Radical Perineal Prostatectomy (RPP) at Northern Institute of Urology (NIU)

"The most cost-effective method for obtaining the best overall results in managing localized prostate cancer."

Why doesn’t NIU use robotics in prostatectomy?
We have incorporated an extensive clinical research program to achieve some of the best short-term and long-term clinical outcomes in prostate cancer treatment. At the same time, important economic factors are incorporated into the use of available technologies to improve results without unnecessary expense. The most apparent example has been the ability to obtain excellent results without the need for a robotic program. While robot-assisted surgery programs are widely available, the addition of associated costs has NOT resulted in an improvement in clinical outcomes to justify its use in a perineal prostatectomy program. Institutions incorporating robotic technologies to improve results in retropubic prostatectomy have yet to demonstrate superiority over non-robotic and non-laparoscopic techniques (although their marketing campaigns would like patients to think otherwise). When the perineal approach is utilized, the cost structure out performs open and laparoscopic approaches by several orders of magnitude. Importantly, the clinical results of the expensive approaches, at a cost of 3 to 4 times greater than perineal, still barely approach the results seen at Northern Institute of Urology.

What is special about the RPP program at NIU?
In 1993, Dr. Harris started a prospective database to measure cancer-related results and quality of life, functional results. Variations in technique are numerically coded and analyzed with the outcome measures to identify technical modifications that result in superior results. Over time, the best techniques are further modified based on extensive review of data. At the same time, PSA screening has reduced the average cancer burden in men presenting with prostate cancer. Earlier stage disease allows for the preservation of more urinary sphincter length and erectile nerves. The preservation of these structures results in better urinary and sexual function following effective cancer management. Table 1 illustrates the trend to smaller cancers over the three time periods studied. As a direct result, we are preserving erectile nerves in over 70% of men in 2006 as compared to only 10% of men in 1993. During this same time interval, more men are being cured of prostate cancer. See the section titled “Dr. Harris’s Prostatectomy Outcomes” for more information on results.

What does NIU do that makes us stand apart from other practices?
At NIU, hundreds of data points are obtained, prospectively, and studied periodically to influence our practice methods. We obtain detailed cancer related data, physician reported results and an extensive, validated, patient reported health related quality of life (HR-QOL) questions. Men complete the Expanded Prostate cancer Index Composite (EPIC) before treatment and at 2, 6, 12, 18, 24 months and annually after surgery. The results are entered into a database by our staff and sent to a third party research department for analysis. The EPIC was produced by a collaborative research effort at the University of Michigan and UCLA and validated through research. Importantly, the operating surgeon does not come into contact with this data during accumulation and analysis of this data. These results are published in peer-reviewed journals in the United States and Europe and presented at urology conferences internationally. This is one of the most extensive outcomes analysis program in prostate cancer treatments, anywhere. This data and these results are of particular interest to men with localized prostate cancer who are trying to find the best solution for their prostate cancer problem. If you can find better results, at any price, you should consider having your prostate cancer treated by that urologist.

How do your charges compare with other centers of excellence?
In order to examine comparable costs, we look to the charge to uninsured patients presenting for radical prostatectomy at a few centers of excellence in the United States. These charges are estimates and may change since this data was obtained in 2006. See Table 2 for estimates of charges for cash paying patients to prominent prostatectomy centers in the United States.

How can NIU provide these results at such low costs?
NIU has eliminated all third party interference and costs from the practice of urology. In 2001, we discontinued all relationships with Medicare and commercial insurance contracts. By doing so, our overhead expenses decreased by 75%! Most of our administrative costs were directly related to bureaucracy that did not improve the health of our patients. This payment policy made resources available to expand our outcomes research program and improved our treatment results while lowering cost. Our patient satisfaction improved dramatically. Patients with commercial insurance submit their own claims for our services and get reimbursed directly from their insurance company, based upon their insurance policy. The hospital, anesthesia and pathology services contract with most insurance plans and they are reimbursed based upon their contracts with our patient’s insurance policies. Medicare covered patients do not receive reimbursement from Medicare for our services but often get reimbursed from non-Medigap secondary insurance plans, if they have that type of insurance. Medicare has contracts with the hospital, anesthesia and pathologists that serve our patients.

How can patients from out-of-state or country benefit from this opportunity?
We have many patients from far away that come to Traverse City for surgery. Cherry Capital Airport in Traverse City has jet service by American Airlines, United Airlines and Northwest Airlines. Local hotels provide affordable rates for suites or regular hotel rooms and are located near NIU. Interested patients contact us in advance so that prior planning can make the visit as short and productive as possible. For men traveling from outside Michigan, a 14 day stay is recommended. This allows patients ample time to be well along the road of recovery before leaving our immediate area.

Are any forms of prostate radiation comparable?
Radiation can be delivered by several methods to include external beam with 3-D conformal therapy, intensity modulated radiation therapy, image guided radiation therapy, low dose rate permanent seed implants, high dose rate temporary seed implant with external beam combination or combinations of the above. In general, radiation is more expensive than surgery, from institution to institution with the range of about $35,000 to over $100,000. Given that radiation offers less chance for long-term cure and difficult-to-manage late toxicities, it is not much of a bargain for patients that seek affordable and effective treatment. If results are followed for more than 10 years after treatment, the differences between well done surgery and well done radiation become evident. See the section titled “Localized prostate cancer” for more discussion on radiation options.

Can I get NIU-quality care near my home?
Research has shown that treatment results vary significantly from physician to physician in all prostate cancer treatments. Two surgeons doing the same operation rarely have identical results. The best method of choosing a physician to treat prostate cancer is to study his personal outcomes. If you can get excellent results near your home for a fair price, you should seek care there. Ultimately, you have many options to choose from, and plenty of time to decide. Do not rush into a treatment decision without good information. We remain available to answer questions at 231-935-0935.