Surgical case order does not affect outcomes during robot-assisted radical prostatectomy

Fatigue has been implicated in medical errors. There has not been any report in the surgical literature addressing the impact of case order on patient outcomes. The purpose of this study was to determine whether the order of robot-assisted radical prostatectomy (RARP) has an influence on surgical outcomes. All patients undergoing RARP by a single surgeon (J.V.J.) on days during which there were three consecutive RARP cases were divided into three groups based on case order. They were compared with respect to pre-operative, intra-operative, and post-operative parameters. Complications were classified as surgical (bladder neck contracture, urinary tract infection, post-operative bleeding) or medical (deep venous thrombosis, myocardial infarction, C. difficile colitis) and compared between the groups. A total of 381 patients were evaluated, 127 in each group. The median start time for group 1 was 0732 hours (range 0722-0900 hours), group 2 was 1108 hours (range 1008-1344 hours), and group 3 was 1458 hours (range 1258-1742 hours). Patient age, body mass index, pre-operative PSA, pre-operative Gleason score, and clinical stage were all similar amongst the groups. The total operative time was equivalent, as was the estimated blood loss. Prostate volume and pathologic Gleason score showed no significant changes between groups. Pathologic stage showed a slight trend toward increasing percentages of T3 disease with increasing group number (group 1 = 17%, group 2 = 19%, and group 3 = 24%). Positive margin rates were lowest in group 3 (11.8% for group 1, 12.6% for group 2, and 3.9% for group 3). Complication rates were equivalent at 5-7% overall (2-6% surgical complications, 2-4% medical). Three patients from each group had PSA recurrence. With an experienced surgical team, three RARP procedures may be performed in 1 day without significant variation in surgical outcomes among the cases.