrative data. Moreover, the recovery of urinary and sexual function plateaus 18 to 24 months after prostatectomy,18 limiting our ability to detect significant differences in most patients during the 3-year study period. 3) While men undergoing retropubic radical prostatectomy performed by high volume surgeons have fewer complications and shorter length of stay,7 MarketScan comprises multiple health plans, of which each has unique, encrypted identifiers that preclude aggregation to determine surgeon volume. Thus, we were unable to assess the influence of surgeon volume on our outcomes of interest. 4) Minimally invasive radical prostatectomy included procedures performed with and without robotic assistance since these procedures share a common CPT code. Therefore, we were unable to discern whether the robot was used for assistance during minimally invasive radical prostatectomy. However, the intraoperative strategy is similar. Several reports suggest that robotic assistance may shorten the learning curve for minimally invasive radical prostatectomy19,20 but additional research is necessary to determine whether differences in outcomes exist between minimally invasive radical prostatectomy with and without robotic assistance. Despite these limitations our national, cross-sectional, longitudinal analysis demonstrates recent practice patterns and the outcomes of varying surgical approaches for prostate cancer. Furthermore, in contrast to population based studies of Medicare beneficiaries restricted to older men 65 years or older, our study includes men of all ages.
RADICAL PROSTATECTOMY PATTERNS OF CARE IN UNITED STATES CONCLUSIONS Minimally invasive radical prostatectomy diffused rapidly during the study period, while the conversion rate to open surgery decreased. In addition, minimally invasive vs retropubic radical prostatectomy was associated with shorter length of stay and a lower risk of perioperative complications, blood transfusions and anastomotic strictures. However, physician practice
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patterns may influence length of stay. While the use of perineal radical prostatectomy decreased, men undergoing perineal vs retropubic radical prostatectomy also experienced a shorter length of stay and were less likely to receive transfusion or have anastomotic strictures. Prospective studies are needed to determine variations in cancer control, and urinary and sexual function by surgical approach.
APPENDIX Radical prostatectomy complications Diagnosis Codes Perioperative complications (0–30 days): Cardiac Respiratory Vascular Wound or bleeding
Procedure Codes
410.x, 402.01, 402.11, 402.91, 428.x, 427.5, 997.1 518.0, 514, 518.4, 466.x, 480.x, 481, 482.x, 483.x, 485, 486, 518.5, 518.81, 581.82, 799.1, 997.3 415.1, 451.1x, 451.2, 451.81, 451.9, 453.8, 453.9, 997.2, 999.2, 444.22, 444.81, 433.x, 434.x, 436, 437.x 567.x, 998.3, 998.5x, 998.6
Genitourinary
595.89, 590.1x, 590.2, 590.8x, 590.9, 591, 997.5, 596.1, 596.2, 596.6, 593.3, 593.4, 593.5, 593.81, 593.82
Miscellaneous medical
584.x, 586, 785.5x, 995.0, 995.4, 998.0, 999.4, 999.5, 999.6, 999.7, 999.8, 457.8, 560.1, 560.8x, 560.9, 997.4, 353.0, 354.2, 723.4, 955.1, 955.3, 955.7, 955.8, 955.9, 593.4, 531.1, 531.2, 531.3, 531.4, 531.5, 531.6, 531.9, 532.1, 532.2, 532.3, 532.4, 532.5, 532.6, 532.9, 533.1, 533.2, 533.3, 533.4, 533.5, 533.6, 533.9, 782.4, 573.8 599.1, 596.1, 596.2, 596.6, 565.1, 569.3, 569.83, 569.4, 569.4x, 998.1x, 998.83, 998.9, 998.2, 998.4, 998.7, 604.0, E870.0, E870.4, E870.7, E870.8, E870.9, E871.0, E873.0, E876.0, 956.0, 956.1, 956.4, 956.5, 956.8, 956.9, 902.50, 902.51, 902.52, 902.53, 902.54, 902.59 596.0, 598.0, 598.1, 598.2, 598.8, 598.9
Miscellaneous surgical
Anastomotic stricture (0–180 days)
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8.
1.
9.
10.
11.
12.
13.
ICD-9: 54.61, 54.91, 54.0, 54.19, 59.19 Healthcare Common Procedure Coding System: 26990, 45020, 49060, 51080 ICD-9: 55.02, 55.03, 55.12, 55.93, 55.94, 59.93, 97.61, 97.62, 56.1, 56.41, 56.74, 56.75, 56.81, 56.84, 56.86, 56.89, 56.91 Healthcare Common Procedure Coding System: 50040, 50120, 50125, 50395, 50398, 50605, 52290, 52332, 52334, 50600, 50700, 50715, 50760, 50770, 50780, 50782, 50783, 50785, 50800, 50810, 50815, 50820, 50825, 50840, 50900, 50940
ICD-9: 46.03, 46.04, 46.10, 46.11, 46.14, 48.4x, 48.5, 48.6x, 48.7x, 48.9x
ICD-9: 57.0, 57.1x, (except 57.11), 57.2x, 57.92, 58.6, 57.4x, 57.85, 57.91, 58.0, 58.1, 58.3x, 58.44, 58.5 Healthcare Common Procedure Coding System: 51010, 51040, 52510, 52281, 52283, 53600, 53601, 53605, 53620, 53621, 53640, 51800, 51820, 52275, 52276, 52310, 52500, 52620, 52640, 53000, 53010, 53020, 53400, 53405, 53410, 53415, 53420, 53425
Mouraviev V, Nosnik I, Sun L, Robertson CN, Walther P, Albala D et al: Financial comparative analysis of minimally invasive surgery to open surgery for localized prostate cancer: a single-institution experience. Urology 2007; 69: 311. Menon M, Tewari A, Baize B, Guillonneau B and Vallancien G: Prospective comparison of radical retropubic prostatectomy and robot-assisted anatomic prostatectomy: the Vattikuti Urology Institute experience. Urology 2002; 60: 864. Nelson B, Kaufman M, Broughton G, Cookson MS, Chang SS, Herrell SD et al: Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy. J Urol 2007; 177: 929. Pappas TN and Jacobs DO: Laparoscopic resection for colon cancer–the end of the beginning? N Engl J Med 2004; 350: 2091. Rassweiler J, Seemann O, Schulze M, Teber D, Hatzinger M and Frede T: Laparoscopic versus open radical prostatectomy: a comparative study at a single institution. J Urol 2003; 169: 1689. Smith JA Jr and Herrell SD: Robotic-assisted laparoscopic prostatectomy: do minimally invasive approaches offer significant advantages? J Clin Oncol 2005; 23: 8170.
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Guillonneau B and Vallancien G: Laparoscopic radical prostatectomy: the Montsouris experience. J Urol 2000; 163: 418. 15. Miller DC, Wei JT, Dunn RL and Hollenbeck BK: Trends in the diffusion of laparoscopic nephrectomy. JAMA 2006; 295: 2480. 16. Guillonneau B, Rozet F, Cathelineau X, Lay F, Barret E, Doublet JD et al: Perioperative complications of laparoscopic radical prostatectomy: the Montsouris 3-year experience. J Urol 2002; 167: 51. 17. Gawande AA, Kwaan MR, Regenbogen SE, Lipsitz SA and Zinner MJ: An Apgar score for surgery. J Am Coll Surg 2007; 204: 201.
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Litwin MS, Melmed GY and Nakazon T: Life after radical prostatectomy: a longitudinal study. J Urol 2001; 166: 587. 19. Menon M, Shrivastava A, Tewari A, Sarle R, Hemal A, Peabody JO et al: Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol 2002; 168: 945. 20. Ahlering TE, Skarecky D, Lee D and Clayman RV: Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J Urol 2003; 170: 1738.