A systematic review of the volume-outcome relationship for radical prostatectomy

Hospital volume-outcome relationships for robot-assisted surgeries: a population-based analysis

BACKGROUND

Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data are limited regarding which hospitals should be using the technology.

STUDY DESIGN

Using administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital.

RESULTS

A total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval [CI] - 23 to - 10), 8-min decrease for RAPN (95% CI - 14 to - 2), 24-min decrease for RPL-4 (95% CI - 29 to - 19), and no significant change for TRH (- 7 min; 95% CI - 17 to 3).

CONCLUSION

The risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications.

The Soleymani and Collins Obstetric morbidity score (SaCOMS): A quantitative tool for measuring maternal morbidity from complex obstetric surgery such as placenta accreta spectrum (PAS)

It is currently very difficult to compare different management strategies for complex obstetric surgery, such as hysterectomy for severe Placenta Accreta Spectrum (PAS), as there is no widely accepted consensus for the classification of maternal surgical morbidity. Many studies focus on the amount of blood products transfused or admission to intensive care units (ICU). However, these are dependent on local policies and available resources. It also gives an incomplete representation of the entire 'patient journey' after they leave the operating room. Subsequent repeat procedures for lower urinary track damage is arguably worse from the woman's perspective than a short stay on an intensive care unit (ICU) for observation. We suggest a version of the Clavien-Dindo morbidity classification specific to obstetrics. Then employ it to build a quantitative morbidity score which aims to reflect the whole 'patient experience' including the post-operative pathway. We then demonstrate the utility of this system in a cohort of women with Placenta Accreta Spectrum (PAS). The Clavien-Dindo classification was modified to reflect obstetric procedures and a quantitative morbidity measure, the Soleymani and Collins Obstetric Morbidity Score (SaCOMS), was developed based on this. Both were then validated using a survey-based consultation of a panel of experts in PAS and retrospectively applied to a cohort of 54 women who underwent caesarean hysterectomy for PAS. Clinicians with expertise in PAS believe that the Modified Obstetric Clavien-Dindo classification system and the novel SaCOMS tool can improve assessment of maternal morbidity, and better reflect the 'patient experience'. Application of the classification system to a single-centre PAS cohort suggested that surgery by gynecologic-oncology surgeons may be associated with decreased incidence and cumulative morbidity outcomes for women with PAS, especially those with the most severe presentation. This study presents a clinically useful obstetric-specific classification system for surgical morbidity. SaCOMS also provides a quantitative reflection of the full patient- journey experienced as a result of surgical complications enabling a more patient-centered representation of morbidity.

Individualized center-based analysis of urinary and sexual functional outcome after radical prostatectomy based on the prostate cancer outcome study: a post hoc pathway to patient outcome measurement analysis for quality improvement

PURPOSE

We evaluate differences of patient-reported outcome measurements (PROM) based urinary continence and sexual function 12 months after radical prostatectomy (RPE) based on perioperative, surgical, and patient-specific characteristics in a large European academic urology center.

MATERIALS AND METHODS

All men enrolled in the Prostate Cancer Outcome Study (PCO) study who were treated with RPE between 2017 and 2021 completed EPIC-26 information surveys before and 12 months after RPE. Survey data were linked to clinical data of our institution. Logistic regression analyses were performed to examine the correlation between individual surgeons, patient characteristics, patient clinical data, and their urinary continence and sexual function.

RESULTS

In total, data of 429 men were analyzed: unstratified mean (SD) EPIC-26 domain score for urinary function decreased from 93.3 (0.7) to 60.4 (1.5) one year after RPE, respectively for sexual function from 64.95 (1.6) to 23.24 (1.1). Patients with preoperative adequate urinary function (EPIC-26 score > 80) reported significantly different mean urinary function scores between 53.35 (28.88) and 66.25 (25.15), p= 0.001, stratified by surgeons experience. On binary logistic regression analyses, only nerve sparing techniques (OR: 1,83, 95% CI: 1.01;3.21; p = 0.045) and low body mass index (OR: 0.91, CI: 0.85;0.99, p= 0.032) predicted adequate postoperative urinary function.

CONCLUSIONS

The results show how using provider-specific data from a larger cohort study enables to develop institution-specific analysis for functional outcomes after RPE. These models can be used for internal quality improvement as well as enhanced and provider-specific patient communication and shared decision making.

Prevention of complications in endourological management of stones: What are the basic measures needed before, during, and after interventions?

Objective

This narrative review aims to describe measures to minimise the risk of complications during percutaneous nephrolithotomy (PCNL), ureteroscopy, and retrograde intrarenal surgery.

Methods

A literature search was conducted from the PubMed/PMC database for papers published within the last 10 years (January 2012 to December 2022). Search terms included "ureteroscopy", "retrograde intrarenal surgery", "PCNL", "percutaneous nephrolithotomy", "complications", "sepsis", "infection", "bleed", "haemorrhage", and "hemorrhage". Key papers were identified and included meta-analyses, systematic reviews, guidelines, and primary research. The references of these papers were searched to identify any further relevant papers not included above.

Results

The evidence is assimilated with the opinions of the authors to provide recommendations. Best practice pathways for patient care in the pre-operative, intra-operative, and post-operative periods are described, including the identification and management of residual stones. Key complications (sepsis and stent issues) that are relevant for any endourological procedure are then be discussed. Operation-specific considerations are then explored. Key measures for PCNL include optimising access to minimise the chance of bleeding or visceral injury. The role of endoscopic combined intrarenal surgery in this regard is discussed. Key measures for ureteroscopy and retrograde intrarenal surgery include planning and technique to minimise the risk of ureteric injury. The role of anaesthetic assessment is discussed. The importance of specific comorbidities on each step of the pathway is highlighted as examples.

Conclusion

This review demonstrates that the principles of meticulous planning, interdisciplinary teamworking, and good operative technique can minimise the risk of complications in endourology.

Outcomes for Arthroplasties in Military Health: A Retrospective Analysis of Direct Versus Purchased Care

INTRODUCTION

The Department of Defense is reforming the military health system where surgeries are increasingly referred from military treatment facilities (MTFs) with direct care to higher-volume civilian hospitals under purchased care. This shift may have implications on the quality and cost of care for TRICARE beneficiaries. This study examined the impact of care source and surgical volume on perioperative outcomes and cost of total hip arthroplasties (THAs) and total knee arthroplasties (TKAs).

MATERIALS AND METHODS

We examined TRICARE claims for patients who underwent THA or TKA between 2006 and 2019. The 30-day readmissions, complications, and costs between direct and purchased care were evaluated using the logistic regression model for surgical outcomes and generalized linear models for cost.

RESULTS

We included 71,785 TKA and THA procedures. 11,013 (15.3%) were performed in direct care. They had higher odds of readmissions (odds ratio, OR 1.29 [95% CI, 1.12-1.50]; P < 0.001) but fewer complications (OR 0.83 [95% CI, 0.75-0.93]; P = 0.002). Within direct care, lower-volume facilities had more complications (OR 1.27 [95% CI, 1.01-1.61]; P = 0.05). Costs for index surgeries were significantly higher at MTFs $26,022 (95% CI, $23,393-$28,948) vs. $20,207 ($19,339-$21,113). Simulating transfer of care to very high-volume MTFs, estimated cost savings were $4,370/patient and $20,229,819 (95% CI, $17,406,971-$25,713,571) in total.

CONCLUSIONS

This study found that MTFs are associated with lower odds of complications, higher odds of readmission, and higher costs for THA and TKA compared to purchased care facilities. These findings mean that care in the direct setting is adequate and consolidating care at higher-volume MTFs may reduce health care costs.

Clinical outcomes for men with positive surgical margins after radical prostatectomy-results from the South Australian Prostate Cancer Clinical Outcomes Collaborative community-based registry

Objective

Positive surgical margins (PSMs) after radical prostatectomy (RP) indicate failure of surgery to completely clear cancer. PSMs confer an increased risk of biochemical recurrence (BCR), but how more robust outcomes are affected is unclear. This study investigated factors associated with PSMs following RP and determined their impact on clinical outcomes (BCR, second treatment [radiotherapy and/or androgen deprivation therapy], and prostate cancer-specific mortality [PCSM]).

Methods

The study cohort included men diagnosed with prostate cancer (pT2-3b/N0/M0) between January 1998 and June 2016 who underwent RP from the South Australian Prostate Cancer Clinical Outcomes Collaborative database. Factors associated with risk of PSMs were identified using Poisson regression. The impact of PSMs on clinical outcomes (BCR, second treatment, and PCSM) was assessed using competing risk regression.

Results

Of the 2827 eligible participants, 28% had PSMs-10% apical, 6% bladder neck, 17% posterolateral, and 5% at multiple locations. Median follow-up was 9.6 years with 81 deaths from prostate cancer recorded. Likelihood of PSM increased with higher pathological grade and pathological tumor stage, and greater tumour volume, but decreased with increasing surgeon volume (odds ratio [OR]: 0.93; 95% confidence interval [CI]: 0.88-0.98, per 100 previous prostatectomies). PSMs were associated with increased risk of BCR (adjusted sub-distribution hazard ratio [sHR] 2.5; 95% CI 2.1-3.1) and second treatment (sHR 2.9; 95% CI 2.4-3.5). Risk of BCR was increased similarly for each PSM location, but was higher for multiple margin sites. We found no association between PSMs and PCSM.

Conclusion

Our findings support previous research suggesting that PSMs are not independently associated with PCSM despite strong association with BCR. Reducing PSM rates remains an important objective, given the higher likelihood of secondary treatment with associated comorbidities.

Robot-Assisted Laparoscopic Prostatectomy Experience and Pathological Quality: Are They Always Linked?

Objective: We investigated whether pathological outcomes improved with experience and surgeon generation after robot-assisted laparoscopic prostatectomy (RALP). Materials and Methods: The study included 1338 patients who underwent RALP between February 2010 and April 2020. We created learning curves for pelvic lymph node dissection (PLND), number of lymph nodes (LNs) removed, and positive surgical margin (PSM) after adjustment for confounders. We compared the outcomes between the first and second generation of surgeons in regression models. Results: The learning curve regarding PLND indications showed a significant increase with experience for the first generation, whereas the second generation had a learning curve that remained flat at a higher level (92.3%) and significantly better than the first generation (p < 0.001). Similarly, the number of LN removed showed a significant increase with experience in both generations, but the overall median number of LN removed was significantly higher in the second generation compared with the first generation (12 vs 10, p < 0.001). However, the learning curve for PSM remained flat at ∼20% after adjustment and did not show improvement with experience in both generations of surgeons (p = 0.794). Conclusions: Surgeons showed improvement with experience and education with RALP with respect to the indications for PLND and number of LNs removed. However, there was no improvement over time and generations for PSM. Experience based solely on the number of patients operated on is not an intrinsic factor in the pathological quality of RALP. Factors other than experience may also play a role in oncologic improvement.

Technical surgical skill assessment of neurovascular bundle dissection and urinary continence recovery after robotic-assisted radical prostatectomy

Purpose

To examine the association between the quality of neurovascular bundle dissection and urinary continence recovery after robotic-assisted radical prostatectomy.

Materials and Methods

Patients who underwent RARPs from 2016 to 2018 in two institutions with ≥1-year postoperative follow-up were included. The primary outcomes were time to urinary continence recovery. Surgical videos were independently assessed by 3 blinded raters using the validated Dissection Assessment for Robotic Technique (DART) tool after standardized training. Cox regression was used to test the association between DART scores and urinary continence recovery while adjusting for relevant patient features.

Results

121 RARP performed by 23 surgeons with various experience levels were included. The median follow-up was 24 months (95% CI 20 - 28 months). The median time to continence recovery was 7.3 months (95% CI 4.7 - 9.8 months). After adjusting for patient age, higher scores of certain DART domains, specifically tissue retraction and efficiency, were significantly associated with increased odds of continence recovery (p<0.05).

Conclusions

Technical skill scores of neurovascular bundle dissection vary among surgeons and correlate with urinary continence recovery. Unveiling the specific robotic dissection skillsets which impact patient outcomes has the potential to focus surgical training.

How to create value with constrained budgets in oncological care? A narrative review

INTRODUCTION

As a result of an increasing focus on patient-centered care within oncology and more pressure on the sustainability of health-care systems, the discussion on what exactly constitutes value re-appears. Policymakers seek to improve patient values; however, funding all values is not sustainable.

AREAS COVERED

We collect available evidence from scientific literature and reflect on the concept of value, the possible incorporation of a wide spectrum of values in reimbursement decisions, and alternative strategies to increase value in oncological care.

EXPERT OPINION

We state that value holds many different aspects. For reimbursement decisions, we argue that it is simply not feasible to incorporate all patient values because of the need for efficient resource allocation. We argue that we should shift the value debate from the individual perspective of patients to creating value for the cancer population at large. The different strategies we address are as follows: (1) shared decision-making; (2) biomarkers and molecular diagnostics; (3) appropriate evaluation, payment and use of drugs; (4) supportive care; (5) cancer prevention and screening; (6) monitoring late effect; (7) concentration of care and oncological networking; and (8) management of comorbidities. Important preconditions to support these strategies are strategic planning, consistent cancer policies and data availability.

Racial inequities in the quality of surgical care among Medicare beneficiaries with localized prostate cancer

BACKGROUND

US Black men are twice as likely to die from prostate cancer as men of other races. Lower quality care may contribute to this higher death rate.

METHODS

Sociodemographic and clinical data were obtained for men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with clinically localized prostate cancer (cT1-4N0/xM0/x) and managed primarily by radical prostatectomy (2005-2015). Surgical volume was determined for facility and surgeon. Relationships between race, surgeon and/or facility volume, and characteristics of treating facility with survival (all-cause and cancer-specific) were assessed using multivariable Cox regression and competing risk analysis.

RESULTS

Black men represented 6.7% (n = 2123) of 31,478 cohort. They were younger at diagnosis, had longer time from diagnosis to surgery, lower socioeconomic status, higher prostate-specific antigen (PSA), and higher comorbid status compared with men of other races (p < .001). They were less likely to receive care from a surgeon or facility in the top volume percentile (p < .001); less likely to receive surgical care at a National Cancer Institute-designated cancer center and more likely seen at a minority-serving hospital; and less likely to travel ≥50 miles for surgical care. On multivariable analysis stratified by surgical volume, Black men receiving care from a surgeon or facility with lower volumes demonstrated increased risk of prostate cancer mortality (hazard ratio, 1.61; 95% confidence interval, 1.01-2.69) adjusting for age, clinical stage, PSA, and comorbidity index.

CONCLUSIONS

Black Medicare beneficiaries with prostate cancer more commonly receive care from surgeons and facilities with lower volumes, likely affecting surgical quality and outcomes. Access to high-quality prostate cancer care may reduce racial inequities in disease outcomes, even among insured men.

PLAIN LANGUAGE SUMMARY

Black men are twice as likely to die of prostate cancer than other US men. Lower quality care may contribute to higher rates of prostate cancer death. We used surgical volume to evaluate the relationship between race and quality of care. Black Medicare beneficiaries with prostate cancer more commonly received care from surgeons and facilities with lower volumes, correlating with a higher risk of prostate cancer death and indicating scarce resources for care. Access to high-quality prostate cancer care eases disparities in disease outcomes. Patient-centered interventions that increase access to high-quality care for Black men with prostate cancer are needed.

Effect of Surgeon and Facility Volume on Outcomes of Benign Prostatic Hyperplasia Surgery: Implications of Disparities in Access to Care at High-Volume Centers

OBJECTIVE

To report the effect of surgeon and facility volume on outcomes of transurethral resection of the prostate (TURP) and laser treatment of benign prostatic hyperplasia (BPH). We also investigate disparities in access to care by identifying demographic predictors of receipt of treatment at high-volume facilities.

METHODS

We used New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) data. We included 18,041 (41.4%) and 25,577 (58.6%) adult patients that underwent TURP and laser procedures in the outpatient setting between January 2005 and December 2018, respectively. Average annual surgeon and facility volumes were broken down by tertile. The effect of volume on short-term outcomes (30-day and 90-day readmission) was examined using mixed-effect logistic regression models. Cox-proportional-hazard models were used to assess the association between volume and long-term stricture development and reoperation. Demographic predictors of treatment at high-volume facilities were assessed using multinomial logistic regression.

RESULTS

High-volume facilities were more likely to offer laser procedures compared to low-volume facilities. Higher facility and surgeon volume were associated with lower odds of 30 and 90-day readmissions compared to low-volume facilities. There was no difference in reoperation and stricture development between surgeon volume groups. Medicaid insurance, Hispanic ethnicity, and Black race were inversely associated with treatment at high-volume facilities.

CONCLUSION

Higher surgeon and facility volumes were associated with lower odds of readmission. Higher facility volume was associated with lower hazards of reoperation and developing strictures. Medicaid insurance and non-white race were associated with lower odds of treatment at high-volume facilities, highlighting racial and socioeconomic disparities in access to high-volume BPH surgery facilities.

Association of hospital volume with perioperative and oncological outcomes of robot-assisted laparoscopic radical prostatectomy: a retrospective multicenter cohort study

BACKGROUND

This retrospective multicenter cohort study investigated the association of hospital volume with perioperative and oncological outcomes in patients treated with robot-assisted radical prostatectomy (RARP).

METHODS

We collected the clinical data of patients who underwent RARP at eight institutions in Japan between September 2012 and August 2021. The patients were divided into two groups based on the treatment site-high- and non-high-volume hospitals. We defined a high-volume hospital as one where RARP was performed for more than 100 cases per year.

RESULTS

After excluding patients who received neoadjuvant therapy, a total of 2753 patients were included in this study. In the high-volume hospital group, console time and estimated blood loss were significantly (p < 0.001) lower than that of the non-high-volume hospital group. However, the continence rate at 3 months after RARP, positive surgical margins, and prostate-specific antigen (PSA)-relapse-free survival showed no significant differences between the two groups. Furthermore, the console time was significantly shorter after 100 cases in the non-high-volume hospital group but not in the high-volume hospital group.

CONCLUSIONS

A higher hospital volume was significantly associated with shorter console time and less estimated blood loss. However, oncological outcomes and early continence recovery appear to be comparable regardless of the hospital volume in Japan.

Association between Surgical Technical Skills and Clinical Outcomes: A Systematic Literature Review and Meta-Analysis

Background

A systematic literature review and meta-analysis was conducted to assess the association between intraoperative surgical skill and clinical outcomes.

Methods

Peer-reviewed, original research articles published through August 31, 2021 were identified from PubMed and Embase. From the 1,513 potential articles, seven met eligibility requirements, reporting on 151 surgeons and 17,932 procedures. All included retrospective assessment of operative videos. Associations between surgical skill and outcomes were assessed by pooling odds ratios (OR) using random-effects models with the inverse variance method. Eligible studies included pancreaticoduodenectomy, gastric bypass, laparoscopic gastrectomy, prostatectomy, colorectal, and hemicolectomy procedures.

Results

Meta-analytic pooling identified significant associations between the highest vs. lowest quartile of surgical skill and reoperation (OR: 0.44; 95% confidence interval [CI]: 0.23, 0.83), hemorrhage (OR: 0.66; 95% CI, 0.65, 0.68), obstruction (OR: 0.33; 95% CI, 0.30, 0.35), and any medical complication (OR: 0.23, 95% CI, 0.19, 0.27). Nonsignificant inverse associations were noted between skill and readmission, emergency department visit, mortality, leak, infection, venous thromboembolism, and cardiac and pulmonary complications.

Conclusions

Overall, surgeon technical skill appears to predict clinical outcomes. However, there are surprisingly few articles that evaluate this association. The authors recommend a thoughtful approach for the development of a comprehensive surgical quality infrastructure that could significantly reduce the challenges identified by this study.

Impact of centralization of prostate cancer services on the choice of radical treatment

OBJECTIVE

To assess the impact of centralization of prostate cancer surgery and radiotherapy services on the choice of prostate cancer treatment.

PATIENTS AND METHODS

This national population-based study used linked cancer registry data and administrative hospital-level data for all 16 621 patients who were diagnosed between 1 January 2017 and 31 December 2018 with intermediate-risk prostate cancer and who underwent radical prostatectomy (RP) or radical radiation therapy (RT) in the English National Health Service (NHS). Travel times by car to treating centres were estimated using a geographic information system. We used logistic regression to assess the impact of the relative proximity of alternative treatment options on the type of treatment received, with adjustment for patient characteristics.

RESULTS

Of the 78 NHS hospitals that provide RT or RP for prostate cancer, 41% provide both, 36% provide RT and 23% provide RP. Compared to patients who had both treatment options available at their nearest centre where overall 57% of patients received RT and 43% RP, patients were less likely to receive RT if their nearest centre offered RP only and the extra travel time to a hospital providing RT was >15 min (52% of patients received RT and 48% RP%, odds ratio [OR] 0.70 (0.58-0.85); P < 0.001). Conversely, patients were more likely to receive RT if their nearest centre offered RT and the extra travel time to a hospital providing RP was >15 min (63% of patients received RT and 37% RP, OR 1.23 (1.08-1.40); P < 0.001). There was a negligible impact on the type of treatment received if centres providing alternative treatment options were ≤15-min travel time from each other.

CONCLUSION

The relative proximity of prostate cancer treatment options to a patient's residence is an independent predictor for the type of radical treatment received. Centralization policies for prostate cancer should not focus on one treatment modality but should consider all treatments to avoid a negative impact on treatment choice.

Systematic literature review of cost-effectiveness analyses of robotic-assisted radical prostatectomy for localised prostate cancer

OBJECTIVES

Review and assess cost-effectiveness studies of robotic-assisted radical prostatectomy (RARP) for localised prostate cancer compared with open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP).

DESIGN

Systematic review.

SETTING

PubMed, Embase, Scopus, International HTA database, the Centre for Reviews and Dissemination database and various HTA websites were searched (January 2005 to March 2021) to identify the eligible cost-effectiveness studies.

PARTICIPANTS

Cost-effectiveness, cost-utility, or cost-minimization analyses examining RARP versus ORP or LRP were included in this systematic review.

INTERVENTIONS

Different surgical approaches to treat localized prostate cancer: RARP compared with ORP and LRP.

PRIMARY AND SECONDARY OUTCOME MEASURES

A structured narrative synthesis was developed to summarize results of cost, effectiveness, and cost-effectiveness results (eg, incremental cost-effectiveness ratio [ICER]). Study quality was assessed using the Consensus on Health Economic Criteria Extended checklist. Application of medical device features were evaluated.

RESULTS

Twelve studies met inclusion criteria, 11 of which were cost-utility analyses. Higher quality-adjusted life-years and higher costs were observed with RARP compared with ORP or LRP in 11 studies (91%). Among four studies comparing RARP with LRP, three reported RARP was dominant or cost-effective. Among ten studies comparing RARP with ORP, RARP was more cost-effective in five, not cost-effective in two, and inconclusive in three studies. Studies with longer time horizons tended to report favorable cost-effectiveness results for RARP. Nine studies (75%) were rated of moderate or good quality. Recommended medical device features were addressed to varying degrees within the literature as follows: capital investment included in most studies, dynamic pricing considered in about half, and learning curve and incremental innovation were poorly addressed.

CONCLUSIONS

Despite study heterogeneity, RARP was more costly and effective compared with ORP and LRP in most studies and likely to be more cost-effective, particularly over a multiple year or lifetime time horizon. Further cost-effectiveness analyses for RARP that more thoroughly consider medical device features and use an appropriate time horizon are needed.

PROSPERO REGISTRATION NUMBER

CRD42021246811.

Cost-effectiveness of Robotic-Assisted Radical Prostatectomy for Localized Prostate Cancer in the UK

IMPORTANCE

The cost-effectiveness of different surgical techniques for radical prostatectomy remains a subject of debate. Emergence of recent critical clinical data and changes in surgical equipment costs due to their shared use by different clinical specialties necessitate an updated cost-effectiveness analysis in a centralized, largely government-funded health care system such as the UK National Health Service (NHS).

OBJECTIVE

To compare robotic-assisted radical prostatectomy (RARP) with open radical prostatectomy (ORP) and laparoscopic-assisted radical prostatectomy (LRP) using contemporary data on clinical outcomes, costs, and surgical volumes in the UK.

DESIGN, SETTING, AND PARTICIPANTS

This economic analysis used a Markov model developed to compare the cost-effectiveness of RARP, LRP, and ORP to treat localized prostate cancer. The model was constructed from the perspective of the UK NHS. The model simulated 65-year-old men who underwent radical prostatectomy for localized prostate cancer and were followed up for a 10-year period. Data were analyzed from May 1, 2020, to July 31, 2021.

EXPOSURES

Robotic-assisted radical prostatectomy, LRP, and ORP.

MAIN OUTCOMES AND MEASURES

Quality-adjusted life-years (QALYs), costs (direct medical costs and costs outside the NHS), and incremental cost-effectiveness ratios (ICERs).

RESULTS

Compared with LRP, RARP cost £1785 (US $2350) less and had 0.24 more QALYs gained; thus, RARP was a dominant option compared with LRP. Compared with ORP, RARP had 0.12 more QALYs gained but cost £526 (US $693) more during the 10-year time frame, resulting in an ICER of £4293 (US $5653)/QALY. Because the ICER was below the £30 000 (US $39 503) willingness-to-pay threshold, RARP was more cost-effective than ORP in the UK. The most sensitive variable influencing the cost-effectiveness of RARP was the lower risk of biochemical recurrence (BCR). Scenario analysis indicated RARP would remain more cost-effective than ORP as long as the BCR hazard ratios comparing RARP vs ORP were less than 0.99.

CONCLUSIONS AND RELEVANCE

These findings suggest that in the UK, RARP has an ICER lower than the willingness-to-pay threshold and thus is likely a cost-effective surgical treatment option for patients with localized prostate cancer compared with ORP and LRP. The results were mainly driven by the lower risk of BCR for RARP. These findings may differ in other health care settings where different thresholds and costs may apply.

Effect of Radiation Treatment at a High-Volume Center on Outcomes in Intermediate-Risk Prostate Cancer: An Analysis of the National Cancer Database

OBJECTIVE

To investigate the effect of radiation treatment at a high-volume center on overall survival in men with intermediate-risk prostate cancer.

METHODS

From 2004-2015, 430,347 patients with intermediate-risk prostate cancer were identified in the NCDB. Radiation case volume (RCV) of each hospital was calculated based on number of patients treated. After excluding certain patients including those with metastatic disease, our final analysis population included 116,091 intermediate-risk prostate cancer patients receiving radiation therapy (RT) or radiation with androgen deprivation therapy (RT+ADT). Characteristics analyzed include age, race, distance to treatment facility, Charlson-Deyo Score (CDS), and socioeconomic factors. Primary outcome was overall survival (OS). 5-year survival rates were estimated using the Kaplan-Meier method. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) were computed using multivariate analysis (MVA). Cox regression and propensity score-matched (PSM) analysis was performed.

RESULTS

Median follow up was 63.5 months and estimated 5-year OS was 90.1% at high RCV centers and 88.2% at low RCV centers (p<0.0001). Treatment at high RCV facility was associated with significantly lower mortality compared to treatment at a low RCV facility on MVA and PSM analysis. The survival benefit of treatment at a high RCV facility remained when high RCV facilities were defined as those above the 80^th, 90^th, and 95^th percentile in patient volume (p<0.05).

CONCLUSIONS

Treatment at a high radiation case volume facility is associated with improved OS in patients with radiation-treated intermediate-risk prostate cancer. This survival benefit is important to consider when choosing a treatment center for radiation therapy.

Prospective Multicenter Comparison of Open and Robotic Radical Prostatectomy: The PROST-QA/RP2 Consortium

PURPOSE

Our goal was to evaluate the comparative effectiveness of robot-assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) in a multicenter study.

MATERIALS AND METHODS

We evaluated men with localized prostate cancer at 11 high-volume academic medical centers in the United States from the PROST-QA (2003-2006) and the PROST-QA/RP2 cohorts (2010-2013) with a pre-specified goal of comparing RALP (549) and ORP (545). We measured longitudinal patient-reported health-related quality of life (HRQOL) at pre-treatment and at 2, 6, 12, and 24 months, and pathological and perioperative outcomes/complications.

RESULTS

Demographics, cancer characteristics, and margin status were similar between surgical approaches. ORP subjects were more likely to undergo lymphadenectomy (89% vs 47%; p <0.01) and nerve sparing (94% vs 89%; p <0.01). RALP vs ORP subjects experienced less mean intraoperative blood loss (192 vs 805 mL; p <0.01), shorter mean hospital stay (1.6 vs 2.1 days; p <0.01), and fewer blood transfusions (1% vs 4%; p <0.01), wound infections (2% vs 4%; p=0.02), other infections (1% vs 4%; p <0.01), deep venous thromboses (0.5% vs 2%; p=0.04), and bladder neck contractures requiring dilation (1.6% vs 8.3%; p <0.01). RALP subjects reported less pain (p=0.04), less activity interference (p <0.01) and higher incision satisfaction (p <0.01). Surgical approach (RALP vs ORP) was not a significant predictor of longitudinal HRQOL change in any HRQOL domain.

CONCLUSIONS

In high-volume academic centers, RALP and ORP patients may expect similar long-term HRQOL outcomes. Overall, RALP patients have less pain, shorter hospital stays, and fewer post-surgical complications such as blood transfusions, infections, deep venous thromboses, and bladder neck contractures.

Urologist practice structure and quality of prostate cancer care

Objective

To examine three aspects of urologist practice structure that may affect quality of prostate cancer care: practice size, ownership of an intensity modulated radiation therapy (IMRT) device, participation within a multi-specialty group (MSG). Health care reforms focused on improving quality are particularly relevant for prostate cancer given its prevalence and concerns for overdiagnosis and overtreatment.

Methods

Using data from the Surveillance, Epidemiology and End-Results (SEER)-Medicare linked registry, we examined quality of prostate cancer treatment according to each treating urologist's practice size, type (single-specialty vs. MSG) and ownership of IMRT. Mixed models were used to adjust for patient differences.

Results

We identified 22,412 men with newly diagnosed prostate cancer treated by 2,199 urologists during the study. We observed minimal differences for most quality metrics according to practice size, type, and ownership of IMRT. Adherence to all eligible quality metrics was better among MSGs compared to single specialty groups (20.0% adherence versus 18.2%, p=0.01) whereas there was no significant difference by ownership of IMRT (17.1% adherence in owners versus 18.9% non-owners, p=0.09).

Conclusion

Differences in quality across practice size, type and ownership of IMRT were modest, with substantial room for improvement regardless of practice structure.

Centralisation of Care for Prevalent Urological Malignancies: The Case for Prostate Cancer

Prostate cancer presents a significant challenge and burden for health care centres across the world. In the UK and other parts of Europe, as well as areas of the USA, centralisation of services has been implemented. In the UK and Europe, hospital centres are split into a hub-and-spoke system. High-volume centres carry out treatment as hubs and local hospitals carry out diagnostics and referrals as spokes. In this narrative mini-review we evaluate whether centralisation of services has improved patient outcomes, streamlined the use of resources, and reduced costs. We also discuss the positive and negative impacts of centralisation of prostate cancer services. PATIENT SUMMARY: This mini-review discusses the current use of centralisation of prostate cancer services. We assess the evidence in favour of centralisation as well as the issues it can present to both health care systems and patients.

Do Patients Residing in Provincial Areas Transport and Spend More on Cancer Treatment in Korea?

Background: With the increasing burden of cancer worldwide, a need exists to investigate patterns of healthcare utilization and costs. This study aimed to investigate whether the area of residence is associated with the likelihood of a patient receiving treatment at an institution located outside their residing region. This study also analyzed whether medical travel was related to levels of healthcare utilization and costs. Methods: This study used the 2007 to 2015 National Health Insurance (NHI) claims data. The residing area was categorized into capital area, metropolitan cities, and provincial area. Healthcare utilization was measured based on days of care and costs based on direct, covered medical costs. Chi-square test and analysis of variance (ANOVA) was conducted to investigate the general characteristics of the study population. The relationship between the dependent and independent variables were analyzed using the generalized estimating equation (GEE) model. Results: Of the 64,505 participants included in this study, 19,975 (31.0%) visited medical institutions located outside their residing area. Compared to individuals residing in the capital area, those living in provincial regions (OR 2.202, 95% CI 2.068–2.344) were more likely to visit medical institutions outside their residing area. Healthcare costs were higher in individuals receiving treatment at hospitals located elsewhere (RR 1.054, 95% CI 1.017–1.093). Conclusion: Cancer patients residing in provincial areas were likely to visit institutions located outside their residing area for treatment. Medical travel was associated with higher levels of spent healthcare costs. Policies should focus on preventing possible related regional cancer disparity and promoting optimal configuration of cancer services.

Patient reported outcome measures concerning urinary incontinence after robot assisted radical prostatectomy: development and validation of an online prediction model using clinical parameters, lower urinary tract symptoms and surgical experience

The prediction of post-prostatectomy incontinence (PPI) after robot-assisted radical prostatectomy (RARP) depends on multiple clinical, anatomical and surgical factors. There are only few risk formulas, tables or nomograms predicting PPI that may assist clinicians and their patients in adequate risk counseling on postoperative side-effects. Prospective data collection of 1814 patients who underwent RARP between 2009 and 2017 was done. Pre-operative parameters were age, body mass index (BMI), prostate volume, the American Society of Anesthesiologists (ASA) score, severity of Lower Urinary Tract Symptoms (LUTS), type of planned nerve-sparing surgery and surgical experience. The continence status was reported using Patient Reported Outcome Measurements (PROMs) using the validated pad-use questionnaire EPIC26. Continence was defined as either the use of zero pads or one safety pad. Multivariable logistic regression analysis was performed to identify predictors of PPI within one year after RARP. An online prediction tool was developed and validated. The median follow-up was 36 months (range 12-108). The response rate was high at 85.2%. A total of 85% (1537/1814) of patients was continent on follow-up. One-year continence rate was 80.1% (95% CI 78.3-81.9%) (1453/1814) and increased to 87.4% (95% CI 85.4-89.4%) after 5 years. On multivariable analysis, severity of LUTS (OR = 0.56 p = 0.004), higher age (OR = 0.73 p = 0.049), extend of nerve-sparing surgery (OR = 0.60 p = 0.001) and surgeon experience (OR = 1.48 p = 0.025) were significant independent predictors for PPI. The online prediction model performed well in predicting continence status with poor discrimination and good calibration. An intuitive online tool was developed to predict PPI after RARP that may assist clinicians and their patients in counseling of treatment.

Association of surgeon and hospital volume with short-term outcomes after robot-assisted radical prostatectomy: Nationwide, population-based study

Background and objective

Few studies have investigated the association between surgical volume and outcome of robot-assisted radical prostatectomy (RARP) in an unselected cohort. We sought to investigate the association between surgical volume with peri-operative and short-term outcomes in a nation-wide, population-based study group.

Methods

9,810 RARP’s registered in the National Prostate Cancer Register of Sweden (2015–2018) were included. Associations between outcome and volume were analyzed with multivariable logistic regression including age, PSA-density, number of positive biopsy cores, cT stage, Gleason score, and extent of lymph node dissection.

Results

Surgeons and hospitals in the highest volume group compared to lowest group had shorter operative time; surgeon (OR 9.20, 95% CI 7.11–11.91), hospital (OR 2.16, 95% CI 1.53–3.06), less blood loss; surgeon (OR 2.58. 95% CI 2.07–3.21) hospital (no difference), more often nerve sparing intention; surgeon (OR 2.89, 95% CI 2.34–3.57), hospital (OR 2.02, 95% CI 1.66–2.44), negative margins; surgeon (OR 1.90, 95% CI 1.54–2.35), hospital (OR 1.28, 95% CI 1.07–1.53). There was wide range in outcome between hospitals and surgeons with similar volume that remained after adjustment.

Conclusions

High surgeon and hospital volume were associated with better outcomes. The range in outcome was wide in all volume groups, which indicates that factors besides volume are of importance. Registration of surgical performance is essential for quality control and improvement.

An observational study of volume-outcome effects for robot-assisted radical prostatectomy in England

OBJECTIVES

To investigate volume-outcome relationships in robot-assisted radical prostatectomy (RARP) for cancer using data from the Hospital Episodes Statistics (HES) database for England.

MATERIALS AND METHODS

Data for all adult, elective RPs for cancer during the period January 2013-December 2018 (inclusive) were extracted from the HES database. The HES database records data on all National Health Service (NHS) hospital admissions in England. Data were extracted for the NHS trust and surgeon undertaking the procedure, the surgical technique used (laparoscopic, open or robot-assisted), hospital length of stay (LOS), emergency readmissions, and deaths. Multilevel modelling was used to adjust for hierarchy and covariates.

RESULTS

Data were available for 35 629 RPs (27 945 RARPs). The proportion of procedures conducted as RARPs increased from 53.2% in 2013 to 92.6% in 2018. For RARP, there was a significant relationship between 90-day emergency hospital readmission (primary outcome) and trust volume (odds ratio [OR] for volume decrease of 10 procedures: 0.99, 95% confidence interval [CI] 0.99-1.00; P = 0.037) and surgeon volume (OR for volume decrease of 10 procedures: 0.99, 95% CI 0.99-1.00; P = 0.013) in the previous year. From lowest to highest volume category there was a decline in the adjusted proportion of patients readmitted as an emergency at 90 days from 10.6% (0-49 procedures) to 7.0% (≥300 procedures) for trusts and from 9.4% (0-9 procedures) to 8.3% (≥100 procedures) for surgeons. LOS was also significantly associated with surgeon and trust volume, although 1-year mortality was associated with neither.

CONCLUSIONS

There is evidence of a volume-outcome relationship for RARP in England and minimising low-volume RARP will improve patient outcomes. Nevertheless, the observed effect size was relatively modest, and stakeholders should be realistic when evaluating the likely impact of further centralisation at a population level.

Potential for optimizing the perioperative care in robotic prostatectomy patients by adoption of enhanced recovery after surgery principles

Several benefits have been reported after applying the principles of enhanced recovery after surgery (ERAS) into the perioperative care of patients undergoing robot-assisted radical prostatectomy (RARP). Nevertheless, there are still barriers. We aimed to identify the key areas by systematically surveying urology departments in Germany and Austria. A 27-question survey on the adoption of ERAS principles for the perioperative care of RARP patients was designed, in compliance with the guidelines on good practice in conducting and reporting of survey research. After positive testing for face and content validity, the survey was distributed via postal mail to 82 departments performing RARP. In total, 39 departments responded to our survey (response rate 48%). The ERAS adoption rates ranged from 21 to 97%, with nine ERAS principles being widely adopted (72-92% of the departments). The lowest adoption rates and, subsequently, the largest potential for optimization were detected for the preoperative nutrition counselling (21%), preoperative pelvic floor physiotherapy (54%), postoperative early initiation of nutrition (44%) and postoperative patient audit for further quality improvement (36%). High-volume centers performed more frequently a perioperative nutrition counselling (8/27; 30%) than low-volume centers (0/12; 0%; p = 0.036). The implementation of the ERAS principles into the perioperative care algorithm were medium-to-high, yet not optimal. Our real-world data assessment revealed four key areas showing low adoption rates (nutrition counselling, preoperative pelvic floor physiotherapy, early initiation of nutrition and patient audit), implying a great potential for further optimization.

Identification of patients at risk for biochemical recurrence after radical prostatectomy with intra-operative frozen section

OBJECTIVE

To identify patients at risk for biochemical recurrence (BCR) of prostate cancer (PCa) after radical prostatectomy (RP) with intra-operative whole-mount frozen section (FS) of the prostate.

MATERIAL AND METHODS

We examined differences in BCR between patients with initial negative surgical margins at FS, patients with final negative surgical margins with initial positive margins at FS without residual PCa after secondary tumour resection, and patients with final negative surgical margins with initially positive margins at FS with residual PCa in the secondary tumour resection specimen. Institutional data of 883 consecutive patients undergoing RP were collected. Intra-operative whole-mount FS was routinely used to check for margin status and, if necessary, to resect more periprostatic tissue in order to achieve negative margins. Patients with lymph node-positive disease or final positive surgical margins were excluded from the analysis. Kaplan-Meier curves and multivariable Cox proportional hazards regression analyses adjusting for clinical covariates were employed to examine differences in biochemical recurrence-free survival (BRFS) according to the resection status mentioned above.

RESULTS

The median follow-up was 22.4 months. The 1- and 2-year BRFS rates in patients with (81.0% and 72.9%, respectively; P = 0.001) and without residual PCa (90.3% and 82.3%, respectively; P = 0.033) after secondary tumour resection were significantly lower compared to patients with initial R0 status (93.4% and 90.9%, respectively). On multivariable Cox regression only residual PCa in the secondary tumour resection was associated with a higher risk of BCR compared to initial R0 status (hazard ratio 1.99, 95% confidence interval 1.01-3.92; P = 0.046).

CONCLUSION

Despite being classified as having a negative surgical margin, patients with residual PCa in the secondary tumour resection specimen face a high risk of BCR. These findings warrant closer post-RP surveillance of this particular subgroup. Further research of this high-risk subset of patients should focus on examining whether these patients benefit from early salvage therapy and how resection status impacts oncological outcomes in the changing landscape of PCa treatment.

Comparative effectiveness of robotic and open radical prostatectomy

Radical prostatectomy (RP) has undergone a remarkable transformation from open to minimally-invasive surgery over the last two decades. However, it is important to recognize there is still conflicting evidence regarding key outcomes. We aimed to summarize current literature on comparative effectiveness of robotic and open RP for key outcomes including oncologic results, health-related quality of life (HRQOL) measures, safety and postoperative complications, and healthcare costs. The bulk of the paper will discuss and interpret limitations of current data. Finally, we will also highlight future directions of both surgical approaches and its potential impact on health care delivery.

[Quality criteria in urology : How to obtain comparable results?]

The standardization of procedural flow and medical documentation increasingly allows further possibilities. The best-known example of process standardization is the centralized treatment of complex clinical pictures, while patient-reported outcome measurements (PROMs) enable standardized documentation. Using the example of prostate cancer, existing literature on the topic of quality optimization in medicine is discussed. The following key points are addressed: (1) Increasing use of standardized PROMs for outcome documentation. (2) The transfer of complex clinical pictures to dedicated specialized centers has been shown to increase the quality of patient care as long as standardized PROMs are used. (3) Healthcare policymakers benefit from the use of PROMs and increasingly pursue a "value-based healthcare" approach.

"Robotic fatigue?" - The impact of case order on positive surgical margins in robotic-assisted laparoscopic prostatectomy

PURPOSE

Multiple robotic-assisted surgeries are often performed within a single operating day; however, the impact of this practice on patient outcomes has not been examined. We aim to determine whether outcomes for robotic-assisted laparoscopic prostatectomy (RALP) differed when performed sequentially.

MATERIALS AND METHODS

A multi-institutional, retrospective cohort study was conducted involving a total of 8 academic centers between years 2015 and 2018. Participants were adult males undergoing RALP for localized prostate cancer on operative days in which 2 RALP cases were performed sequentially by the same resident-attending team. The primary outcome of the study was presence of positive surgical margin (PSM). Secondary outcomes were lymph node yield, operative time, and estimated blood loss. The primary analysis was a random effects meta-analysis model for PSM.

RESULTS

Overall, 898 RALP cases (449 sequential pairs) were included in the study. There was no significant difference in PSM rate (27.2% vs. 30.3%, P= 0.338) between first and second case groups, respectively. Utilizing random effects meta-analysis, the second case cohort had no increased risk of PSM (OR _0.761.23_1.97, P= 0.40). Higher blood loss was noted in the second case cohort (186.7 ml vs. 221.7 ml, P = 0.002). Additionally, factors associated with PSM were increasing prostate specific antigen, higher percent tumor involvement, extraprostatic extension, and seminal vesicle invasion.

CONCLUSION

Case sequence was not associated with PSM, lymph node yield, or operative time for RALP. Disease specific factors and institutional experience are associated with increased risk for positive surgical margin which can aid providers in scheduling of patients.

Surgeon heterogeneity significantly affects functional and oncological outcomes after radical prostatectomy in the Swedish LAPPRO trial

Objectives

To evaluate how surgeon heterogeneity – the variation in outcomes between individual surgeons – influences functional and oncological outcomes after robot‐assisted laparoscopic prostatectomy (RALP) and retropubic radical prostatectomy (RRP), and to assess whether surgeon heterogeneity affects the comparison between RALP and RRP.

Patients and Methods

Laparoscopic Prostatectomy Robot Open (LAPPRO) is a prospective, controlled, non‐randomized trial performed at 14 Swedish centres with 68 operating surgeons. A total of 4003 men with localized prostate cancer were enrolled between 2008 and 2011. The endpoints were urinary incontinence, erectile dysfunction (ED) and recurrence at 24 months after surgery. Logistic regression models were built to evaluate surgeon heterogeneity and, secondarily, surgeon‐specific factors were added to the models to investigate their influence on heterogeneity and the comparison between RALP and RRP.

Results

Among surgeons who performed at least 20 surgeries during the study period (n=25), we observed statistically significant heterogeneity for incontinence (P = 0.001), ED (P < 0.001) and rate of recurrent disease (P < 0.001). The significant heterogeneity remained when analysing only experienced surgeons with a stated experience of at least 250 radical prostatectomies (n=12). Among all participating surgeons (n=68), differences in surgeon volume explained 42% of the observed heterogeneity for incontinence (P = 0.003), 11% for ED (P = 0.03) and 19% for recurrence (P = 0.01). Taking surgeon volume into account when comparing RALP and RRP had a significant impact on the results. The effect was greatest for functional outcomes, and the additional adjustments for the surgeons' previous experience changed whether the difference between techniques was statistically significant or not. The surgeons’ annual volume had the greatest effect on the recurrence rate.

Conclusions

There was a large degree of heterogeneity among surgeons regarding both functional and oncological outcomes and this had a significant impact on the results when comparing RALP and RRP. Some of the observed heterogeneity was explained by differences in surgeon volume. Efforts to decrease heterogeneity are warranted and variation among surgeons must be accounted for when conducting comparative analyses between surgical techniques.

Patient reported outcome measures concerning urinary incontinence after robot assisted radical prostatectomy: development and validation of an online prediction model using clinical parameters, lower urinary tract symptoms and surgical experience

The prediction of post-prostatectomy incontinence (PPI) after robot-assisted radical prostatectomy (RARP) depends on multiple clinical, anatomical and surgical factors. There are only few risk formulas, tables or nomograms predicting PPI that may assist clinicians and their patients in adequate risk counseling on postoperative side-effects. Prospective data collection of 1814 patients who underwent RARP between 2009 and 2017 was done. Pre-operative parameters were age, body mass index (BMI), prostate volume, the American Society of Anesthesiologists (ASA) score, severity of Lower Urinary Tract Symptoms (LUTS), type of planned nerve-sparing surgery and surgical experience. The continence status was reported using Patient Reported Outcome Measurements (PROMs) using the validated pad-use questionnaire EPIC26. Continence was defined as either the use of zero pads or one safety pad. Multivariable logistic regression analysis was performed to identify predictors of PPI within one year after RARP. An online prediction tool was developed and validated. The median follow-up was 36 months (range 12–108). The response rate was high at 85.2%. A total of 85% (1537/1814) of patients was continent on follow-up. One-year continence rate was 80.1% (95% CI 78.3–81.9%) (1453/1814) and increased to 87.4% (95% CI 85.4–89.4%) after 5 years. On multivariable analysis, severity of LUTS (OR = 0.56 p = 0.004), higher age (OR = 0.73 p = 0.049), extend of nerve-sparing surgery (OR = 0.60 p = 0.001) and surgeon experience (OR = 1.48 p = 0.025) were significant independent predictors for PPI. The online prediction model performed well in predicting continence status with poor discrimination and good calibration. An intuitive online tool was developed to predict PPI after RARP that may assist clinicians and their patients in counseling of treatment.

Current evidence between hospital volume and perioperative outcome: Prospective assessment of robotic radical prostatectomy safety profile in a regional center of medium annual caseload

INTRODUCTION

We aimed to present the safety profile of robotic radical prostatectomy (RARP) performed in a single center of medium surgical volume since its introduction and identify predictors of postoperative complications.

METHODS

We prospectively collected clinical data from 317 consecutive patients undergoing RARP between August 2011 and November 2019 in a medium-volume center. Surgical procedures were performed by a single experienced surgeon. Complications were collected according to the Martin criteria for reporting and the Clavien-Dindo classification for rating. Preoperative, intraoperative, and postoperative data were analyzed and compared with available literature.

RESULTS

A total of 102 complications were observed in 96 (30.3%) patients and were minor in 84.4% of cases (Clavien grade 1 and 2). Transfusion rate was 1.3%. Complications of grade 4b or 5 did not occur. The most frequent complications were urinary retention (7.3%) and anastomotic leak (5.9%). At multivariate analysis, the nerve-sparing technique was an independent predictor of complications (odds ratio [OR] 0.55, p=0.02).

CONCLUSIONS

The study shows that a high safety profile may be achieved in a medium-volume hospital. The nerve-sparing technique was a predictor of complications. Further studies are needed to define the current relationship between surgical volume and perioperative outcome for RARP.

[Radical prostatectomy for prostate cancer, perioperative management by French urologists in 2018]

INTRODUCTION

Prostatectomy (PT) is a common procedure performed by many urologists. In 2018, 20,207 prostatectomies were performed in France, and few studies evaluated the perioperative habits of urologists. As part of writing guidelines for enhanced recovery after surgery (ERAS) we wished to evaluate practice of urologists in their hospital management of a prostatectomy.

MATERIEL AND METHODS

A questionnaire was sent by Survey Monkey in June and July 2018 to all urologists who are members of the French Association of Urology.

RESULTS

One hundred and sixty seven urologists (14%) answered the questionnaire, 62% have private practice. The average number of operators per center performing PT was 4, with a median number of 70 interventions (0 to 486) per center in 2018. Open surgery is still gold standard (39.13%), followed by the robot-assisted transperitoneal laparoscopic (34.78%) and standard laparoscopic (24.22%). Alimentation, like first stand-up, was re-established on the first post-operative day, and the average hospital stay was 4±2 nights. The removal of the bladder catheter was most often performed at home by nurse (49.06%), one week after surgery. Only 10.06% of urologists systematically perform a cystography before removal urinary catheter.

CONCLUSION

The perioperative management of prostatectomy in France is relatively homogeneous, between urologists. The length of hospital stay remains important and could be reduced by proposing an ERAS protocol as has been obtained for cystectomy.

LEVEL OF EVIDENCE

III.

Simulating the impact of centralization of prostate cancer surgery services on travel burden and equity in the English National Health Service: A national population based model for health service re-design

Introduction

There is limited evidence on the impact of centralization of cancer treatment services on patient travel burden and access to treatment. Using prostate cancer surgery as an example, this national study analysis aims to simulate the effect of different centralization scenarios on the number of center closures, patient travel times, and equity in access.

Methods

We used patient‐level data on all men (n = 19,256) undergoing radical prostatectomy in the English National Health Service between January 1, 2010 and December 31, 2014, and considered three scenarios for centralization of prostate cancer surgery services A: procedure volume, B: availability of specialized services, and C: optimization of capacity. The probability of patients travelling to each of the remaining centers in the choice set was predicted using a conditional logit model, based on preferences revealed through actual hospital selections. Multivariable linear regression analysed the impact on travel time according to patient characteristics.

Results

Scenarios A, B, and C resulted in the closure of 28, 24, and 37 of the 65 radical prostatectomy centers, respectively, affecting 3993 (21%), 5763 (30%), and 7896 (41%) of the men in the study. Despite similar numbers of center closures the expected average increase on travel time was very different for scenario B (+15 minutes) and A (+28 minutes). A distance minimization approach, assigning patients to their next nearest center, with patient preferences not considered, estimated a lower impact on travel burden in all scenarios. The additional travel burden on older, sicker, less affluent patients was evident, but where significant, the absolute difference was very small.

Conclusion

The study provides an innovative simulation approach using national patient‐level datasets, patient preferences based on actual hospital selections, and personal characteristics to inform health service planning. With this approach, we demonstrated for prostate cancer surgery that three different centralization scenarios would lead to similar number of center closures but to different increases in patient travel time, whilst all having a minimal impact on equity.

Modern Plastic Surgical Practice: Technical Competence Alone Is Not Enough

Annually, an estimated 234 million major surgical operations occur worldwide, with concomitant seven million complications and one million deaths. It is now well established that technical competence is necessary, but not sufficient for modern surgical practice and outcomes. Breakdown in non-technical skills has been attributed as a key root cause for near misses and patient harm in the operating room. This article discusses the multi-faceted skills-set that is necessary for the modern surgeon to succeed and for optimal patient outcomes. This includes technical skills, non-technical skills, with a focus on key CanMEDS framework domains, including leadership, communication, evidence-based surgery and mentorship.

The Impact of Radiotherapy Facility Volume on the Survival and Guideline Concordance of Patients With Muscle-invasive Bladder Cancer Receiving Bladder-preservation Therapy

OBJECTIVES

Higher facility surgical volume predicts for improved outcomes in patients with muscle-invasive bladder cancer (MIBC) who undergo radical cystectomy. We investigated the association between facility radiotherapy (RT) case volume and overall survival (OS) for patients with MIBC who received bladder-preserving RT, and the relationship with adherence to National Comprehensive Cancer Network (NCCN) guidelines for bladder preservation.

METHODS

The National Cancer Database was used to identify patients diagnosed with nonmetastatic MIBC from 2004 to 2015 and received RT at the reporting center. Facility case volume was defined as the total MIBC patients treated with RT during the period. Facilities were stratified into high-volume facility (HVF) or low-volume facility at the 80th percentile of RT case volume. OS was assessed using Kaplan-Meier analysis. Rates of compliance with NCCN guidelines regarding the use of transurethral resection of the bladder tumor before RT, planned use of concurrent chemotherapy, and total RT dose were compared. Cox proportional hazard model was used to evaluate predictors of OS.

RESULTS

There were 7562 patients included. No differences in age, Charlson-Deyo score, T stage, or node-positive rates were observed between groups. HVFs exhibited greater compliance with NCCN guidelines for bladder preservation (P<0.0001). Treatment at an HVF was associated with the improved OS for all patients (P=0.001) and for the subset of patients receiving NCCN-recommended RT doses (P=0.0081). Volume was an independent predictor of OS (P=0.002).

CONCLUSIONS

Treatment at an HVF is associated with improved OS and greater guideline-concordant management among patients with MIBC.

Propofol-based total intravenous anesthesia is associated with better survival than desflurane anesthesia in robot-assisted radical prostatectomy

Background

Previous researches have shown that anesthetic techniques may influence the patients’ outcomes after cancer surgery. Here, we studied the relationship between the type of anesthetic techniques and patients’ outcomes following elective robot-assisted radical prostatectomy.

Methods

This was a retrospective cohort study of patients who received elective, robot-assisted radical prostatectomy between January 2008 and December 2018. Patients were grouped according to the anesthesia they received, namely desflurane or propofol. A Kaplan–Meier analysis was conducted, and survival curves were presented from the date of surgery to death. Univariable and multivariable Cox regression models were used to compare hazard ratios for death after propensity matching. Subgroup analyses were performed for tumor-node-metastasis stage and disease progression. The primary outcome was overall survival, and the secondary outcome was postoperative biochemical recurrence.

Results

A total of 365 patients (24 deaths, 7.0%) under desflurane anesthesia, and 266 patients (2 deaths, 1.0%) under propofol anesthesia were included. The all-cause mortality rate was significantly lower in the propofol anesthesia than in the desflurane anesthesia during follow-up (P = 0.001). Two hundred sixty-four patients remained in each group after propensity matching. The propofol anesthesia was associated with improved overall survival (hazard ratio, 0.11; 95% confidence interval, 0.03–0.48; P = 0.003) in the matched analysis. Subgroup analyses showed that patients under propofol anesthesia had less postoperative biochemical recurrence than those under desflurane (hazard ratio, 0.20; 95% confidence interval, 0.05–0.91; P = 0.038) in the matched analysis.

Conclusions

Propofol anesthesia was associated with improved overall survival in robot-assisted radical prostatectomy compared with desflurane anesthesia. In addition, patients under propofol anesthesia had less postoperative biochemical recurrence.

Considering the role of radical prostatectomy in 21st century prostate cancer care

The practice of radical prostatectomy for treating prostate cancer has evolved remarkably since its general introduction around 1900. Initially described using a perineal approach, the procedure was later popularized using a retropubic one, after it was first described as such in 1948. The open surgical method has now largely been abandoned in favour of the minimally invasive robot-assisted method, which was first described in 2000. Until 1980, the procedure was hazardous, often accompanied by massive blood loss and poor outcomes. For patients in whom surgery is indicated, prostatectomy is increasingly being used as the first step in a multitherapeutic approach in advanced local, and even early metastatic, disease. However, contemporary molecular insights have enabled many men to safely avoid surgical intervention when the disease is phenotypically indolent and use of active surveillance programmes continues to expand worldwide. In 2020, surgery is not recommended in those men with low-grade, low-volume Gleason 6 prostate cancer; previously these men - a large cohort of ~40% of men with newly diagnosed prostate cancer - were offered surgery in large numbers, with little clinical benefit and considerable adverse effects. Radical prostatectomy is appropriate for men with intermediate-risk and high-risk disease (Gleason score 7-9 or Grade Groups 2-5) in whom radical prostatectomy prevents further metastatic seeding of potentially lethal clones of prostate cancer cells. Small series have suggested that it might be appropriate to offer radical prostatectomy to men presenting with small metastatic burden (nodal and or bone) as part of a multimodal therapeutic approach. Furthermore, surgical treatment of prostate cancer has been reported in cohorts of octogenarian men in good health with minimal comorbidities, when 20 years ago such men were rarely treated surgically even when diagnosed with localized high-risk disease. As medical therapies for prostate cancer continue to increase, the use of surgery might seem to be less relevant; however, the changing demographics of prostate cancer means that radical prostatectomy remains an important and useful option in many men, with a changing indication.

ECCO Essential Requirements for Quality Cancer Care: Prostate cancer

BACKGROUND

ECCO Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give oncology teams, patients, policymakers and managers an overview of essential care throughout the patient journey.

PROSTATE CANCER

Prostate cancer is the second most common male cancer and has a wide variation in outcomes in Europe. It has complex diagnosis and treatment challenges, and is a major healthcare burden. Care must only be a carried out in prostate/urology cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

The 30-day unplanned readmission rate and hospital volume: a national population-based study in South Korea

OBJECTIVE

To examine the association between hospital volume and the unplanned 30-day readmission rate as a quality measure.

DESIGN

A retrospective cross-sectional study.

SETTING

The Korea healthcare system is operated by a single payer under the National Health Insurance Service.

PARTICIPANTS

Using national health claims data of the Health Insurance Review and Assessment in South Korea, we examined 1 296 275 adult discharges (≥18 years old) from 90 hospitals (≥500 beds) in the 2013 calendar year.

MAIN OUTCOME MEASURES

We analysed the 30-day, unplanned, observed-to-expected standardized readmission rate for hospitals and for five specialty cohorts: medicine, surgery/gynaecology, cardiovascular, cardiorespiratory, and neurology. We assessed the association between hospital volume by tertiles and the 30-day standardized readmission rates with and without adjustment for hospital characteristics.

RESULTS

The rate for the lowest-volume hospitals was 6.10 compared with 6.20 for the highest-volume hospitals. We observed the standardized readmission rates did not differ significantly between the lowest- and highest-volume groups, except for the neurology cohort, which remained significant after adjusting for hospital characteristics.

CONCLUSIONS

The standardized readmission rates were not associated with hospital volume, except for the neurology cohort, in which the standardized readmission rate was significantly higher in the highest-volume hospitals than in lowest- and intermediate-volume hospitals, which was not consistent with the typical association of greater hospital volume with better outcomes. This association was independent of hospital characteristics. Therefore, the rate of readmissions should be used with caution when gauging the quality of hospital care according to hospital volume.

Understanding volume-outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme

OBJECTIVES

To investigate volume-outcome relationships in nephrectomy and cystectomy for cancer.

MATERIALS AND METHODS

Data were extracted from the UK Hospital Episodes Statistics database, which records data on all National Health Service (NHS) hospital admissions in the England. Data were included for a 5-year period (April 2013-March 2018 inclusive) and data on emergency and paediatric admissions were excluded. Data were extracted on the NHS trust and surgeon undertaking the procedure, the surgical technique used (open, laparoscopic or robot-assisted) and length of hospital stay during the procedure. This dataset was supplemented by data on mortality from the UK Office for National Statistics. A number of volume thresholds and volume measures were investigated. Multilevel modelling was used to adjust for hierarchy and confounding factors.

RESULTS

Data were available for 18 107 nephrectomy and 6762 cystectomy procedures for cancer. There was little evidence of trust or surgeon volume influencing readmission rates or mortality. There was some evidence of shorter length of hospital stay for high-volume surgeons, although the volume measure and threshold used were important.

CONCLUSIONS

We found little evidence that further centralization of nephrectomy or cystectomy for cancer surgery will improve the patient outcomes investigated. It may be that length of stay can be optimized though training and support for lower-volume centres, rather than further centralization.

Radiation Therapy for Prostate Cancer

Randomized controlled trials provide evidence-driven clinical decision making in the management of newly diagnosed nonmetastatic and oligometastatic prostate cancer. Advances in technology (eg, multiparametric MRI, MR/transrectal ultrasound fusion biopsy, image-guided radiation therapy, stereotactic body radiation therapy) have transformed diagnosis and treatment of prostate cancer while improving cancer control and quality-of-life outcomes. Exciting breakthroughs are revealing possible new indications for radiotherapy, particularly with respect to oligometastatic prostate cancer. Ongoing studies using next-generation androgen receptor-targeted agents hold promise to continue to improve important clinical outcomes, including metastasis-free prostate cancer-specific and overall survival in addition to health-related quality of life.

Influence of the facility caseload on the subsequent survival of men with localized prostate cancer undergoing radical prostatectomy

BACKGROUND

Several studies have investigated the relationship between experience measured by caseload and oncological outcomes, economics, and access to care for prostate cancer care. Oncological outcomes have been limited to biochemical failure after radical prostatectomy. Questions remain regarding the more definitive measures of outcomes and their relationship with caseload.

METHODS

The National Cancer Database was used to investigate the outcomes of radical prostatectomy in the United States. With overall survival (OS) as the primary outcome, the relationship between the facility annual caseload (FAC) for all prostate cancer encounters and the facility annual surgical caseload (FASC) for those requiring radical prostatectomy was examined with a Cox proportional hazards model. Four volume groups were defined by caseload: <50th percentile (volume group 1 [VG1]), 50th to 74th percentiles (volume group 2 [VG2]), 75th to 89th percentiles (volume group 3 [VG3]), and ≥90th percentile (volume group 4 [VG4]). By FAC/FASC, 11%/8%, 17%/18%, 25%/26%, and 47%/49% of patients were treated in VG1 through VG4, respectively.

RESULTS

Between 2004 and 2014, 488,389 patients underwent radical prostatectomy. At a median follow-up of 60.75 months, the median OS was not reached. There was a significant OS benefit as the caseload increased. For FAC, the adjusted OS difference between VG1 and VG4 at 90th percentile survivorship reached 13.2 months (hazard ratio [HR], 1.30; 95% CI, 1.23-1.36; P < .0001). For FASC, this was 11.3 months (HR, 1.25; 95% CI, 1.192-1.321; P < .0001).

CONCLUSIONS

There is a statistically significant OS advantage from performing radical prostatectomy at a facility with a high annual caseload. Caseload measured by all prostate cancer encounters is a better predictor of favorable outcomes than the number of surgeries performed at a facility.

LAY SUMMARY

An in-depth analysis of 488,389 cases of radical prostatectomy performed in more than 1000 facilities over a 10-year period showed better survival when surgery was performed in facilities with more experience and greater caseload. A survival difference of up to 13 months was observed when comparing patients treated at less experienced versus more experienced centers.   Experience across all stages of prostate cancer was a stronger predictor of survival outcome than just the number of surgeries performed.

Point-of-care influences orchiectomy rates in pediatric patients with testicular torsion

OBJECTIVES

The objective of this study was to determine whether point-of-care (community hospitals vs. tertiary centers) or treatment-delaying variables (transfer, emergency room [ER] throughput, and distance traveled) affect orchiectomy rates in minors with testicular torsion (TT) using a national database.

STUDY DESIGN

This was a retrospective cohort study using prospectively collected data by the Canadian Institute of Health Information (CIHI) between 2010 and 2015. All Canadian male patients in the CIHI database aged <18 years with TT based on International Classification of Diseases (ICD) codes were included, except for those residing in Quebec. Variables collected were age, type of treating institution (community small/medium, community large, or tertiary/academic), transfer for definitive treatment, road distance traveled, and ER throughput. The outcome was testicular loss based on intervention codes for orchiectomy/orchidopexy. Univariable and multivariable analyses were performed using logistic regression.

RESULTS

A total of 1713 minors with TT were included. Overall orchiectomy rate was 28%. Most patients (52%) were treated at tertiary hospitals. Small/medium community hospitals depicted the lowest odds of orchiectomy on univariable and multivariable analyses (odds ratio [OR] = 0.54, confidence interval [CI]: 0.37-0.79, p < 0.001); academic hospitals were also associated with a lower odds of orchiectomy than large community ones. Transfer and distance traveled were not associated with the outcome. Age >12 and ER throughput less than 1 h were significantly associated with lower orchiectomy rates. In a subgroup analysis of patients aged <12 years (n = 278), transfer was the only factor associated with increased risk of orchiectomy (OR = 2.41 , CI: 1.09-5.33; p = 0.03).

DISCUSSION

This study showed that small and medium community hospitals had the lowest orchiectomy rates in minors with TT in Canada (Figure). However, on multivariable analysis, they performed similarly to tertiary/academic hospitals, with both being superior to large community hospitals. Transfer and distance traveled did not affect orchiectomy rates. Emergency room throughput had a statistically significant association with orchiectomy rates in every analysis and based on the study data would constitute the best target for policies aimed at reducing orchiectomy rates for TT in minors. The main limitation of this study is the inability to evaluate long-term testicular viability of patients not undergoing orchiectomy (i.e., true testicular salvage).

CONCLUSIONS

Type of hospital treating facility (point-of-care) affects orchiectomy rates in minors with TT. Small/medium community hospitals depict the lowest orchiectomy rates in Canada. Transfer to another facility for definitive care and distance traveled did not affect orchiectomy rates, except in a subgroup analysis of prepubertal boys. Longer ER throughput and prepubertal age were consistently associated with loss of the testicle.

Treatment Facility Volume and Survival in Patients with Advanced Prostate Cancer

BACKGROUND

Despite improvements in medical management of advanced prostate cancer (aPC), it continues to be a leading cause of cancer death in men. Contemporary management of men with aPC is complex and requires resources to be more readily available at high-volume facilities.

OBJECTIVE

To determine the relationship between facility volume and survival in men with aPC.

DESIGN, SETTING, AND PARTICIPANTS

The National Cancer Database (NCDB) was queried from 2004 to 2013 for aPC, defined as T4, N+, or M+ disease, identifying 64815 patients. Six predefined patient cohorts were evaluated. Cohort "A" included all patients with aPC. "B" cohorts included only M0 patients. "C" cohorts included only M1 patients. Facilities were divided into quartiles based on median treatment volume (patients/yr).

INTERVENTION

Diagnosis and management of aPC at an NCDB-reporting facility.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Overall survival (OS) was assessed as a function of facility volume. Multivariable Cox regression models were fitted. Cox regressions using natural cubic splines were used to test for nonlinear relationships between volume and OS.

RESULTS AND LIMITATIONS

OS improved as facility volume increased (top quartile vs bottom quartile, hazard ratio 0.82, 95% confidence interval 0.77-0.88, p<0.001) and was consistent across patient cohorts. Spline models demonstrate a continuous decrease in hazard of death as volume increases. Limitations include the retrospective analysis and a lack of precise treatment information.

CONCLUSIONS

In this retrospective analysis of nearly 65000 men who presented with aPC, we demonstrate an association between higher facility volume and improvements in OS. This OS advantage persisted with similar magnitudes of effect after narrowing the cohorts by disease and treatment characteristics.

PATIENT SUMMARY

In this retrospective review of the National Cancer Database, we analyzed the association between treatment facility volume and survival in men who are diagnosed with advanced prostate cancer. We found that survival improved as volume increased, indicating a possible imbalance of resources and expertise that favors higher-volume facilities.