Impact of surgical case order on perioperative outcomes for robotic-assisted radical prostatectomy

Objectives: Since its introduction, there have been many refinements in the technique and implementation of robotic-assisted radical prostatectomy (RARP). However, it is unclear whether operative outcomes are influenced by surgical case order. We evaluated the effect of case order on perioperative outcomes for RARP within a large health maintenance organization. Materials and Methods: We conducted a retrospective review of RARP cases performed at our institution from September 2008 to December 2010 using a single robotic platform. Case order was determined from surgical schedules each day and surgeries were grouped into 1st, 2nd and 3rd round cases. Fourth round cases (n = 1) were excluded from analysis. We compared clinicopathological variables including operative time, estimated blood loss (EBL), surgical margin rates and complication rates between groups. Results: Of the 1018 RARP cases in this cohort, 476 (47%) were performed as 1st round cases, 398 (39%) 2nd round cases and 144 (14%) 3rd round cases by a total of 18 surgeons. Mean operative time was shorter as cases were performed later in the day (213 min vs. 209 min vs. 180 min, P < 0.0001) and similarly, EBL also decreased with surgical order (136 mL vs. 134 mL vs. 103 mL, P = 0.01). Transfusion rates, surgical margin rates and complication rates did not significantly differ between groups. Patients undergoing RARP later in the day were much more likely to have a hospital stay of 2 or more days than earlier cases (10% vs. 11% vs. 32%, P = 0.01). Conclusions: Surgical case order may influence perioperative outcomes for RARP with decreased operative times and increased length of hospital stay associated with later cases. These findings indicate that select perioperative factors may improve with ascending case order as the surgical team "warms up" during the day. In addition, 3rd round cases can increase hospital costs associated with increased lengths of hospital stay. Knowledge of these differences may assist in surgical planning to improve outcomes and limit costs.