Role of surgeon volume in radical prostatectomy outcomes

Racial variation in the pattern and quality of care for prostate cancer in the USA: mind the gap

OBJECTIVE

To review the literature on racial variation in the pattern of care (PoC) and quality of care (QoC) for prostate cancer, as there are known racial disparities in the incidence and outcomes of prostate cancer. While there are some biological explanations for these differences, they do not completely explain the variation. Differences in the appropriateness and QoC delivered to men of different racial groups may contribute to disparities in outcome.

METHODS

We searched the USA National Library of Medicine PubMed system for articles pertaining to quality indicators in prostate cancer and racial disparities in QoC for prostate cancer.

RESULTS

While standards for appropriate treatment are not clearly defined, racial variation in the PoC has been reported in several studies, suggesting that African-American men may receive less aggressive treatment. There are validated QoC indicators in prostate cancer, and researchers have begun to evaluate racial variation in adherence to these quality indicators. Further quality comparisons, particularly in structural measures, may need to be performed to fully evaluate differences in QoC.

CONCLUSIONS

There is mounting evidence for racial variation in the PoC and QoC for prostate cancer, which may contribute to observed differences in outcome. While some of the sources of racial variation in quality and outcome have been identified through the development of evidence-based guidelines and validated quality indicators, opportunities exist to identify, study and attempt to resolve other components of the quality gap.

[Anastomotic stricture after radical prostatectomy for prostate cancer]

The present paper intends to review diagnosis and treatment issues of bladder neck anastomosis stricture after radical prostatectomy for localised prostate cancer. Even though cancer control is not necessarily a concern, quality of life may be greatly altered. Patients may suffer from dysuria, urgency and the feeling of incomplete bladder emptying. Flowmetry, cystoscopy and cystography contribute to its diagnosis. Treatment should be graded according to the severity of the disease and the quality of life of the patient. Cold-Knife incisions and pneumatic dilatation are the first line treatments. Holmium laser shows good results on the stricture in a second line treatment. A two-stage strategy with an endoluminal stent followed by artificial urinary sphincter implant is the ultimate option to manage severe strictures, while maintaining acceptable quality of life. Continence sparing is the challenge of the treatment of this type of stricture.

Overcoming the learning curve for robotic-assisted laparoscopic radical prostatectomy

Robotic-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted in the last few years despite having a prolonged learning curve. This article describes the RALP learning curve, reviews in detail the challenging steps of the operation, describes the authors' RALP technique, and concludes with tips to overcome the learning curve.

Visual cues as a surrogate for tactile feedback during robotic-assisted laparoscopic prostatectomy: posterolateral margin rates in 1340 consecutive patients

OBJECTIVE

To analyse consecutive cases of robotic-assisted laparoscopic prostatectomy (RALP), present the incidence of nerve-sparing-related positive surgical margins (SM+), include visual cues that might assist in smoothly changing to the robotic platform, and discuss the scientific rationale for 'intersensory integration' which might explain the 'reverse Braille' phenomenon, i.e. the ability to feel when vision is greatly enhanced, as the lack of tactile feedback during RALP is often cited as a disadvantage of robotic surgery, interfering with a surgeon's ability to make intraoperative oncological decisions.

PATIENTS AND METHODS

Data from 1340 consecutive patients undergoing RALP from one institution were analysed and trends for positive posterolateral SM+ (PLSM+) were correlated with oncological variables before and after RALP. A sample of patient slides were reviewed by a extramural pathologist. Multivariate regression modelling was used to compare the projected rates of PLSM+ vs the actual rate, given the effect of a conscious effort to use visual cues. Finally, video recordings of the procedure were systematically reviewed and correlated with anatomical and histopathological images in an integrated session involving the surgeon and the pathology team.

RESULTS

The incidence of PLSM+ was 2.1%, which gradually declined to 1.0% in the last 100 patients. The reduction in PLSM+ occurred despite an increased rate of high-risk tumours operated on during this period. Forecasting analysis showed that the actual PLSM+ rate declined by half in the most recent 1000 patients, due to an integrated effort involving the use of visual cues during surgery. The following visual cues were considered important; appreciation of periprostatic (lateral prostatic) fascial compartments; colour and texture of the tissue; periprostatic veins as a landmark for athermal dissection; signs of inflammation; and a freely separating bloodless plane showing loose shiny areolar tissue.

CONCLUSION

Adapting to the robotic platform is easy and there is no compromise of the oncological safety of this procedure. Experienced surgeons can use visual cues to assist during nerve-sparing RALP and achieve low PLSM+ rates.

Development of a training curriculum for microsurgery

Recent changes in healthcare necessitate revision of the current apprenticeship model of surgical training. Current methods of assessment such as examinations and logbooks are not criteria-based, so are subjective and lack validity and reliability. The objective feedback of technical skills is crucial to the structured learning of surgical skills. We review current publications about training and methods of assessment in microsurgery. Searches on PubMed using keywords (microsurgery, training, assessment, simulation, and skill) were used to retrieve relevant articles, and further cross-referencing was done to obtain more information. New methods of assessment that are objective include checklists, global rating scales (GRS), and dexterity analysis, which give feedback of technical skills during training. Vital (living), non-vital, prosthetic, and virtual reality simulation models can be used to train surgeons to a proficient level outside the operating theatre before they operate on real patients. After reviewing the current evidence we propose a curriculum for microsurgical training that starts outside the operating theatre. The surgical community should follow the example of other high-risk industries such as aviation, where continuous assessment on simulators is a part of training, but further research is necessary before such methods can be used for summative assessment and revalidation.

Surgeon volume is predictive of 5-year survival in patients with hepatocellular carcinoma after resection: a population-based study

BACKGROUND AND AIM

No study has examined associations between physician volume or hospital volume and survival in patients with liver malignancies in the hepatitis B virus-endemic areas such as Taiwan. This study was to examine the effect of hospital and surgeon volume on 5-year survival and to determine whether hospital or surgeon volume is the stronger predictor in patients with hepatocellular carcinoma after hepatic resection in Taiwan.

METHODS

Using the 1997-1999 Taiwan National Health Insurance Research Database and the 1997-2004 Cause of Death Data File, we identified 2,799 patients who underwent hepatic resection and 1,836 deaths during the 5-year follow-up period. The Cox proportional hazard regressions were performed to adjust for patient demographics, comorbidity, physician, and hospital characteristics when assessing the association of hospital and surgeon volume with 5-year survival.

RESULTS

When we examined the effect of physician and hospital volumes separately, both physician and hospital volumes significantly predicted 5-year survival after adjusting for characteristics of patient, surgeon, and hospital. However, after we adjusted for characteristics of physician and hospital, only physician volume remained a significant predictor of the 5-year survival.

CONCLUSIONS

Physician volume is a stronger predictor of 5-year survival in hepatocellular carcinoma patients receiving hepatic resection.

Thromboembolic complications of sling surgery for stress urinary incontinence among female Medicare beneficiaries

OBJECTIVES

To determine the rate of thromboembolic complications after sling surgery for stress urinary incontinence among female Medicare beneficiaries aged 65 and older.

METHODS

We analyzed the 1999-2001 Medicare public use files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries. Women undergoing sling procedures from January 1, 1999 to July 31, 2000 were identified by the Physicians Current Procedural Terminology Coding System (4th edition) codes and tracked for 12 months. Diagnoses of postoperative thromboembolism were identified with International Classification of Diseases (9th revision) codes. Multivariate analysis was used to determine independent risk factors for developing a thromboembolic event.

RESULTS

A total of 1356 slings were performed on patients in the 5% sample of female Medicare beneficiaries during the 18-month index period. Concomitant prolapse surgery was performed in 467 (34.4%) cases. At 3 months after surgery, thromboembolic complications had occurred in 0.9% women undergoing a sling alone and in 2.2% women undergoing concomitant prolapse surgery (P = .05). Multivariate analysis revealed that concomitant prolapse surgery was associated with nearly 3 times the odds of thromboembolic complications (odds ratio 2.86, 95% confidence interval 1.10-7.45).

CONCLUSIONS

Our results show a low rate of thromboembolism after an isolated sling procedure. However, we found an increased rate of deep venous thrombosis and pulmonary embolism among women undergoing sling surgery with prolapse repair, which emphasizes the need for appropriate deep venous thrombosis prophylaxis in this patient group.

The critical limitations of volume-outcome analysis

There is a justified assumption that the patient outcome is in large part determined by the quality of the care they receive. For certain procedures outside of the field of urology, it has been demonstrated that higher surgical volume, either at the hospital or surgeon level is a proxy for higher quality of care. Multiple studies have followed this line of inquiry and attempted to show that volume may also predict outcome for certain urologic procedures. Review of the published studies shows that the association appears quite weak. However, the real weakness of this line of study is not so much in the findings, but in the universally used and critically flawed study methodology. This article demonstrates how a simple study design flaw has proved to be the Achilles heal of this entire line of research.

Bladder neck contracture after retropubic radical prostatectomy: incidence and risk factors from a large single-surgeon experience

OBJECTIVE

To examine a large, single-surgeon series of patients with prostate cancer who underwent retropubic radical prostatectomy (RRP) for men with postoperative bladder neck contractures (BNCs).

PATIENTS AND METHODS

From 1983 to 2007, 4132 men underwent RRP for prostate cancer by one surgeon. All patients had BN reconstruction with mucosal eversion. The bladder to membranous urethral anastomosis was made using six 2/0 chromic catgut sutures over an 18 F Foley catheter. The catheter was left in place for 10 days. Data from these men is stored in a prospective database, which was reviewed in this study for men with BNCs after RRP. Men with BNCs were compared with all other men in the series to determine risk factors for BNC development.

RESULTS

Overall, BNCs developed in 110 patients (2.5%). Examining our last 500 patients there was a contemporary BNC rate of <1%. The median (range) follow-up was 44 (12-233) months. Tumour characteristics were similar in the men with BNCs and those with no BNCs, and the rates of organ-confined disease were also similar (65% vs 70%, P = 0.27). Men with BNCs had higher median preoperative prostate-specific antigen (PSA) levels (6.7 vs 5.7 mg/dL; P = 0.009) and were more likely to have PSA failure after RRP (30% vs 16%, P < 0.001). On multivariate analysis, non-nerve sparing (P = 0.003) and a surgical date before 1992 (P < 0.001) were significant predictors of BNC. Patients with BNCs had lower potency rates (49% vs 63%, P < 0.003) and continence rates (88% vs 94%, P = 0.07) at the 18-month follow-up.

CONCLUSIONS

BNCs are rare, occurring in <1% in our modern series. The important surgical factors in preventing BNCs are to avoid closing the BN too tightly and attaining good apposition of the BN with the urethral stump with a watertight closure. BNCs are more common with non-nerve-sparing surgery and early in a surgeon's experience.

Radical prostatectomy: Hospital volumes and surgical volumes - does practice make perfect?

Background

Between the years 1993 and 2003, more than 140,000 men underwent radical prostatectomy (RP), thus making RP one of the most common treatment options for localized prostate cancer in the United States.

Discussion

Localized prostate cancer treated by RP is one of the more challenging procedures performed by urologic surgeons. Studies suggest a definite learning curve in performing this procedure with optimal results noted after performing >500 RPs. But is surgical volume everything? How do hospital volumes of RP weigh in? Could fellowship training in RP reduce the critical volume needed to reach an 'experienced' level?

Summary

As we continue to glean data as to how to optimize outcomes after RP, we must not only consider surgeon and hospital volumes of RP, but also consider training of the individual surgeon.

Bladder neck contracture after radical retropubic prostatectomy using an intussuscepted vesico-urethral anastomosis: incidence with long-term follow-up

OBJECTIVE

To evaluate the incidence of bladder neck contracture (BNC), a known complication of radical retropubic prostatectomy (RRP), after a 9-year experience by one surgeon using a novel approach to lower urinary tract reconstruction, the intussuscepted vesico-urethral anastomosis (IVUA).

PATIENTS AND METHODS

After institutional review board approval, the charts of 406 patients who had RRP for clinically localized prostate cancer from March 1998 to July 2007 were reviewed retrospectively. All patients had lower urinary tract reconstruction using the IVUA technique, which involves a looped urethral suture using six double-armed sutures that are drawn 'inside-to-out' from staggered points on the urethral stump through the bladder neck opening. When the sutures are tied down, the urethra is intussuscepted into the bladder neck opening.

RESULTS

At a median follow-up of 48 months, three patients developed BNC: one was at increased risk secondary to a previous TURP; one had his catheter removed on the second day after RRP in the presence of a suprapubic tube and developed a BNC at his 'dry' anastomosis; and one with no risk factors developed a BNC. Balloon dilatation, laser incision and self obturation were successful in stabilizing the strictures while preserving continence. Overall, the incidence of BNC in this series was three of 406 (0.74%).

CONCLUSIONS

IVUA gives a lower incidence of BNC over a long-term follow-up than rates cited in previous reports. IVUA is a valuable technique for lower urinary tract reconstruction in patients undergoing RRP.

Assessing the quality of the volume-outcome relationship in uro-oncology

OBJECTIVE

To assess systematically the quality of evidence for the volume-outcome relationship in uro-oncology, and thus facilitate the formulating of health policy within this speciality, as 'Implementation of Improving Outcome Guidance' has led to centralization of uro-oncology based on published studies that have supported a 'higher volume-better outcome' relationship, but improved awareness of methodological drawbacks in health service research has questioned the strength of this proposed volume-outcome relationship.

METHODS

We systematically searched previous relevant reports and extracted all articles from 1980 onwards assessing the volume-outcome relationship for cystectomy, prostatectomy and nephrectomy at the institution and/or surgeon level. Studies were assessed for their methodological quality using a previously validated rating system. Where possible, meta-analytical methods were used to calculate overall differences in outcome measures between low and high volume healthcare providers.

RESULTS

In all, 22 studies were included in the final analysis; 19 of these were published in the last 5 years. Only four studies appropriately explored the effect of both the institution and surgeon volume on outcome measures. Mortality and length of stay were the most frequently measured outcomes. The median total quality scores within each of the operation types were 8.5, 9 and 8 for cystectomy, prostatectomy and nephrectomy, respectively (possible maximum score 18). Random-effects modelling showed a higher risk of mortality in low-volume institutions than in higher-volume institutions for both cystectomy and nephrectomy (odds ratio 1.88, 95% confidence interval 1.54-2.29, and 1.28, 1.10-1.49, respectively).

CONCLUSION

The methodological quality of volume-outcome research as applied to cystectomy, prostatectomy and nephrectomy is only modest at best. Accepting several limitations, pooled analysis confirms a higher-volume, lower-mortality relationship for cystectomy and nephrectomy. Future research should focus on the development of a quality framework with a validated scoring system for the bench-marking of data to improve validity and facilitate rational policy-making within the speciality of uro-oncology.

Patterns of care for radical prostatectomy in the United States from 2003 to 2005

PURPOSE

The demand for minimally invasive radical prostatectomy is increasing, although population based outcomes remain unclear. We assessed use and outcomes in American men undergoing radical prostatectomy.

MATERIALS AND METHODS

We identified 14,727 men undergoing minimally invasive, perineal and retropubic radical prostatectomy during 2003 to 2005 using nationally representative, employer based administrative data. We assessed the association between surgical approach and outcomes, adjusting for age, race, comorbidity and geographic region.

RESULTS

Minimally invasive radical prostatectomy use increased from 5.4% to 24.4%, while conversion to open surgery decreased from 28.6% to 4.5% in the 3-year study. Men undergoing minimally invasive and perineal radical prostatectomy vs retropubic radical prostatectomy experienced fewer 30-day complications (14.2% and 14.9% vs 17.5%, p = 0.001), blood transfusions (2.2% and 3.6% vs 9.1%, p <0.001) and anastomotic strictures (6.8% and 8.5% vs 12.9%, p <0.001), and shorter median length of stay (1 and 2 days, respectively, vs 4, p <0.001). On adjusted analysis minimally invasive vs retropubic radical prostatectomy was associated with fewer 30-day complications (OR 0.78, 95% CI 0.66, 0.92), transfusions (OR 0.24, 95% CI 0.16, 0.34) and anastomotic strictures (OR 0.50, 95% CI 0.40, 0.62), and shorter length of stay (parameter estimate -0.53, 95% CI -0.58, -0.49). Similarly perineal vs retropubic radical prostatectomy was associated with fewer transfusions (OR 0.50, 95% CI 0.31, 0.82) and anastomotic strictures (OR 0.65, 95% CI 0.47, 0.90), and shorter length of stay (parameter estimate -0.53, 95% CI -0.42, -0.29).

CONCLUSIONS

While the use of minimally invasive radical prostatectomy surged, men undergoing minimally invasive vs perineal radical prostatectomy experienced a lower risk of 30-day complications, blood transfusions and anastomotic strictures, and a shorter length of stay. Furthermore, perineal vs retropubic radical prostatectomy was also associated with relatively favorable outcomes. Further study is needed to assess continence, potency and cancer control.

Adverse prognostic impact of capsular incision at radical prostatectomy for Japanese men with clinically localized prostate cancer

OBJECTIVES

The objective of this study was to evaluate the significance of capsular incision (CI) at radical prostatectomy (RP) for men with prostate cancer.

MATERIALS AND METHODS

This study included 267 men who underwent RP without neoadjuvant therapy and were pathologically diagnosed as having organ-confined disease. CI was defined as exposing benign or malignant glands at the inked margin without documented extraprostatic extension.

RESULTS

Pathological examinations identified CI in 53 RP specimens (19.9%), while CI was not detected in the remaining 214 specimens (80.1%). The locations of CIs in RP specimens from these 53 patients were as follows: 39 (73.6%) at the apex, 11 (20.0%) at the anterior site, 4 (7.5%) at the posterior site and 12 (22.6%) at the bladder neck. The incidence of CI was significantly affected by surgical procedure, preoperative serum PSA and microvenous invasion in RP specimen. During the observation period of this study, biochemical recurrence occurred in 10 (18.9%) of the 53 with CI and 20 (9.3%) of the 214 without CI, and the biochemical recurrence-free survival in patients with CI was significantly poorer than those without CI. Furthermore, of several factors examined, biochemical recurrence was significantly associated with preoperative serum PSA, Gleason score, perineural invasion and capsular incision, among which only preoperative serum PSA appeared to be an independent predictor of biochemical recurrence.

CONCLUSIONS

Despite the lack of independent significance, the presence of CI has an adverse impact on biochemical outcome in patients undergoing RP for clinically localized prostate cancer.

Radical prostatectomy: surgical planning, execution, and outcomes

Open radical prostatectomy has evolved in the past 25 years to become the standard of care for most clinically significant tumors localized to the prostate gland. This operation effectively interrupts the natural progression of prostate cancer, yet it is sensitive to nuances in surgical technique and execution that affect cancer control and perioperative and functional outcomes. In general, surgical technique improves with experience, yet involves a steep learning curve that typically requires a couple hundred cases to overcome. Moreover, there is significant variability in outcomes even among experienced surgeons. Surgeons beginning practice and those adopting new techniques, such as robotics, should measure results carefully, realizing that there may be an oncologic learning curve different from that needed to execute the procedure. This article recognizes the formidable challenges for randomized clinical trials (eg, assuring stratification among surgeons in terms of randomization and demonstrating the absence of significant heterogeneity among providers that may explain differences among arms). Research is needed to identify the most effective technical steps that can be taught through formal educational programs.

Health services research

The discipline of health services research, often loosely referred to as outcomes research, is primarily focused on the study of access to care, costs of care, and quality of care. Access to care includes everything that facilitates or impedes the actual use of medical services. Costs of care include financial and nonfinancial payments by insurers and individuals for medical services as well as the opportunity cost of lost wages and the societal cost of decreased productivity. Quality of care encompasses elements of the structure, process, and outcome of medical care.

Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go?

OBJECTIVE

To evaluate the association between provider characteristics and treatment location and racial/ethnic minority patients' knowledge of breast cancer treatment risks and benefits.

DATA SOURCES/DATA COLLECTION

Survey responses and clinical data from breast cancer patients of Detroit and Los Angeles SEER registries were merged with surgeon survey responses (N=1,132 patients, 277 surgeons).

STUDY DESIGN

Cross-sectional survey. Multivariable regression was used to identify associations between patient, surgeon, and treatment setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast conserving surgery with radiation.

PRINCIPAL FINDINGS

Half (51 percent) of respondents had survival knowledge, while close to half (47.6 percent) were uncertain regarding recurrence knowledge. Minority patients and those with lower education were less likely to have adequate survival knowledge and more likely to be uncertain regarding recurrence risk than their counterparts (p<.001). Neither surgeon characteristics nor treatment location attenuated racial/ethnic knowledge disparities. Patient-physician communication was significantly (p<.001) associated with both types of knowledge, but did not influence racial/ethnic differences in knowledge.

CONCLUSIONS

Interventions to improve patient understanding of the benefits and risks of breast cancer treatments are needed across surgeons and treatment setting, particularly for racial/ethnic minority women with breast cancer.

Association between hospital and surgeon radical prostatectomy volume and patient outcomes: a systematic review

PURPOSE

We examined the association between hospital and surgeon volume, and patient outcomes after radical prostatectomy.

MATERIALS AND METHODS

Databases were searched from 1980 to November 2007 to identify controlled studies published in English. Information on study design, hospital and surgeon annual radical prostatectomy volume, hospital status and patient outcome rates were abstracted using a standardized protocol. Data were pooled with random effects models.

RESULTS

A total of 17 original investigations reported patient outcomes in categories of hospital and/or surgeon annual number of radical prostatectomies, and met inclusion criteria. Hospitals with volumes above the mean (43 radical prostatectomies per year) had lower surgery related mortality (rate of difference 0.62, 95% CI 0.47-0.81) and morbidity (rate difference -9.7%, 95% CI -15.8, -3.6). Teaching hospitals had an 18% (95% CI -26, -9) lower rate of surgery related complications. Surgeon volume was not significantly associated with surgery related mortality or positive surgical margins. However, the rate of late urinary complications was 2.4% lower (95% CI -5, -0.1) and the rate of long-term incontinence was 1.2% lower (95% CI -2.5, -0.1) for each 10 additional radical prostatectomies performed by the surgeon annually. Length of stay was lower, corresponding to surgeon volume.

CONCLUSIONS

Higher provider volumes are associated with better outcomes after radical prostatectomy. Greater understanding of factors leading to this volume-outcome relationship, and the potential benefits and harms of increased regionalization is needed.

The effect of concomitant prolapse repair on sling outcomes

PURPOSE

We analyzed the effect of concomitant prolapse surgery performed at the time of sling surgery on short-term postoperative outcomes in women with urinary incontinence.

MATERIALS AND METHODS

We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of female beneficiaries who underwent sling procedures. Subjects were tracked for 12 months after surgery to assess short-term complications. Concomitant prolapse repairs and prolapse repairs performed in the first 12 months after sling surgery were identified by CPT-4 procedure codes. Postoperative complications and treatments were identified by ICD-9 diagnosis codes and CPT-4 procedure codes, respectively. Bivariate and multivariate analyses were performed to measure the effect of concomitant prolapse surgery on sling outcomes.

RESULTS

Concomitant prolapse repairs were performed in 34.4% of sling cases. Women who underwent prolapse repair at the time of the sling surgery were significantly more likely to be diagnosed with postoperative outlet obstruction (9.4% vs 5.5%, p <0.007) than those who did not. Women who underwent concomitant prolapse repair were less likely to undergo a repeat procedure for stress incontinence in postoperative year 1 (4.7% vs 10.2%, p = 0.0005). Multivariate analysis revealed that women who underwent prolapse repair at the time of the sling surgery were significantly less likely to undergo a reoperation for prolapse within 1 year after the sling surgery (OR 0.31, 95% CI 0.22-0.44).

CONCLUSIONS

Our findings suggest that addressing prolapse at the time of stress incontinence surgery may avoid an early repeat operation for either prolapse or stress incontinence. However, rates of postoperative outlet obstruction are higher.

Utilization and outcomes of minimally invasive radical prostatectomy

PURPOSE

Demand for minimally invasive radical prostatectomy (MIRP) to treat prostate cancer is increasing; however, outcomes remain unclear. We assessed utilization, complications, lengths of stay, and salvage therapy rates for MIRP versus open radical prostatectomy assessed whether MIRP surgeon volume is associated with better outcomes.

METHODS

We identified 2,702 men undergoing MIRP and open radical prostatectomy during 2003 to 2005 from a national 5% sample of Medicare beneficiaries. We assessed the association between surgical approach and outcomes, adjusting for surgeon volume, age, race, comorbidity, and geographic region.

RESULTS

MIRP utilization increased from 12.2% in 2003 to 31.4% in 2005. Men undergoing MIRP versus open radical prostatectomy had fewer perioperative complications (29.8% v 36.4%; P = .002) and shorter lengths of stay (1.4 v 4.4 days; P < .001); however, they were more likely to receive salvage therapy (27.8% v 9.1%, P < .001). In adjusted analyses, MIRP versus open radical prostatectomy was associated with fewer perioperative complications (odds ratio [OR], 0.73; 95% CI, 0.60 to 0.90), shorter lengths of stay (parameter estimate, -2.99; 95% CI, -3.45 to -2.53) but more anastomotic strictures (OR, 1.40; 95% CI, 1.04 to 1.87) and higher rates of salvage therapy (OR, 3.67; 95% CI, 2.81 to 4.81). Patients of high-volume MIRP experienced fewer anastomotic strictures (OR, 0.93; 95% CI, 0.87 to 0.99) and less salvage therapy (OR, 0.92; 95% CI, 0.88 to 0.98).

CONCLUSION

Men undergoing MIRP versus open radical prostatectomy have lower risk for perioperative complications and shorter lengths of stay, but are at higher risk for salvage therapy and anastomotic strictures. However, risk for these unfavorable outcomes decreases with increasing MIRP surgical volume.

High surgical volume is associated with a lower rate of secondary therapy after radical prostatectomy for localized prostate cancer

OBJECTIVE

To assess the relationship between surgical volume (SV), defined as the number of radical prostatectomies (RPs) within a calendar year, and the time to secondary therapy (ST) after RP, as this might represent an important determinant of cancer control.

PATIENTS AND METHODS

The study included 7937 men treated with RP by 130 urologists between 1989 and 2000. Radiotherapy or any form of hormonal manipulation represented ST. Univariable and multivariable Cox regression analyses was used to evaluate the time to ST after RP.

RESULTS

SV was an independent (P = 0.02) predictor of ST-free survival after RP, and the multivariable rate of ST sharply decreased with increasing SV.

CONCLUSIONS

The use of ST is inversely proportional to SV of up to 24 RPs per year. A higher annual SV might be indicative of less restrictive use of RP in high-risk patients who eventually require combined treatments.

Surgeon experience is strongly associated with biochemical recurrence after radical prostatectomy for all preoperative risk categories

PURPOSE

We have previously reported that there is a learning curve for open radical prostatectomy. In the current study we determined whether the effects of the learning curve are modified by patient risk, as defined by preoperative tumor characteristics.

MATERIALS AND METHODS

The study included 7,683 eligible patients with prostate cancer treated with open radical prostatectomy by 1 of 72 surgeons. Surgeon experience was coded as the total prior number of radical prostatectomies done by the surgeon before a patient surgery. Multivariate survival time regression models were used to evaluate the association between surgeon experience and biochemical recurrence separately in each preoperative risk group.

RESULTS

We saw no evidence that patient risk affected the learning curve. There was a statistically significant association between biochemical recurrence and surgeon experience on all analyses. The absolute risk difference in a patient receiving treatment from a surgeon with 10 vs 250 prior radical prostatectomies was 6.6% (95% CI 3.4-10.3), 12.0% (95% CI 6.9-18.2) and 9.7% (95% CI 1.2-18.2) in patients at low, medium and high preoperative risk. Recurrence-free probability in patients with low risk disease approached 100% for the most experienced surgeons.

CONCLUSIONS

Cancer control after radical prostatectomy improves with increasing surgeon experience irrespective of patient risk. Excellent rates of cancer control in patients with low risk disease treated by the most experienced surgeons suggest that the primary reason that recurrence develops in such patients is inadequate surgical technique. The results have significant implications for clinical care.

The effect of age on outcomes of sling surgery for urinary incontinence

OBJECTIVES

To measure the effect of patient age on outcomes of sling surgery for stress urinary incontinence.

DESIGN

Analysis of Medicare claims data.

SETTING

Analysis of the 1999 to 2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries.

PARTICIPANTS

Women who underwent sling procedures between July 1, 1999, and December 31, 2000, were identified according to Common Procedural Terminology, Fourth Edition, code 57288 (sling operation for stress incontinence). Subjects were tracked for 6 months before surgery to identify preoperative comorbidities and for 12 months after surgery to assess short-term complications. Subjects were stratified for analysis at age 75.

MEASUREMENTS

Bivariate analyses were conducted with patients stratified at age 75, and multivariate analyses were also conducted to identify the independent effects of patient age and comorbidities on outcomes.

RESULTS

A total of 1,356 procedures were performed during the 18-month index period. This extrapolates to 27,120 procedures in all Medicare beneficiaries. At 1 year after surgery, overall outcomes in younger women (aged 65-74) were significantly better than in older women with respect to postoperative urge incontinence (20.0% vs 12.6%), treatment failure (10.5% vs 7.2%), and outlet obstruction (10.5% vs 6.6%). Older age and greater comorbidity were associated with greater risk of nonurological events (e.g., pulmonary embolism and cardiac events).

CONCLUSION

Women aged 75 and older are more likely to experience postoperative urge incontinence, treatment failure, and outlet obstruction after sling surgery. Older age and comorbidities were associated with higher rates of nonurological complications.

Effects of pathologic stage on the learning curve for radical prostatectomy: evidence that recurrence in organ-confined cancer is largely related to inadequate surgical technique

OBJECTIVES

We previously demonstrated that there is a learning curve for open radical prostatectomy. We sought to determine whether the effects of the learning curve are modified by pathologic stage.

METHODS

The study included 7765 eligible prostate cancer patients treated with open radical prostatectomy by one of 72 surgeons. Surgeon experience was coded as the total number of radical prostatectomies conducted by the surgeon prior to a patient's surgery. Multivariable regression models of survival time were used to evaluate the association between surgeon experience and biochemical recurrence, with adjustment for PSA, stage, and grade. Analyses were conducted separately for patients with organ-confined and locally advanced disease.

RESULTS

Five-year recurrence-free probability for patients with organ-confined disease approached 100% for the most experienced surgeons. Conversely, the learning curve for patients with locally advanced disease reached a plateau at approximately 70%, suggesting that about a third of these patients cannot be cured by surgery alone.

CONCLUSIONS

Excellent rates of cancer control for patients with organ-confined disease treated by the most experienced surgeons suggest that the primary reason such patients recur is inadequate surgical technique.

Understanding differences between high and low volume hospitals for radical prostatectomy

OBJECTIVES

We evaluated the impact of the specialized medical and ancillary services available at low vs. high volume prostatectomy centers on prolonged length of stay (LOS) outcomes after radical prostatectomy.

METHODS

Using the Nationwide Inpatient Sample, we identified patients who underwent prostatectomy (n = 9,266) for prostate cancer in 2003 using ICD-9 codes. Hospital characteristics were ascertained using the American Hospital Association file. Differences in health services availability according to hospital prostatectomy volume were estimated using logistic regression. Logistic models were fitted to measure the effect of available health services on a prolonged LOS (>90 percentile for sample was 5 days).

RESULTS

Among patients undergoing radical prostatectomy in 2003, 19.0% and 5.4% of patients had a prolonged LOS at low and high volume hospitals, respectively (unadjusted OR 4.2, 95% CI 2.5-6.9). After adjusting for differences in patients and availability of select health services, those treated at low volume centers were 3.3 times more likely to have a prolonged hospitalization compared with those treated at high volume hospitals (95% CI 1.9-5.6). Adjusting for hospital differences attenuated the volume effect by 14.8%.

CONCLUSIONS

There are substantial differences in the health care environment according to radical prostatectomy volume. Generally, high volume hospitals offer a much wider array of health care services specific to both post-prostatectomy and general medical care.