Predictors of prolonged operative time during robot‐assisted laparoscopic radical prostatectomy

Abstract

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Robotic prostatectomy has now become the most common surgical approach in the United States for patients with prostate cancer. There is a significant learning curve for this procedure and this paper attempts to help understand what factors will make the operative times longer. Very little to date has been written on this topic. OBJECTIVE To determine risk factors for prolonged operative time (OT) during robot‐assisted laparoscopic radical prostatectomy (RALP). Being able to predict prolonged OT is of pivotal importance both to the physician for patient counseling and to the hospital management. PATIENTS AND METHODS Retrospective review of patient records undergoing RALP between 2003 and 2009 at a tertiary academic center with a structured teaching program. The following variables were recorded: age, race, body‐mass index (BMI), previous abdominal surgery (yes/no), nerve‐sparing technique (yes/no), lymph nodes dissection (yes/no), pathological stage (organ‐confined versus non), cumulative surgical experience with RALP (expressed as number of years since introduction of RALP at our center), prostate weight and OT calculated skin‐to‐skin by the anesthesiologists. Prolonged OT was defined as the upper quintile (20%) according to the distribution. Multivariate regression model was generated to assess potential predictors of prolonged OT. RESULTS A total of 523 records were retrieved. Caucasians accounted for 77.8% of the cohort. Median age was 60.3 years (interquartile range, IQR, 55.0–64.6 years), median BMI 28.1 (25.8–30.7 kg/m2), prostate weight 46.0 g (37.0–57.8 g). Eighty‐six (16.4%) patients had previous abdominal surgery, lymph nodes dissection was performed in 341 (65.2%) and nerve‐sparing technique was done in 310 (59.3%) cases. Median OT was 175 min (IQR 146–220 min). Prolonged OT was set at >230 min, thereby 105 (20.1%) records were classified as such. On multivariate analysis, cumulative surgical experience with RALP (P < 0.001), nerve sparing (P= 0.023) and prostate weight (P < 0.001) were independent predictors of prolonged OT. CONCLUSIONS Larger prostates are associated with longer OT and this effect is maintained independently of cumulative robotic experience that represents another independent factor in determining OT.

Independent predictors of prolonged operative time during robotic-assisted radical prostatectomy

“…A retrospective cohort study by Yong et al [14] has also attempted to identify predictors of prolonged operative time. These authors identified cumulative surgical experience, prostate weight, and nerve sparing as independent predictors of prolonged operative time.…”

“…The primary driver of prolonged operative times during RARP is surgeon experience and this has been well described [13][14][15][16][17]. However in large volume centers, most surgeons have completed their early learning curve period; therefore, additional study of factors which increase operative time among experienced surgeons is warranted.…”

Dedicated robotics team reduces pre-surgical preparation time

“…[14–17] Palmer and associates previously reported on the economic feasibility of RALRP. [18] In this report OR utilization was found to account for nearly 35% of the cost per procedure.…”

The Role of Cryosurgery of the Prostate for Nonsurgical Candidates

“…9 There is considerable variability in the length of operative time among patients and among surgeons, especially early in the surgeon's RARP experience. 8,10 Although increased operative time is known to increase the overall cost and risk of complications, 11,12 less is known about how operative time increases the risk for VTE development. In a multi-institutional series of 5951 patients undergoing laparoscopic radical prostatectomy or RARP, the incidence of symptomatic VTEs was low overall, at 0.5%, but variable among surgeons (0.2%–6.2%) and operative time was associated with increased VTE risk.…”