title: The diffusion of minimally invasive radical prostatectomy in the United States: a case study of the introduction of new surgical devices.
abstract: BACKGROUND
  The diffusion of minimally invasive radical prostatectomy (MIRP) in the United States may have led to adverse patient outcomes due to rapid surgeon adoption and collective inexperience. We hypothesized that throughout the early period of minimally invasive surgery, MIRP patients had inferior outcomes as compared with those who had open radical prostatectomy (ORP).
  
  
  METHODS
  We used the Surveillance, Epidemiology and End RESULTS-Medicare dataset and identified men who had ORP and MIRP for prostate cancer from 2003-2009. Study endpoints were receipt of subsequent cancer treatment, and evidence of postoperative voiding dysfunction, erectile dysfunction (ED) and bladder outlet obstruction. We used proportional hazards regression to estimate the impact of surgical approach on each endpoint, and included an interaction term to test for modification of the effect of surgical approach by year of surgery.
  
  
  RESULTS
  ORP (n=5362) and MIRP (n=1852) patients differed in their clinical and demographic characteristics. Controlling for patient characteristics and surgeon volume, there was no difference in subsequent cancer treatments (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.76-1.05), although MIRP was associated with a higher risk of voiding dysfunction (HR 1.31, 95% CI 1.20-1.43) and ED (HR 1.43, 95% CI 1.31-1.56), but a lower risk of bladder outlet obstruction (HR 0.86, 95% CI 0.75-0.97). There was no interaction between approach and year for any outcome. When stratifying the analysis by year, MIRP consistently had higher rates of ED and voiding dysfunction with no substantial improvement over time.
  
  
  CONCLUSIONS
  MIRP patients had adverse urinary and sexual outcomes throughout the diffusion of minimally invasive surgery. This may have been a result of the rapid adoption of robotic surgery with inadequate surgeon preparedness.
authors.affiliation: The Urology Service, Department of Surgery, Sidney Kimmel Center for Prostate and Urological Malignancies and Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: C B
authors.initials: CB
authors.lastname: Anderson
authors.affiliation: Department of Epidemiology and Biostatistics Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: E B
authors.initials: EB
authors.lastname: Elkin
authors.affiliation: Department of Epidemiology and Biostatistics Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: C L
authors.initials: CL
authors.lastname: Atoria
authors.affiliation: The Urology Service, Department of Surgery, Sidney Kimmel Center for Prostate and Urological Malignancies and Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: J A
authors.initials: JA
authors.lastname: Eastham
authors.affiliation: The Urology Service, Department of Surgery, Sidney Kimmel Center for Prostate and Urological Malignancies and Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: P T
authors.initials: PT
authors.lastname: Scardino
authors.affiliation: The Urology Service, Department of Surgery, Sidney Kimmel Center for Prostate and Urological Malignancies and Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: K
authors.initials: K
authors.lastname: Touijer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D023381:Endpoint Determination; D007172:Erectile Dysfunction / Q000453:epidemiology / Q000473:pathology; D006801:Humans; D008297:Male; D011183:Postoperative Complications; D011468:Prostatectomy / Q000009:adverse effects*; D011471:Prostatic Neoplasms / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome; D014481:United States