Impact of physician awareness on hospital charges for radical retropubic prostatectomy

PURPOSE

We determine if physician awareness of hospital costs for radical retropubic prostatectomy affects physician practice patterns.

MATERIALS AND METHODS

We reviewed 256 consecutive radical retropubic prostatectomies performed by 14 urologists during 4 years at a community hospital. After 2 years the physicians were provided information on factors that may decrease charges.

RESULTS

Charges decreased significantly following intervention, from +f417,134 within the initial 2 years to +f413,826 within the last 2 years (p < 0.005). Significant decreases were noted for length of stay, need for intensive care, operating time and blood loss.

CONCLUSIONS

Traditional methods of physician education can impact practice patterns to decrease hospital charges for radical retropubic prostatectomy.

The role of the physician in effecting change in hospital charge for radical prostatectomy

BACKGROUND

Continuing effort is being made to provide the best medical care in a cost-effective manner, requiring an evaluation of factors that control charges. The number of cases of carcinoma of the prostate gland and the number of radical retropubic prostatectomies performed have increased in recent years, with an estimate of several hundred million dollars being spent annually on this procedure in the United States of America. Because physicians are reported to effect the majority of charges for a hospitalization, this study examines the influence of notification of the physician of hospital charges on the overall hospital charges for radical retropubic prostatectomy.

STUDY DESIGN

Total hospital charge and duration per hospitalization were determined for all patients having radical prostatectomies performed at five community hospitals in Richmond, VA, between January 1991 and December 1993. Patients included 625 males diagnosed with carcinoma of the prostate gland undergoing radical prostatectomy by one of 20 urologists from several different private practice groups. Halfway into the time period studied, physicians were notified of data collection and of factors that seemed to have a role in hospital charges. Total hospital charges before and after physician notification were measured to determine whether or not physicians could effect hospital charges.

RESULTS

Overall, hospital charges decreased significantly after notification of physicians in the study. The decline in total charges continued throughout the follow-up period. Duration of hospitalization decreased throughout the entire study period, while total charge per hospital day increased.

CONCLUSIONS

Physician awareness of hospital charges for operative procedures and accompanying hospitalizations may influence the overall decrease in charges.

Color Doppler ultrasound for the diagnosis of segmental testicular infarction

We report a case of segmental infarction of the testis associated with scrotal pain diagnosed by color Doppler ultrasound. Histological examination of the testis confirmed the diagnosis. Use of this imaging modality may obviate surgical exploration in select cases.

The interaction between electrosurgical generators, endoscopic electrodes, and tissue

Endoscopic monopolar and bipolar devices were compared during cutting and coagulation. It was observed on appropriate animal models that the initial resistance (impedance) values recorded correspond to the normal tissue impedance at the electrode. The subsequent impedance values increase 25 to 50 ohms for the coagulator which relates to tissue desiccation and for the cutting electrodes the impedance increases greater than 1000 ohms during the arcing process. At similar power settings, typical monopolar generators produce maximum power at 300 to 500 ohms while typical bipolar generators produce maximum power at 25 to 100 ohms. With impedances greater than 1000 ohms, monopolar generators are capable of higher power output than are bipolar generators. Since cutting is a high impedance process, bipolar cutting electrodes do not perform as intended with typical bipolar generators. Therefore, bipolar cutting electrodes should be employed with a monopolar generator or a generator designed specifically for their use.

Endourological treatment of ureteroenteric anastomotic strictures: long-term followup

In 1987 we reported our initial experience with an endosurgical incisional approach to ureteroenteric anastomotic strictures (that is endoureterotomy). We have extended that initial report to encompass 15 patients with 19 ureteroenteric strictures followed for an average of 2.5 years. In all cases an endosurgical approach was well tolerated, blood loss was less than 50 cc and hospital stay averaged 3.5 days. A 16 to 22F external stent was left in place for 4 to 6 weeks postoperatively in 14 strictures. A permanent external 12F catheter was left in 5 strictures due to the presence of metastatic disease (4) and a complete dense stricture (1). The only major complication was a ureteroenteric fistula that healed over a ureteral stent without any open surgical intervention. Among 14 ureteroenteric strictures in which the stent was removed, the ureteroenteric area has remained patent in 8 (57%) with an average followup of 28.6 months (range 9 to 57 months). Failures were associated with metastatic disease in 2 cases, generalized debility in 2 and unexplained in 2. In this series an endosurgical approach to ureteroenteric strictures provided long-term satisfactory management of the problem in the majority of patients with benign and malignant disease. By current standards, only 1 patient (7%) would have been considered a candidate for open surgical repair.

In vivo effect of 5 French bipolar and monopolar electrosurgical probes on the porcine bladder

Previous in vitro studies have indicated bipolar electrosurgical probes would electrodesiccate tissue in a normal saline solution. This study applies similar sized monopolar and bipolar electrosurgical probes to porcine bladder in order to compare each probe's effect in vivo. The power delivered by each probe was calculated; the width and depth of the porcine bladder damage was measured and the volume of the damage calculated. The animals were sacrificed at 24, 48 and 96 h post-procedure so that the amount of tissue destruction could be quantitated relative to the bladder's natural tissue reaction. The data shows the power (watts) delivered by the monopolar probe to be approximately six times that of the bipolar probe. Likewise, the area of bladder wall damage was larger with monopolar at all time periods sampled and showed significant differences at 24 and 48 h. These studies indicate that in viable bladder, tissue bipolar probes will electrodessicate at a lower power and with less shortterm tissue damage.

Direct-current potentials created by arcing during monopolar radiofrequency electrosurgery

Muscle and nerve stimulation during radiofrequency electrosurgery has been a well-known phenomenon for over 50 years. However, as electrosurgery expands into new procedures, such as tissue ablation in the heart, the mechanism of the potentially deleterious stimulation becomes more important. This article presents data showing that large DC currents are generated during electrosurgery and that these potentials increase with increasing sparking at the active electrode. The data also show DC potentials generated by various generators, different operation modes (cut, coagulation, fulguration), and operations on tissues of various impedances.

Use of 5F bipolar electrosurgical probe in endoscopic urological procedures

Experimental data have shown bipolar electrodes to function in saline solution with less volume and depth of tissue destruction compared to similar sized monopolar electrodes. We applied the same bipolar generator and electrodes used in laboratory testing in 41 procedures on 36 patients to determine if the bipolar electrode will provide clinically adequate hemostasis. The bipolar electrode was used for bladder fulguration in 37 procedures and ureteral fulguration in 4. The procedures were performed by 7 urological surgeons and in normal saline solution. The bipolar electrode was believed to perform as well as the standard monopolar probe in 39 procedures. The 2 failures included 1 bladder tumor fulguration and 1 electroincision of a ureterointestinal anastomotic stricture. There were no episodes of recurrent bleeding after any procedure. The bipolar system has the added advantage of not requiring a return electrode (ground pad), thereby eliminating the possibility of skin burns.

A comparison of urologic application of bipolar versus monopolar five French electrosurgical probes

Urologic endoscopic procedures often involve electrosurgery. Recently bipolar probes have become commercially available. This study compares monopolar and bipolar electrosurgical probes in relation to power losses in urologic endoscopic instruments with the infusion of sterile water and saline, and the power transmitted by probes to tissue correlated to tissue destruction in each fluid. The power losses through each instrument in both solutions were minimal. The bipolar electrode functioned at a much lower power output than did the monopolar electrode. The bipolar probe was also more effective in saline than sterile water. The depth, width and volume of tissue damage for both electrodes were found to vary with generator power output. The data shows the burns had similar diameters for both probes but the bipolar probe caused significantly less burn depth than the monopolar probe. These initial studies indicate that bipolar electrodes can function in normal saline with less depth damage compared to the monopolar probe.

Magnetic resonance imaging in the diagnosis and followup of idiopathic retroperitoneal fibrosis

Four cases of idiopathic retroperitoneal fibrosis are reported. Magnetic resonance and computerized tomographic images were obtained for diagnosis in each case, and followup scans were obtained at various intervals after therapy. In all 4 cases magnetic resonance imaging was equal or superior to computerized tomography in the diagnosis of retroperitoneal fibrosis, outlining the extent of involvement, preoperative planning and assessing response to medical or surgical therapy.

Management of benign ureteral structures: open surgical repair or endoscopic dilation?

We reviewed 20 cases of ureteral strictures, 15 of which were secondary to ureteral trauma. Of the patients 6 were managed initially by open repair and 14 underwent endoscopic manipulation. All 6 open repairs were successful, compared to 9 of the 14 patients who underwent endoscopic dilation of the ureteral stricture. Of the 5 failures 3 were due to the inability to cannulate the strictured ureter with a guide wire and 2 failed to respond to balloon dilation. Of these 5 patients 4 were treated successfully by an open operation. There were no serious intraoperative or postoperative complications. The average hospitalization was less for the endoscopic group (2.1 days) compared to the open surgical group (8.3 days). Followup ranged from 6 to 48 months.

Invasive adenocarcinoma of bladder response to cisplatinum, methotrexate, and vinblastine chemotherapy

Primary invasive adenocarcinoma of the bladder was diagnosed in a fifty-two-year-old male with a two-month history of irritative voiding symptoms. He was treated with three courses of cisplatinum, methotrexate, and vinblastine with marked regression of tumor shown radiographically and cystoscopically. Subsequent prostatocystectomy and ileal loop diversion revealed invasive tumor through the bladder wall to regional lymph nodes. The patient had two postoperative courses of the same chemotherapeutic regimen and is without evidence of disease recurrence at one year.

A simple and inexpensive method for measuring electrosurgical variables

A simple circuit that demodulates the high-frequency output of an electrosurgical generator to proportional DC values can be employed to monitor generator voltage and electrosurgical current. An example of the use of the circuit in a urologic application is given. Employing this monitoring circuit, quantitative comparisons of electrosurgical equipment and performances can be made.

Advances in endosurgery. Treatment of ureteral-enteric anastomotic strictures

The described endourologic technique of incision and dilation of a ureteral-intestinal stricture is effective in most patients. Indeed, with the outlined treatment regimen, less than 30 per cent of patients with ureteral-intestinal anastomotic strictures will eventually require open surgical revision. Further advances in the use of lasers or the endourologic positioning of free tissue grafts may further improve the success rate of the endoscopic approach.

Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair

The established treatment for ureterointestinal anastomotic strictures is open surgical revision. In an effort to evaluate the efficacy of endourological surgery for this problem, we compared 7 patients (9 strictures) who underwent open revision to 6 patients (7 strictures) who underwent endoscopic incision and balloon dilation of the stricture. The success rate (that is patent ureter and no stent) was 89 per cent for the open revision group and 71 per cent (5 of 7) for the endoscopic group. All open revisions required use of general anesthesia, while 3 of the endoscopic procedures were performed with the patient under assisted local anesthesia. The endoscopic group had markedly shorter hospitalization, decreased blood loss, diminished patient discomfort and no postoperative complications. While the endoscopic procedure for ureteroileal anastomotic strictures is less successful than open revision, the lower morbidity, decreased cost and shorter hospital stay associated with the endourological approach favor its use over open revision. For elderly patients who fail initial endoscopic revision and for patients with metastatic transitional cell cancer, placement of an indwelling stent is a reasonable alternative. Given these guidelines, less than 30 per cent of the patients who suffer a ureteroileal anastomotic stricture will require open surgical revision.

The value of testosterone deprivation in stage D1 carcinoma of the prostate

The question of whether hormonal manipulation is effective in the treatment of stage D1 carcinoma of the prostate has yet to be determined conclusively. To study this question a retrospective review was conducted of 68 patients with stage D1 disease. Of the patients 22 underwent immediate orchiectomy, 24 delayed orchiectomy and 11 exogenous antiandrogen treatment (8 immediate and 3 delayed treatment), and 11 had no androgen deprivation. The patients were placed into 2 groups consisting of those receiving immediate hormonal deprivation (30) and those having treatment at the time of bone metastasis or who are as yet untreated (38). The minimum followup was 60 months. The median interval to progression to bone metastasis was 43 months in the delayed treatment group compared to 100 months in the immediate hormonal deprivation group. This difference was statistically significant (p equals 0.0087). Likewise, the median period from diagnosis to death was 90 months in the delayed treatment group and 150 months in the immediate treatment group. This difference was not significant (p equals 0.1110). Thus, orchiectomy or adequate androgen deprivation from our data significantly prolongs the interval to bone metastasis in patients with metastatic prostate cancer limited to the pelvic lymph nodes. The apparent increased length of survival of the immediate treatment group lacks statistical confirmation.

Flexible cystoscopy and retrograde catheterization in renal transplant patients

Catheterizing the ureteral orifice of a renal transplant patient can be difficult using traditional rigid instruments. This report describes our experience with 4 patients who underwent cystoscopy and attempted retrograde catheterization of a transplanted ureter. In all cases attempted catheterization using rigid instruments was unsuccessful, while in 3 of the 4 patients, successful cannulation was accomplished using the flexible cystoscope. These results are attributed to the expanded range of motion achieved with the tip of the flexible cystoscope. The increased mobility afforded by this instrument facilitates access to the ureteral orifice, which is often positioned on the distensible portion of the bladder.

Extracorporeal shock wave lithotripsy for the treatment of bulbous urethral stones

Extracorporeal shock wave lithotripsy was used to treat multiple, large, bulbous urethral calculi in a paraplegic man. Prior attempt at endoscopic extraction was unsuccessful owing to the size and location of the calculi. Two treatments of 3,000 shocks each resulted in fragmentation of the calculi

Giant prostate carcinoma: computed tomography findings and review of previous reports

Two patients with massive prostate adenocarcinoma were evaluated by several imaging modalities. Computed tomography provided excellent anatomic delineation of the tumors. In one patient, computed tomography demonstrated significant tumor regression following orchiectomy. Giant prostate carcinoma should be considered in the differential diagnosis of a large, inhomogeneous pelvic mass.

Ureteral perforation during ureterorenoscopy: treatment and management

Ureterorenoscopy has become a popular diagnostic and therapeutic tool for the modern urologist but this procedure is not without complications and risks. The technique may result in perforation of the ureter and subsequent stricture formation in some cases. In this study a ureteral perforation rate of 17 per cent was noted after 142 ureteroscopic procedures, with stricture formation occurring in 5 per cent. The type of dilation, reason for the procedure or placement of a postoperative stent did not seem to affect the formation of stricture but the location of the injury appeared to be significant. Of those injuries not requiring immediate surgical repair perforations within the pelvis (6 of 11) led to strictures more often than those beyond the pelvis (1 of 9). Treatment of the strictures with either an open repair or percutaneous antegrade dilation was successful.

Extracorporeal shock wave lithotripsy in children

Extracorporeal shock wave lithotripsy has proved to be an effective method of treating upper urinary tract calculi. We report on 14 patients 17 years old or younger who were treated with the Dornier lithotriptor. Special adjustments of the gantry and water level, as well as shielding of the lungs, were necessary in those children less than 135 cm. in height or 30 kg. in weight. Hospital stay averaged 2.5 days and ranged from 1 to 6 days. There were no major intraoperative complications. Postoperative pulmonary edema developed in 1 patient and only 3 required parenteral analgesics for postoperative pain control. Of the 12 patients for whom a 3-month followup is available 10 are free of stone. One patient required ureterolithotomy for removal of impacted stone fragments. We conclude that extracorporeal shock wave lithotripsy is a safe and effective method of treating renal calculi in children.

Use of local anesthesia for extracorporeal shock wave lithotripsy

Extracorporeal shock wave lithotripsy is being performed at many centers with the use of either general or epidural anesthesia. We report our experience with 39 patients treated by extracorporeal shock wave lithotripsy under local anesthesia. These patients tolerated the procedure well and had good fragmentation of the stones. Of the patients 18 were treated on an outpatient basis. In selected patients local anesthesia offers an alternative that can decrease the risk of anesthesia, and reduce the cost and hospital stay associated with extracorporeal shock wave lithotripsy.

Extracorporeal shock wave lithotripsy for the treatment of urinary calculi in the elderly

Renal calculus in the elderly patient is associated with the same symptoms and risks as in other patient populations. With the recent development of extracorporeal shock wave lithotripsy (ESWL), many older patients can now be treated for renal calculi. The Department of Urology at the University of Iowa Hospitals and Clinics has performed 107 ESWL treatments on a total of 96 patients over 70 years of age. This represents over 12% of all patients treated at our institution. No deaths related to ESWL treatment have occurred in this group, nor has increased morbidity been observed in comparison to all patients treated. In spite of the increased age and associated medical problems of this patient population, ESWL offers a safe and effective means of treating upper tract urinary calculi in the geriatric age group.

Endourological management of ureteroileal anastomotic strictures: is it effective?

Ureteroileal stenosis represents a serious postoperative threat to the obstructed kidney and open revision in these patients often is difficult. We evaluated 9 patients with 10 ureteroileal strictures who were treated with semirigid fascial dilators (1), balloon dilation (4) or a combination of balloon dilation and percutaneous intraureteral surgery (4). All 5 patients who had semirigid fascial or balloon dilation alone had early recurrence of the strictures. However, in 4 patients dilation in conjunction with percutaneous intraureteral incision of the stricture through a flexible choledochonephroscope resulted in short-term resolution of each ureteroileal stricture. However, by 6 months these strictures had recurred in 50 per cent of the patients.

Percutaneous transperineal placement of gold 198 seeds for treatment of carcinoma of the prostate

Thirty-one patients have been treated for carcinoma of the prostate with 198Au seeds placed transperineally using transrectal ultrasonic guidance. Twenty patients have been followed postoperatively for periods ranging from 3 to 31 months, with an average follow-up time of 12 months. Cumulative dose of radiation to the prostate calculated by dosimetry was either 9,000 rads or 15,000 rads. Serial transrectal ultrasound examinations performed on these patients showed a decrease in prostate size in all patients within 6 months of treatment, with a statistically significant decrease observed between the third and sixth months. No significant difference in amount or rate of tumor regression was noted when tumor stage and grade were correlated to volume decrease after treatment. Patients who received the larger doses of radiation (15,000 rads) showed a significantly greater rate of decline in prostatic volume than those who received 9,000 rads. Seven patients underwent prostate biopsy between 12 and 18 months after treatment; six biopsies showed residual tumor. Complications after treatment included urinary retention because of prostatic edema (three), radiation urethritis (three), and rectal ulceration (one). Transperineal placement of 198Au is well tolerated and offers an alternative to external beam radiation for treatment of carcinoma of the prostate.

Extracorporeal shock wave lithotripsy. Noninvasive treatment for urinary stones

As with many new treatments in medicine, time will determine the place of extracorporeal shock wave lithotripsy (ESWL) in management of urinary calculi. It may be that a combination of methods will prove most effective. However, at the present time, ESWL provides a noninvasive means of fragmenting calculi so that stones that were previously manageable only by invasive techniques potentially can be passed from the urinary tract. ESWL is a 30- to 45-minute treatment that yields a 50% to 75% stone-free rate at three months after the procedure. Of course, interpretation of success rates can vary on the basis of patient selection and the size, position, and composition of the stone. At this point, ureteroscopy and cystoscopic stone basketing remain the treatments of choice for low ureteral stones. Nonetheless, ESWL is an exciting new weapon in our battle against stone disease.

Bedside flexible cystoscopy: an approach to the critically ill patient

A 15F flexible fiberoptic choledochonephroscope was used to perform bedside flexible cystoscopy in 5 critically ill patients. All 5 patients were receiving pressor agents, and 4 were intubated and dependent on a respirator. A ureteral stent was placed in the renal pelvis in 3 patients. The flexible endoscope enables the urologist to bring diagnostic and therapeutic cystoscopy directly to the bedside.

The frozen section in lymphadenectomy for carcinoma of the prostate

From January 1969 through August 1982 we performed 257 pelvic lymph node dissections for staging of carcinoma of the prostate. One or more lymph nodes were submitted for frozen section in 100 cases (39 per cent): 43 (43 per cent) had positive nodes on frozen and permanent sections, while frozen section was negative in 57 (57 per cent). Of the latter 57 cases (16 per cent) had positive nodes on paraffin sectioning of all tissue submitted. Thus, in our series there was a 16 per cent chance of overlooking metastatic disease at the time of pelvic lymph node dissection even with the aid of intraoperative frozen sections.