Self-reported volume of radical prostatectomies among urologists in the USA

Adding a newly trained surgeon into a high-volume robotic prostatectomy group: are outcomes compromised?

This study evaluates whether a new staff surgeon early in the learning curve can be integrated into a high-volume robotic practice with an established robotic team and mentorship without compromising robot-assisted radical prostatectomy (RARP) outcomes of the practice. We analyzed outcomes of 3064 patients who underwent RARP from 2007 to 2012 at a high-volume tertiary center by a robotic practice comprising three experienced robotic surgeons (2846 patients) and a newly hired surgeon (218 patients) immediately out of training (residency and oncology fellowship with 2 years of RARP exposure). The new surgeon performed RARP with intraoperative mentorship by the senior surgeons during the first year. Complications, biochemical recurrence (BCR), positive surgical margins rate (PSM), operating time (OR time), estimated blood loss (EBL) for the new and senior surgeons were compared. Multivariable linear, logistic and exact logistic regression adjusting for disease and patient characteristics were performed. On regression analyses, case number was the most significant predictor of decrease in probability of major complications (p = 0.025) and BCR (p = 0.004) for the new surgeon. Increasing case number was not associated with decrease in minor complications, PSM, OR time, or EBL (p > 0.05). Inclusion of the new surgeon's outcomes did not adversely impact outcomes of the practice. In conclusion, a new surgeon joining a high-volume robotic prostatectomy program with an established robotic team and mentorship can progress through the learning curve without compromising overall outcomes of the practice. Our results may be relevant for programs hiring newly trained staff to join an established robotic practice.

Arguments against investing widely in robotic prostatectomy in Canada: a wrong focus on tool box rather than surgical expertise

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Searching robotic prostatectomy online: what information is available?

OBJECTIVES

To search online using the Google search engine to determine what information for robotic-assisted radical prostatectomy (RARP) is available and whether the claims made on the Internet are supported by the published peer-reviewed urologic data.

METHODS

The term "robotic prostatectomy" was searched using Google on September 29, 2009. The first 50 Web sites were reviewed for RARP specific outcomes, including oncologic outcomes, potency, continence, recovery, and blood loss. All claims were compared with the accepted standards supported by the existing published urologic data.

RESULTS

Of the first 50 Web sites, 9 were rejected. Of the remaining 41, 29 were from academic practices and 8 from nonacademic practices; for 4, this distinction was not applicable. Also, 19 sites had direct links, photographs, or text from the Intuitive Surgical Web site, and 22 sites did not. Of the 41 Web sites, 20 made no mention of surgeon experience with RARP and 21 did, with an average experience of 1487 ± 1206 cases. More than 60% of the sites claimed better potency outcomes with RARP than with radical retropubic prostatectomy, although 32% of sites omitted this information. Similarly, 63% of the Web sites claimed improved continence with RARP than with radical retropubic prostatectomy, and 29% of the sites made no mention of continence. Data on oncologic efficacy was missing from 22% of the Web sites, 22% suggested the cancer outcomes were equivalent between RARP and radical retropubic prostatectomy, and 56% suggested the cancer outcomes were better with RARP. Concerning postoperative recovery and blood loss, 85% of the sites stated that both were improved with RARP, and only 15% omitted these data.

CONCLUSIONS

Overall, an online search using the Google search engine for robotic prostatectomy yielded many Web sites with unsubstantiated information of variable accuracy.

Baseline serum testosterone in men treated with androgen deprivation therapy and radiotherapy for localized prostate cancer

INTRODUCTION

It is believed that men diagnosed with prostate cancer and a low baseline serum testosterone (BST) may have more aggressive disease, and it is frequently recommended they forego testosterone replacement therapy. We used two large Phase III trials involving androgen deprivation therapy and external beam radiation therapy to assess the significance of a BST.

METHODS AND MATERIALS

All patients with a BST and complete data (n = 2,478) were included in this analysis and divided into four categories: "Very Low BST" (VLBST) ≤16.5th percentile of BST (≤248 ng/dL; n = 408); "Low BST" (LBST) >16.5th percentile and ≤33rd percentile (>248 ng/dL but ≤314 ng/dL; n = 415); "Average BST" (ABST) >33rd percentile and ≤67th percentile (314-437 ng/dL; n = 845); and "High BST" (HBST) >67th percentile (>437 ng/dL; n = 810). Outcomes included overall survival, distant metastasis, biochemical failure, and cause-specific survival. All outcomes were adjusted for the following covariates: treatment arm, BST, age (<70 vs. ≥70), prostate-specific antigen (PSA; <10 vs. 10 ≤ PSA <20 vs. 20 ≤), Gleason score (2-6 vs. 7 vs. 8-10); T stage (T1-T2 vs. T3-T4), and Karnofsky Performance Status (60-90 vs. 100).

RESULTS

On multivariable analysis age, Gleason score, and PSA were independently associated with an increased risk of biochemical failure, distant metastasis and a reduced cause-specific and overall survival (p < 0.05), but BST was not.

CONCLUSIONS

BST does not affect outcomes in men treated with external beam radiation therapy and androgen deprivation therapy for prostate cancer.

Critical appraisal of robotic-assisted radical prostatectomy

PURPOSE OF REVIEW

To perform a contemporary critical appraisal of robotic-assisted radical prostatectomy (RaRP) through a review of the recent literature.

RECENT FINDINGS

Most studies of RaRP are observational and report perioperative, functional and short-term oncological outcomes. RaRP is associated with less blood loss and blood transfusion than open radical prostatectomy (ORP), has a positive margin rate of 9.4-20.9%, potency rate of 79.2-80.4% at 1 year and a continence rate of 90.2-97% at 1 year. Costs of the da Vinci system remain a limitation of this technique.

SUMMARY

RaRP has shown rapid dissemination over the past few years in the US urological community. However, prospective randomized clinical trials with long-term follow-up of RaRP, ORP and laparoscopic radical prostatectomy are still necessary.

Variations in surgeon volume and use of pelvic lymph node dissection with open and minimally invasive radical prostatectomy

OBJECTIVES

Although pelvic lymph node dissection (PLND) during radical prostatectomy (RP) improves staging, controversy remains concerning its indications and benefits on cancer control. We examined the factors associated with PLND use among men undergoing open RP (ORP) and minimally invasive RP (MIRP).

METHODS

Using a 5% national sample of Medicare beneficiaries from 2003 to 2005, we identified 2702 men who had undergone RP. Multivariate logistic regression analysis was used to assess whether the surgical approach, surgeon volume, patient demographics, comorbidity, and geographic region were associated with the likelihood of performing PLND.

RESULTS

Overall, 68% of men underwent PLND, although the rates varied by surgical approach (17% vs 83% for MIRP vs ORP, respectively, P <.001). In adjusted analyses, men undergoing MIRP vs ORP (odds ratio [OR] 0.02, 95% confidence interval [CI], 0.02-0.03), men > or = 75 vs 65-69 years old (OR 0.23, 95% CI 0.17-0.31), and men with multiple vs no comorbidities (OR 0.48, 95% CI 0.35-0.66 for Charlson score > or = 3 vs 0) were less likely to undergo PLND. High-volume minimally invasive surgeons were more likely to perform PLND (OR 1.19, 95% CI 1.14-1.25). Finally, men in the Western vs Southern United States (OR 1.61, 95% CI 1.19-2.17) were more likely to undergo PLND.

CONCLUSIONS

Men undergoing MIRP vs ORP were less likely to undergo PLND, although rates of the procedure increased with surgical volume. Additional studies are needed to determine the indications and benefits of this procedure for men with prostate 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.

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.

The cost of learning robotic-assisted prostatectomy

OBJECTIVES

To describe the costs associated with the learning curve of robotic-assisted prostatectomy (RAP).

METHODS

A theoretical model of the cost of operative time during the learning curve for RAP was constructed. Within the theoretical model varying rates of improvement were considered, and once the learning curve was complete, the total cost of operative time was calculated. This cost was then compared with an actual series of RAP, whose operative time and associated costs during the learning curve were also calculated.

RESULTS

In the theoretical model, surgeons improved at rates of 1, 5, or 10 minutes per case, and began the learning curve that required 8 or 9 hours to perform a single RAP. At the end of the learning curve it took either 3 or 4 hours. The most expensive learning curve was 360 cases long and cost $1.3 million; the least expensive learning curve was 24 cases and cost $95,000. The literature search involved 8 series, with a range of learning curves from 13 to 200 cases. The least expensive learning curve was $49,613 and the most expensive learning curve was $554,694. The average learning curve was 77 cases and cost $217,034.

CONCLUSIONS

Costs associated with operative time while learning RAP are substantial, and should be considered when deciding whether to implement RAP at an individual institution. RAP may best be suited to high volume prostatectomy centers, in which the learning curve can be rapidly traversed, and associated costs minimized.