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Fonseca J, Moraes-Fontes MF, Rebola J, Lúcio R, Almeida M, Muresan C, Palmas A, Gaivão A, Matos C, Santos T, Dias D, Sousa I, Oliveira F, Ribeiro R, Lopez-Beltran A, Fraga A. Retzius-sparing robot-assisted radical prostatectomy in a medium size oncological center holds adequate oncological and functional outcomes. J Robot Surg 2023; 17:1133-1142. [PMID: 36633734 DOI: 10.1007/s11701-022-01517-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 12/31/2022] [Indexed: 01/13/2023]
Abstract
Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has emerged as a surgical option for patients with prostatic cancer in high-volume centers. The objective is to assess oncological and functional outcomes when implementing RS-RARP in a medium-volume center without previous experience of robotic surgery. This is a prospective observational single-center study. Patients operated between July 2017 and April 2020 were divided into two consecutive groups, A and B, each with 104 patients. The surgeons had prior experience in laparoscopic surgery and underwent robotic training. Positive surgical margin (PSM) status, urinary continence, and erectile function projected by Kaplan-Meier curves, together with patient reported quality of life outcomes at 12 months post-surgery were documented. Median patient age was 63 years (IQR = 59-67), overall PSM rate were 33%, 28% for pT2 disease. Pre-operative values showed no significant difference between both groups. The rate of urinary continence dropped from 81 to 78% (SE = 5.7) (Group A) and from 90 to 72% (SE = 6.3) (Group B) using the International Consultation on Incontinence Questionnaire-Short Form. Baseline sexual function was regained in 41% (Group A) and 47% (Group B) of patients. The median Expanded Prostate Index Composite-26 total score decreased from 86 to 82. These outcomes relate favorably to prior reports. There was a clinically significant decrease in median operative time in the successive groups with post-operative complications occurring in less than 2% of surgical procedures overall. A 12-month follow-up suggests that RS-RARP may be safely introduced in a medium-volume center without previous experience of robotic surgery.
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Affiliation(s)
- Jorge Fonseca
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal. .,Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.
| | | | - Jorge Rebola
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Rui Lúcio
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Miguel Almeida
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Ciprian Muresan
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Artur Palmas
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Ana Gaivão
- Centro Clínico Champalimaud, Serviço de Imagiologia, Champalimaud Foundation, Lisbon, Portugal
| | - Celso Matos
- Centro Clínico Champalimaud, Serviço de Imagiologia, Champalimaud Foundation, Lisbon, Portugal
| | - Tiago Santos
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Daniela Dias
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Inês Sousa
- Centro Clínico Champalimaud, Unidade de Investigação Clínica, Champalimaud Foundation, Lisbon, Portugal
| | - Francisco Oliveira
- Centro Clínico Champalimaud, Serviço de Medicina Nuclear, Champalimaud Foundation, Lisbon, Portugal
| | - Ricardo Ribeiro
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal
| | - Antonio Lopez-Beltran
- Centro Clínico Champalimaud, Unidade de Anatomia Patológica, Champalimaud Foundation, Lisbon, Portugal
| | - Avelino Fraga
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal
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Monsen KV, Fosså SD, Myklebust TÅ, Smeland S, Dahl AA, Stensvold A. Long-term satisfaction with curative treatment and follow-up in prostate cancer survivors. Acta Oncol 2022; 61:357-362. [PMID: 35103559 DOI: 10.1080/0284186x.2021.2006775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
PURPOSE In a cross-sectional observational study to explore long-term satisfaction with treatment among men who had undergone radical prostatectomy (RP) or definitive pelvic radiotherapy (RT) for prostate cancer (PCa). METHODS After mean 7 years from therapy (range: 6-8), 431 PCa-survivors (RP: n = 313, RT: n = 118) completed a mailed questionnaire assessing persistent treatment-related adverse effects (AEs) (Expanded Prostate cancer Index Composite [EPIC-26]) and seven Quality indicators describing satisfaction with the health care service following a most often general practitioner (GP)-led follow-up plan. A logistic regression model evaluated the associations between long-term satisfaction and treatment modality, age, the seven satisfaction-related Quality indicators, and persistent AEs. The significance level was set at p< .05. RESULTS Four of five (81%) PCa-survivors reported long-term satisfaction with their treatment. In a multivariable model, satisfaction was positively associated with sufficient information about treatment and AEs, patient-perceived sufficient cooperation between the hospital and the GP and sufficient follow-up of AEs (ref.: insufficient). Age ≥70 years (ref.: <70) and a rising summary score within the EPIC-26 sexual domain additionally increased long-term satisfaction. The treatment modality itself (RP versus RT) did not significantly impact on satisfaction. CONCLUSIONS The majority of curatively treated PCa-survivors are satisfied with their treatment more than 5 years after primary therapy. Sufficient information, improved cooperation between the hospital specialists and the responsible GP and optimized follow-up of AEs may further increase long-term satisfaction among prostatectomized and irradiated PCa-survivors.
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Affiliation(s)
- Kari V. Monsen
- Section for Clinical Cancer Research, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Norway
| | - Sophie D. Fosså
- Section for Clinical Cancer Research, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Norway
| | - Tor Å. Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Cancer Registry of Norway, Oslo, Norway
| | - Sigbjørn Smeland
- Faculty of Medicine, University of Oslo, Norway
- Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Alv A. Dahl
- Section for Clinical Cancer Research, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Norway
| | - Andreas Stensvold
- Division of Clinical Oncology, Østfold Hospital Trust, Kalnes, Norway
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Yang CW, Wang HH, Hassouna MF, Chand M, Huang WJS, Chung HJ. Prediction of a positive surgical margin and biochemical recurrence after robot-assisted radical prostatectomy. Sci Rep 2021; 11:14329. [PMID: 34253832 PMCID: PMC8275750 DOI: 10.1038/s41598-021-93860-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/14/2021] [Indexed: 02/06/2023] Open
Abstract
The positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio [HR] 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.
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Affiliation(s)
- Ching-Wei Yang
- Department of Urology, Cheng-Hsin General Hospital, No. 45, Cheng-Hsin St., Beitou Dist., Taipei, 112, Taiwan
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, 43-45 Foley Street, London, W1W 7JN, UK
| | - Hsiao-Hsien Wang
- Department of Urology, Cheng-Hsin General Hospital, No. 45, Cheng-Hsin St., Beitou Dist., Taipei, 112, Taiwan
| | - Mohamed Fayez Hassouna
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, 43-45 Foley Street, London, W1W 7JN, UK
- Division of Surgical and Interventional Sciences, Charles Bell House, 43-45 Foley St, Fitzrovia, London, W1W 7TY, UK
| | - Manish Chand
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, 43-45 Foley Street, London, W1W 7JN, UK
- Department of Colorectal Surgery, University College London Hospital, 250 Euston Road, London, NW1 2BU, UK
| | - William J S Huang
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan
- Department of Urology, Taipei Veterans General Hospital, 201, Sec 2, Shih-Pai Rd., Beitou Dist., Taipei, 112, Taiwan
| | - Hsiao-Jen Chung
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan.
- Department of Urology, Taipei Veterans General Hospital, 201, Sec 2, Shih-Pai Rd., Beitou Dist., Taipei, 112, Taiwan.
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Association of surgeon and hospital volume with short-term outcomes after robot-assisted radical prostatectomy: Nationwide, population-based study. PLoS One 2021; 16:e0253081. [PMID: 34138904 PMCID: PMC8211177 DOI: 10.1371/journal.pone.0253081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/27/2021] [Indexed: 12/26/2022] Open
Abstract
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.
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Lardas M, Grivas N, Debray TPA, Zattoni F, Berridge C, Cumberbatch M, Van den Broeck T, Briers E, De Santis M, Farolfi A, Fossati N, Gandaglia G, Gillessen S, O'Hanlon S, Henry A, Liew M, Mason M, Moris L, Oprea-Lager D, Ploussard G, Rouviere O, Schoots IG, van der Kwast T, van der Poel H, Wiegel T, Willemse PP, Yuan CY, Grummet JP, Tilki D, van den Bergh RCN, Lam TB, Cornford P, Mottet N. Patient- and Tumour-related Prognostic Factors for Urinary Incontinence After Radical Prostatectomy for Nonmetastatic Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus 2021; 8:674-689. [PMID: 33967010 DOI: 10.1016/j.euf.2021.04.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/23/2021] [Indexed: 12/22/2022]
Abstract
CONTEXT While urinary incontinence (UI) commonly occurs after radical prostatectomy (RP), it is unclear what factors increase the risk of UI development. OBJECTIVE To perform a systematic review of patient- and tumour-related prognostic factors for post-RP UI. The primary outcome was UI within 3 mo after RP. Secondary outcomes included UI at 3-12 mo and ≥12 mo after RP. EVIDENCE ACQUISITION Databases including Medline, EMBASE, and CENTRAL were searched between January 1990 and May 2020. All studies reporting patient- and tumour-related prognostic factors in univariable or multivariable analyses were included. Surgical factors were excluded. Risk of bias (RoB) and confounding assessments were performed using the Quality In Prognosis Studies (QUIPS) tool. Random-effects meta-analyses were performed for all prognostic factor, where possible. EVIDENCE SYNTHESIS A total of 119 studies (5 randomised controlled trials, 24 prospective, 88 retrospective, and 2 case-control studies) with 131 379 patients were included. RoB was high for study participation and confounding; moderate to high for statistical analysis, study attrition, and prognostic factor measurement; and low for outcome measurements. Significant prognostic factors for postoperative UI within 3 mo after RP were age (odds ratio [OR] per yearly increase 1.04, 95% confidence interval [CI] 1.03-1.05), membranous urethral length (MUL; OR per 1-mm increase 0.81, 95% CI 0.74-0.88), prostate volume (PV; OR per 1-ml increase 1.005, 95% CI 1.000-1.011), and Charlson comorbidity index (CCI; OR 1.28, 95% CI 1.09-1.50). CONCLUSIONS Increasing age, shorter MUL, greater PV, and higher CCI are independent prognostic factors for UI within 3 mo after RP, with all except CCI remaining prognostic at 3-12 mo. PATIENT SUMMARY We reviewed the literature to identify patient and disease factors associated with urinary incontinence after surgery for prostate cancer. We found increasing age, larger prostate volume, shorter length of a section of the urethra (membranous urethra), and lower fitness were associated with worse urinary incontinence for the first 3 mo after surgery, with all except lower fitness remaining predictive at 3-12 mo.
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Affiliation(s)
- Michael Lardas
- Department of Urology, Metropolitan General Hospital, Athens, Greece.
| | - Nikos Grivas
- Department of Urology, University General Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Thomas P A Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Fabio Zattoni
- Urology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | | | | | | | | | - Maria De Santis
- Department of Urology, Charité Universitätsmedizin Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Andrea Farolfi
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
| | - Nicola Fossati
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giorgio Gandaglia
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Shane O'Hanlon
- Medicine for Older People, Saint Vincent's University Hospital, Dublin, Ireland
| | - Ann Henry
- Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK
| | - Matthew Liew
- Department of Urology, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Malcolm Mason
- Division of Cancer & Genetics, Cardiff University School of Medicine, Velindre Cancer Centre, Cardiff, UK
| | - Lisa Moris
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Daniela Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VU University, Amsterdam, The Netherlands
| | | | - Olivier Rouviere
- Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Henk van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter-Paul Willemse
- Department of Oncological Urology, University Medical Center, Utrecht Cancer Center, Utrecht, The Netherlands
| | - Cathy Y Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | - Jeremy P Grummet
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, and Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Thomas B Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Philip Cornford
- Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
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6
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Van den Broeck T, Oprea-Lager D, Moris L, Kailavasan M, Briers E, Cornford P, De Santis M, Gandaglia G, Gillessen Sommer S, Grummet JP, Grivas N, Lam TBL, Lardas M, Liew M, Mason M, O'Hanlon S, Pecanka J, Ploussard G, Rouviere O, Schoots IG, Tilki D, van den Bergh RCN, van der Poel H, Wiegel T, Willemse PP, Yuan CY, Mottet N. A Systematic Review of the Impact of Surgeon and Hospital Caseload Volume on Oncological and Nononcological Outcomes After Radical Prostatectomy for Nonmetastatic Prostate Cancer. Eur Urol 2021; 80:531-545. [PMID: 33962808 DOI: 10.1016/j.eururo.2021.04.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 04/19/2021] [Indexed: 12/13/2022]
Abstract
CONTEXT The impact of surgeon and hospital volume on outcomes after radical prostatectomy (RP) for localised prostate cancer (PCa) remains unknown. OBJECTIVE To perform a systematic review on the association between surgeon or hospital volume and oncological and nononcological outcomes following RP for PCa. EVIDENCE ACQUISITION Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. All comparative studies for nonmetastatic PCa patients treated with RP published between January 1990 and May 2020 were included. For inclusion, studies had to compare hospital or surgeon volume, defined as caseload per unit time. Main outcomes included oncological (including prostate-specific antigen persistence, positive surgical margin [PSM], biochemical recurrence, local and distant recurrence, and cancer-specific and overall survival) and nononcological (perioperative complications including need for blood transfusion, conversion to open procedure and within 90-d death, and continence and erectile function) outcomes. Risk of bias (RoB) and confounding assessments were undertaken. Both a narrative and a quantitative synthesis were planned if the data allowed. EVIDENCE SYNTHESIS Sixty retrospective comparative studies were included. Generally, increasing surgeon and hospital volumes were associated with lower rates of mortality, PSM, adjuvant or salvage therapies, and perioperative complications. Combining group size cut-offs as used in the included studies, the median threshold for hospital volume at which outcomes start to diverge is 86 (interquartile range [IQR] 35-100) cases per year. In addition, above this threshold, the higher the caseload, the better the outcomes, especially for PSM. RoB and confounding were high for most domains. CONCLUSIONS Higher surgeon and hospital volumes for RP are associated with lower rates of PSMs, adjuvant or salvage therapies, and perioperative complications. This association becomes apparent from a caseload of >86 (IQR 35-100) per year and may further improve hereafter. Both high- and low-volume centres should measure their outcomes, make them publicly available, and improve their quality of care if needed. PATIENT SUMMARY We reviewed the literature to determine whether the number of prostate cancer operations (radical prostatectomy) performed in a hospital affects the outcomes of surgery. We found that, overall, hospitals with a higher number of operations per year have better outcomes in terms of cancer recurrence and complications during or after hospitalisation. However, it must be noted that surgeons working in hospitals with lower annual operations can still achieve similar or even better outcomes. Therefore, making hospital's outcome data publicly available should be promoted internationally, so that patients can make an informed decision where they want to be treated.
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Affiliation(s)
| | - Daniela Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, VU University, Amsterdam, The Netherlands
| | - Lisa Moris
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Philip Cornford
- Department of Urology, Liverpool University Hospitals, Liverpool, UK
| | - Maria De Santis
- Department of Urology, Charité University Hospital, Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Giorgio Gandaglia
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silke Gillessen Sommer
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Jeremy P Grummet
- Department of Surgery, Central Clinical School, Monash University, Australia
| | - Nikos Grivas
- Department of Urology, Hatzikosta General Hospital, Ioannina, Greece
| | - Thomas B L Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Michael Lardas
- Department of Urology, Metropolitan General Hospital, Athens, Greece
| | - Matthew Liew
- Department of Urology, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Malcolm Mason
- Division of Cancer & Genetics, School of Medicine Cardiff University, Velindre Cancer Centre, Cardiff, UK
| | - Shane O'Hanlon
- Medicine for Older People, Saint Vincent's University Hospital, Dublin, Ireland
| | | | | | - Olivier Rouviere
- Hospices Civils de Lyon, Department of Urinary and Vascular Imaging, Hôspital Edouard Herriot, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Centre, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Henk van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter-Paul Willemse
- Department of Oncological Urology, University Medical Centre, Utrecht Cancer Centre, Utrecht, The Netherlands
| | - Cathy Y Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, Ontario, Canada
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
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7
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Trieu D, Ju IE, Chang SB, Mungovan SF, Patel MI. Surgeon case volume and continence recovery following radical prostatectomy: a systematic review. ANZ J Surg 2020; 91:521-529. [PMID: 33319438 DOI: 10.1111/ans.16491] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/16/2020] [Accepted: 11/29/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Urinary incontinence (UI) is a common complication following radical prostatectomy (RP). Prolonged UI has a substantial impact on quality of life and psychosocial well-being. As the RP technique is complex, it is reasonable to propose that surgeon experience could affect post-operative continence recovery outcomes. This study aimed to systematically evaluate evidence regarding a surgeon's experience and continence recovery after RP. METHODS A comprehensive search of the literature was performed in April 2020 using the Medline, Embase, CINAHL and psychINFO electronic databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. All English language studies investigating UI following RP, stratified by surgeon experience, were included. Surgeon experience was defined as average annual case load or volume. RESULTS Thirteen studies published between 2003 and 2020 met the inclusion criteria and were included in our systematic review. Three prospective and 10 retrospective cohort studies included a total of 47 316 patients undergoing RP via open, laparoscopic or robotic-assisted procedures. Heterogeneity in the definition of surgeon experience and UI did not allow a meta-analysis. The majority of studies reported that surgeons with higher surgical volumes achieved better continence recovery rates at the early (6-week), 3-month, 6-month and later (≥12-month) time points. Most studies where a high surgical volume was defined as >50 cases/year demonstrated a significant difference in continence outcomes. CONCLUSION Better urinary continence recovery results can be expected by patients who undergo RP performed by a surgeon with greater experience. An annual surgical case load of >50 cases/year results in improved continence recovery outcomes following RP.
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Affiliation(s)
- Danny Trieu
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Irene E Ju
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Simon B Chang
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sean F Mungovan
- Westmead Private Physiotherapy Services, Westmead Private Hospital, Sydney, New South Wales, Australia.,The Clinical Research Institute, Sydney, New South Wales, Australia.,Department of Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Manish I Patel
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Urology, Westmead Hospital, Sydney, New South Wales, Australia
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8
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Linear extent of positive surgical margin impacts biochemical recurrence after robot-assisted radical prostatectomy in a high-volume center. J Robot Surg 2020; 14:663-675. [PMID: 31893344 DOI: 10.1007/s11701-019-01039-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/18/2019] [Indexed: 10/25/2022]
Abstract
The objective of this study is to evaluate if surgeon volume and stratifying positive surgical margins (PSM) into focal and non-focal may differentially impact the risk of biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP). Between January 2013 and December 2017, 732 consecutive patients were evaluated. The population included negative cases (control group) and PSM subjects (study group). PSMs were stratified as focal (≤ 1 mm) or non-focal (> 1 mm). A logistic regression model assessed the independent association of factors with the risk of PSM. The risk of BCR of PSM and other factors was assessed by Cox's multivariate proportional hazards. Overall, 192 (26.3%) patients had PSM focal in 133 patients; non-focal in 59 cases. Focal PSM was associated with the percentage of biopsy positive cores (BPC; OR 1.011; p = 0.015), extra-capsular extension (pT3a stage; OR 2.064; p = 0.016), seminal vesicle invasion (pT3b; OR 2.150; p = 0.010), body mass index (odds ratio, OR 0.914; p = 0.006), and high surgeon volume (OR 0.574; p = 0.006). BPC (OR 1.013; p = 0.044), pT3a (OR 4.832; p < 0.0001) and pT3b stage (OR 5.153; p = 0.001) were independent predictors of the risk of non-focal PSM. Surgeon volume was not a predictor of non-focal PSM (p = 0.224). Independent factors associated with the risk of BCR were baseline PSA (hazard ratio, HR 1.064; p = 0.004), BPC (HR 1.015; p = 0.027), ISUP biopsy grade group (BGG) 2/3 (HR 2.966; p 0.003) and BGG 4/5 (HR 3.122; p = 0.022) pathologic grade group 4/5 (HR 3.257; p = 0.001), pT3b (HR 2.900; p = 0.003), and non-focal PSM (HR 2.287; p = 0.012). Surgeon volume was not a predictor of BCR (p = 0.253). High surgeon volume is an independent factor that lowers the risk of focal PSM. Surgeon volume does not affect non-focal PSM and BCR. Negative as well as focal PSM are not associated with BCR.
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Porcaro AB, Tafuri A, Sebben M, Amigoni N, Processali T, Pirozzi M, Rizzetto R, Shakir A, Corsi P, Tiso L, Cerrato C, Migliorini F, Novella G, Brunelli M, Bernasconi R, De Marco V, Siracusano S, Artibani W. High surgeon volume and positive surgical margins can predict the risk of biochemical recurrence after robot-assisted radical prostatectomy. Ther Adv Urol 2019; 11:1756287219878283. [PMID: 31579118 PMCID: PMC6759701 DOI: 10.1177/1756287219878283] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/04/2019] [Indexed: 01/23/2023] Open
Abstract
Background: The aim of this study was to determine whether any clinical factors are independent predictors of positive surgical margins (PSM), and to assess the association of PSM and biochemical recurrence (BR) after robot-assisted radical prostatectomy (RARP). Methods: The population included cases with negative surgical margins (control group) and patients with PSM (study group). Tumor grade was evaluated according to the International Society of Urologic Pathology (ISUP) system. A logistic regression model assessed the independent association of factors with the risk of PSM. The risk of BR was assessed by Cox’s multivariate proportional hazards. Results: A total of 732 consecutive patients were evaluated. Extend pelvic lymph node dissection (ePLND) was performed in 342 cases (46.7%). Overall, 192 cases (26.3%) had PSM. The risk of PSM was positively associated with the percentage of biopsy positive cores (BPC; odds ratio, OR = 1.012; p = 0.004), extracapsular extension (pT3a; OR=2.702; p < 0.0001), invasion of seminal vesicle (pT3b; OR = 2.889; p < 0.0001), but inversely with body mass index (OR = 0.936; p = 0.021), and high surgeon volume (OR = 0.607; p = 0.006). Independent clinical factors associated with the risk of BR were baseline prostate-specific antigen (PSA; hazard ratio, HR = 1.064; p = 0.004), BPC (HR = 1.015; p = 0.027), ISUP biopsy grade group (BGG) 2/3 (HR = 2.966; p = 0.003), and BGG 4/5 (HR = 3.122; p = 0.022). Pathologic factors associated with the risk of BR were ISUP group 4/5 (HR = 3.257; p = 0.001), pT3b (HR = 2.900; p = 0.003), and PSM (HR = 2.096; p = 0.045). Conclusions: In our cohort, features related to host, tumor, and surgeon volume are associated with the risk of PSM, which is also an independent parameter predicting BR after RARP. The surgical volume of the operating surgeon is an independent factor that decreases the risk of PSM, and, as such, the risk of BR.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology Azienda Ospedaliera Universitaria Integrata Verona, Piazzale Stefani 1, Verona, 37126, Italy
| | - Alessandro Tafuri
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Marco Sebben
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Nelia Amigoni
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Tania Processali
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Marco Pirozzi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Riccardo Rizzetto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Aliasger Shakir
- USC Institute of Urology, and Catherine & Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Paolo Corsi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Leone Tiso
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Clara Cerrato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Filippo Migliorini
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giovanni Novella
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Riccardo Bernasconi
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Vincenzo De Marco
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Salvatore Siracusano
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Walter Artibani
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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Storås AH, Sanda MG, Garin O, Chang P, Patil D, Crociani C, Suarez JF, Cvancarova M, Loge JH, Fosså SD. A prospective study of patient reported urinary incontinence among American, Norwegian and Spanish men 1 year after prostatectomy. Asian J Urol 2019; 7:161-169. [PMID: 32257809 PMCID: PMC7096671 DOI: 10.1016/j.ajur.2019.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 10/26/2018] [Accepted: 12/21/2018] [Indexed: 12/03/2022] Open
Abstract
Objective To compare pre- and post-radical prostatectomy (RP) responses in the urinary incontinence domain of Expanded Prostate Cancer Index Composite-26 (EPIC-26) in cohorts from the USA, Norway and Spain. Methods A prospective study of pre- and 1-year post-treatment responses in American (n=537), Norwegian (n=520) and Spanish (n=111) patients, establishing the prevalence of urinary incontinence defined according to published dichotomization. Thereafter we focused on the response alternatives “occasional dribbling”, pad use and problem experience. A multivariate logistic regression analysis (significance level ≤ 0.01) considered risk factors for “not retaining total control”. Results Compared to the European men, the American patients were younger, healthier and more presented with lower risk tumors. Before RP no inter-country differences emerged the prevalence of urinary incontinence (6%). One-year post-treatment urinary incontinence was described by 30% of the American and 41% of the European patients, occasional dribbling being the most frequent type of urinary leakage. In the multivariate analysis the risk of “not retaining total control” increased almost 3-fold in European compared to American patients, with age and co-morbidity being additional independent risk factor. Conclusion After RP patients from Spain and Norway reported more unfavorable outcomes by EPIC-26 than the American patients to most of the urinary incontinence items, the difference between the European and American patients remaining in the multivariate analysis. The most frequent post-RP response alternative “occasional dribbling” needs to be validated with pad weighing as “gold standard”.
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Affiliation(s)
- Anne Holck Storås
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Martin G Sanda
- Department of Urology, Emory University Hospital, Atlanta, USA
| | - Olatz Garin
- IMIM Hospital del Mar Medical Research Institute, CIBER en Epidemiología y Salud Pública, CIBERESP, Universitat Pompeu Fabra, Barcelona, Spain
| | - Peter Chang
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | | | - Catrina Crociani
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | | | - Milada Cvancarova
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Jon Håvard Loge
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway.,University of Oslo, Oslo, Norway
| | - Sophie D Fosså
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway.,University of Oslo, Oslo, Norway
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Porcaro AB, Tafuri A, Sebben M, Corsi P, Processali T, Pirozzi M, Amigoni N, Rizzetto R, Shakir A, Cacciamani G, Mariotto A, Brunelli M, Bernasconi R, Novella G, De Marco V, Artibani W. Surgeon volume and body mass index influence positive surgical margin risk after robot-assisted radical prostatectomy: Results in 732 cases. Arab J Urol 2019; 17:234-242. [PMID: 31489241 PMCID: PMC6711124 DOI: 10.1080/2090598x.2019.1619276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 04/30/2019] [Indexed: 11/24/2022] Open
Abstract
Objectives: To evaluate clinicopathological and perioperative factors associated with the risk of focal and non-focal positive surgical margins (PSMs) after robot-assisted radical prostatectomy (RARP). Patients and methods: The study was retrospective and excluded patients who were under androgen-deprivation therapy or had prior treatments. The population included: negative SM cases (control group), focal and non-focal PSM cases (study groups). PSMs were classified as focal when the linear extent of cancer invasion was ≤1 mm and non-focal when >1 mm. The independent association of factors with the risk of focal and non-focal PSMs was assessed by multinomial logistic regression. Results: In all, 732 patients underwent RARP, from January 2013 to December 2017. An extended pelvic lymph node dissection was performed in 342 cases (46.7%). In all, 192 cases (26.3%) had PSMs, which were focal in 133 (18.2%) and non-focal in 59 (8.1%). Independent factors associated with the risk of focal PSMs were body mass index (odds ratio [OR] 0.914; P = 0.006), percentage of biopsy positive cores (BPC; OR 1.011; P = 0.015), pathological extracapsular extension (pathological tumour stage [pT]3a; OR 2.064; P = 0.016), and seminal vesicle invasion (pT3b; OR 2.150; P = 0.010). High surgeon volume was a protective factor in having focal PSM (OR 0.574; P = 0.006). Independent predictors of non-focal PSMs were BPC (OR 1,013; P = 0,044), pT3a (OR 4,832; P < 0.001), and pT3b (OR 5,153; P = 0.001). Conclusions: In high-volume centres features related to host, tumour and surgeon volume are factors that predict the risk of focal and non-focal PSMs after RARP. Abbreviations: AJCC: American joint committee on cancer; AS: active surveillance; ASA: American society of anesthesiologists; BCR: biochemical recurrence; BMI: body mass index; BPC: percentage of biopsy positive cores; ePLND: extended lymph node dissection; H&E: haematoxylin and eosin; IQR, interquartile range; ISUP: international society of urologic pathology; LNI: lymph node invasion; LOS: length of hospital stay; mpMRI: multiparametric MRI; (c)(p)N: (clinical) (pathological) nodal stage; OR: odds ratio; OT: operating time; PSA-DT: PSA-doubling time; (P)SM: (positive) surgical margin; (NS)(RA)RP: (nerve-sparing) (robot-assisted) radical prostatectomy; RT: radiation therapy; (c)(p)T: (clinical) (pathological) tumour stage
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Affiliation(s)
- Antonio B Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Alessandro Tafuri
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.,Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Marco Sebben
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Paolo Corsi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Tania Processali
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Marco Pirozzi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Nelia Amigoni
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Riccardo Rizzetto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Aliasger Shakir
- Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Giovanni Cacciamani
- Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Arianna Mariotto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Riccardo Bernasconi
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giovanni Novella
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Vincenzo De Marco
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Walter Artibani
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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Porcaro AB, Sebben M, Corsi P, Tafuri A, Processali T, Pirozzi M, Amigoni N, Rizzetto R, Cacciamani G, Mariotto A, Diminutto A, Brunelli M, De Marco V, Siracusano S, Artibani W. Risk factors of positive surgical margins after robot-assisted radical prostatectomy in high-volume center: results in 732 cases. J Robot Surg 2019; 14:167-175. [DOI: 10.1007/s11701-019-00954-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/28/2019] [Indexed: 01/22/2023]
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The implications of fellowship expansion on future pediatric urologist surgical volumes. J Pediatr Urol 2018; 14:246-250. [PMID: 29958643 DOI: 10.1016/j.jpurol.2017.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 10/13/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Over the past 25 years, Pediatric Urology fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) have more than doubled. This increase may lead to a significant decrease in the number of operative cases per surgeon and therefore impact the current practice of pediatric urology. OBJECTIVE The objective in conducting this study is to try and predict the effect of the current number of pediatric urology fellowship training positions on future case volume per surgeon using a mathematical model and to discuss future management of the pediatric urology workforce. DESIGN The current study employed a mathematical model to predict the effect of the number of fellowship graduates on future "case volume per surgeon". We incorporated population growth rates, to calculate incidence rates of key procedures/conditions and the anticipated retirement rate of the current pool of pediatric urologists to help calculate this. RESULTS There is a possibility to increase the number of practicing board-certified pediatric urologists in the next 30 years from approximately 325 to 900 (figure). There will be a twofold reduction in case volume per surgeon compared to the present in model 1. In model 2 the decrease in case volumes is less significant. The annual number of fellows needed to obtain a future-to-current ratio equal to 1 is 16 for model 1, and 26 for model 2. DISCUSSION Our study demonstrates, by using two different models that the current number of pediatric urology fellowship training positions in the United States will ultimately lead to a significant decrease in the case volume per surgeons. Our model has limitations as it relies on multiple assumptions. We are assuming that all fellowship positions would be filled every year and that all fellows would graduate, establish their practices in the United States, and devote 100% of their assumed 30-year professional career to pediatric urology. We also made assumptions of disease occurrence and need for surgical correction. The final assumption we made was that the birth rate would stay static over the next 30 years even though it has been declining for many decades. CONCLUSION This exercise, even with its inherent limitations, is still sufficient to demonstrate that fellowship expansion warrants thoughtful discussion.
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Leow JJ, Leong EK, Serrell EC, Chang SL, Gruen RL, Png KS, Beaule LT, Trinh QD, Menon MM, Sammon JD. Systematic Review of the Volume-Outcome Relationship for Radical Prostatectomy. Eur Urol Focus 2017; 4:775-789. [PMID: 28753874 DOI: 10.1016/j.euf.2017.03.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Radical prostatectomy (RP) is one of the most complex urological procedures performed. Higher surgical volume has been found previously to be associated with better patient outcomes and reduced costs to the health care system. This has resulted in some regionalization of care toward high-volume facilities and providers; however, the preponderance of RPs is still performed at low-volume institutions. OBJECTIVE To provide an updated systematic review of the association of hospital and surgeon volume on patient and system outcomes after RP, including robot-assisted RP. EVIDENCE ACQUISITION A systematic review of literature was undertaken, searching PubMed (1959-2016) for original articles. Selection criteria included RP, hospital and/or surgeon volumes as predictor variables, categorization of hospital and/or surgeon volumes, and measurable end points. EVIDENCE SYNTHESIS Overall 49 publications fulfilled the inclusion criteria. Most of the studies demonstrated that higher-volume surgeries are associated with better outcomes including reduced mortality, morbidity, postoperative complications, length of stay, readmission, and cost-associated factors. The volume-outcome relationship is maintained in robotic surgery. Eleven studies assessed hospital and surgeon volume simultaneously, and findings reflect that neither is an independent predictor variable affecting outcomes. The studies varied in how volume cutoffs were categorized as well as how the volume-outcome relationship was methodologically evaluated. CONCLUSIONS Contemporary evidence continues to support the relationship between high-volume surgeries with improved RP outcomes. Recent studies demonstrate that the volume-outcome relationship applies to robot-assisted RP and may be applied for potential cost savings in health care. An increase in the number of international studies suggests reproducibility of the association. Although regionalization of surgical care remains a contentious issue, there is an increasing body of evidence that short-term outcomes are improved at high-volume centers for RP. PATIENT SUMMARY This systematic review of the latest literature found that higher surgical volume was associated with improved outcomes for radical prostatectomy.
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Affiliation(s)
- Jeffrey J Leow
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Eugene K Leong
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore-Imperial College London, Singapore
| | | | - Steven L Chang
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Russell L Gruen
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore-Imperial College London, Singapore
| | - Keng Siang Png
- Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Lisa T Beaule
- Tufts University School of Medicine, Boston, MA, USA; Division of Urology, Maine Medical Center, Portland, ME, USA; Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mani M Menon
- VUI Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Jesse D Sammon
- Tufts University School of Medicine, Boston, MA, USA; Division of Urology, Maine Medical Center, Portland, ME, USA; Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA.
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Fosså SD, Storås AH, Steinsvik EA, Myklebust TA, Eri LM, Loge JH, Dahl AA. Psychometric testing of the Norwegian version of the Expanded Prostate Cancer Index Composite 26-item version (EPIC-26). Scand J Urol 2016; 50:280-5. [DOI: 10.3109/21681805.2016.1163617] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Sophie D. Fosså
- National Advisory Unit on Late Effects after Cancer Treatment, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
- Cancer Registry of Norway, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne Holck Storås
- National Advisory Unit on Late Effects after Cancer Treatment, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Eivind A. Steinsvik
- Division of Surgery, Department of Otorhinolaryngology, Akershus University Hospital, Lørenskog, Norway
| | | | - Lars M. Eri
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Urology, Oslo University Hospital, Oslo, Norway
| | - Jon H. Loge
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Regional Centre for Excellence in Palliative Care, Oslo University Hospital, Oslo, Norway
| | - Alv A. Dahl
- National Advisory Unit on Late Effects after Cancer Treatment, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Fosså SD, Dahl AA. Global Quality of Life After Curative Treatment for Prostate Cancer: What Matters? A Study Among Members of the Norwegian Prostate Cancer Patient Association. Clin Genitourin Cancer 2015; 13:518-24. [PMID: 26303590 DOI: 10.1016/j.clgc.2015.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/17/2015] [Accepted: 07/18/2015] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The purpose of this study was to identify factors that are associated with quality of life (QoL) in relapse-free patients after radical prostatectomy or high-dose radiotherapy with or without hormone treatment. PATIENTS AND METHODS A cross-sectional postal survey among members of the Norwegian Prostate Cancer Patient Association was used. We analyzed associations between QoL and general health, "typical" adverse effects (sexual, urinary, and bowel assessed using the Expanded Prostate Cancer Composite items) and psychosocial variables (work ability, family life, social life and/or leisure activities) in univariate and multivariate regression analyses. Statistical significance was defined as P < .01. RESULTS Among 612 responders (approximately 50% compliance; median age, 70 years), in univariate analyses QoL was significantly associated with functional aspects and the level of bother within the sexual, urinary, and bowel domains and with general health and psychosocial aspects of daily life. In the multivariate analysis only general health and social life and/or leisure activities remained associated with QoL, with work ability being a third factor in patients younger than 65 years old. Posttreatment worsening of partnership was reported by 12% of the patients. CONCLUSION Prostate cancer patients who are to undergo curative treatment should be informed about the risk of reduced function within the sexual, urinary, and bowel domains, but also about these dysfunctions' relation to bother and QoL, considered together with the patients' general health and their preferences as to their social life activities.
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Affiliation(s)
- Sophie D Fosså
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital Oslo, Oslo, Norway.
| | - Alv A Dahl
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital Oslo, Oslo, Norway
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Laird A, Fowler S, Good DW, Stewart GD, Srinivasan V, Cahill D, Brewster SF, McNeill SA. Contemporary practice and technique-related outcomes for radical prostatectomy in the UK: a report of national outcomes. BJU Int 2014; 115:753-63. [DOI: 10.1111/bju.12866] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Alexander Laird
- Department of Urology; Western General Hospital; Edinburgh UK
| | - Sarah Fowler
- The British Association of Urological Surgeons; London UK
| | - Daniel W. Good
- Department of Urology; Western General Hospital; Edinburgh UK
| | | | | | - Declan Cahill
- Department of Urology; Guy's and St Thomas' NHS Hospital Trust; London UK
| | | | - S. Alan McNeill
- Department of Urology; Western General Hospital; Edinburgh UK
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Müller S, Grønning LE, Nilsen FS, Mygland V, Patel HRH. Robotic and minimal access surgery: technology and surgical outcomes of radical prostatectomy for prostate cancer. Expert Rev Anticancer Ther 2014; 14:1317-21. [PMID: 25266367 DOI: 10.1586/14737140.2014.965689] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the 1990s, minimal access surgery has been utilized in urology. In the past 15 years, robotic surgery has evolved and become a natural part of minimal access surgery. The dissemination has been fast and the opportunity of prospective trials has been missed. Nevertheless, robotic surgery has obvious benefits for the surgeon and patient. Even though the scientific evidence is not strong, robotic surgery is here to stay. However, there are lessons to learn from the implementation of the da Vinci system with regards to patient safety and prospective evaluation of the new technology. The future of surgery will include technologies derived from robotic surgery.
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Affiliation(s)
- Stig Müller
- Department of Urology, Akershus University Hospital, Sykehusveien 23, Lørenskog 1478, Norway
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A comparison of case volumes among urologic surgeons identified on an industry-sponsored website to an all provider peer group. Urol Oncol 2014; 32:1095-100. [PMID: 25260903 DOI: 10.1016/j.urolonc.2014.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/14/2014] [Accepted: 08/15/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Industry-sponsored websites for robotic surgery direct to surgeons listed as performing specific robotic surgical procedures. The purpose of this study was to compare average annual, surgeon-specific, case volumes for those procedures for which they were listed as performing on the commercial website with the volumes of all providers performing these same procedures across a defined geographic region. METHODS A list of providers within the state of Wisconsin cited as performing specific urologic procedures was obtained through the Intuitive Surgical website 〈http://www.davincisurgery.com/da-vinci-urology/〉. Surgeon-specific annual case volumes from 2009 to 2013 for these same cases were obtained for all Wisconsin providers through DataBay Resources (Warrendale, PA) based on International classification of diseases-9 codes. Procedural activity was rank ordered, and surgeons were placed in "volume deciles" derived from the total annual number of cases performed by all surgeons. The distribution of commercially listed surgeon volumes, both 5-year average and most recent year, was compared with the average and 2013 volumes of all surgeons performing a specific procedure. FINDINGS A total of 35 individual urologic surgeons listed as performing robotic surgery in Wisconsin were identified through a "search" using the Intuitive Surgical website. Specific procedure analysis returned 5, 12, 9, and 15 surgeon names for cystectomy, partial nephrectomy, radical nephrectomy, and prostatectomy, respectively. This compared with the total number of surgeons who had performed the listed procedure in Wisconsin at least 1 time during the prior 5 years of 123, 153, 242, and 165, respectively. When distributed by surgeon-volume deciles, surgeons listed on industry-sponsored sites varied widely in their respective volume decile. More than half of site-listed, procedure-specific surgeons fell below the fifth decile for surgeon volume. Data analysis based solely on 2013 case volumes had no effect on the number of website-listed surgeons whose volumes fell below the fifth decile. CONCLUSIONS Surgeons listed on an industry-sponsored website demonstrate wide variation in the actual volume of specific procedures performed. The inferred endorsement of competence by commercial sites has the potential to mislead patients seeking surgical expertise. Providers should consider the ethical and legal implications of these commercial advertising that do not have volume or outcome data.
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Holm HV, Fosså SD, Hedlund H, Schultz A, Dahl AA. How should continence and incontinence after radical prostatectomy be evaluated? A prospective study of patient ratings and changes with time. J Urol 2014; 192:1155-61. [PMID: 24727062 DOI: 10.1016/j.juro.2014.03.113] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2014] [Indexed: 01/22/2023]
Abstract
PURPOSE We examined prevalence rates, and changes in continence and incontinence before and after radical prostatectomy for prostate cancer by comparing different definitions. We also studied the descriptive validity of the grading system of Ellison et al for post-prostatectomy incontinence and baseline predictors of post-prostatectomy incontinence at 12 months. MATERIALS AND METHODS This national prospective study included 844 patients treated with radical prostatectomy between 2005 and 2009. Adverse effects, including urinary dysfunction and bother, were reported by 735 patients (88%) using the EPIC-50 and UCLA-PCI validated questionnaires at baseline and 12-month followup. Linear regression analysis was done to examine baseline predictors and the degree of post-prostatectomy incontinence at followup. RESULTS At 12 months after radical prostatectomy 74% of patients reported post-prostatectomy incontinence, of whom 40% used pads daily, 34% reported occasional dribbling without pads and 26% had total urinary control. When defined as total incontinence/no urinary control, severe post-prostatectomy incontinence was reported by 3% of the men but 25% had severe post-prostatectomy incontinence according to the stratification of Ellison et al. Of patients with preoperative incontinence 14% improved postoperatively. Predictors of post-prostatectomy incontinence were age 65 years or greater, not working, sexual dysfunction and incontinence preoperatively. The latter 2 remained the strongest predictors on multivariate analysis. Prostate cancer related variables were not associated with post-prostatectomy incontinence. CONCLUSIONS The prevalence of post-prostatectomy incontinence varied considerably according to the definition applied. In our opinion incontinence may be reported as any leakage and not only as pad use with grading done on a symptom scale. Preoperative sexual dysfunction and urinary incontinence were the strongest predictors of post-prostatectomy incontinence at 12-month followup.
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Affiliation(s)
| | - Sophie D Fosså
- Department of Oncology, Oslo University Hospital, Radiumhospitalet, Oslo, Norway; University of Oslo, Oslo, Norway
| | - Hans Hedlund
- Department of Urology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; University of Oslo, Oslo, Norway
| | - Alexander Schultz
- Department of Urology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Alv A Dahl
- Department of Oncology, Oslo University Hospital, Radiumhospitalet, Oslo, Norway; University of Oslo, Oslo, Norway
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Storås AH, Sanda MG, Ferrer M, Loge JH, Dahl AA, Steinsvik EAS, Guedea F, Cvancarova M, Fosså SD. Localized prostate cancer in Norway, the United States, and Spain: between-country differences of variables before treatment among patients eligible for curative treatment. Clin Genitourin Cancer 2014; 12:e117-25. [PMID: 24524968 DOI: 10.1016/j.clgc.2013.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 12/30/2013] [Accepted: 12/30/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND In men with PCa, large variations of PROs after RP or high-dose RAD might be related to between-country differences of medical and sociodemographic variables, and differences in PROs before treatment in the sexual and urinary domains. PATIENTS AND METHODS In 1908 patients with localized PCa from Norway, the United States, or Spain, the relation between medical (prostate-specific antigen, Gleason score, cT-category) and sociodemographic variables (age, education, marital status) before treatment was investigated. Using the Expanded Prostate Cancer Index Composite questionnaire, PROs before treatment within the sexual and urinary domains were also considered. RESULTS Compared with the European patients, American patients were younger, fewer had comorbid conditions, and more had a high education level. Fifty-three percent of the US men eligible for RP had low-risk tumors compared with 42% and 31% among the Norwegian and the Spanish patients, respectively. Among the Spanish RAD patients, 54% had had low-risk tumors compared with 34% of the American and 21% of the Norwegian men planned for RAD, respectively. Compared with the European patients, significantly fewer US patients reported moderate or severe sexual dysfunction and related problems. In most subgroups, the number of patients with sexual or urinary dysfunction exceeded that of patients with bother related to the reported dysfunction. CONCLUSION Statistically significant between-country differences were observed in medical and sociodemographic variables, and in PROs before treatment within the sexual and urinary domains. Large differences between reported dysfunction and related problems within the sexual and urinary domains indicate that dysfunction and bother should be reported separately in addition to calculation of summary scores. The documented differences, not at least regarding PROs, might in part explain the large variation of side effects after treatment evident in the medical literature.
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Affiliation(s)
- Anne Holck Storås
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Martin G Sanda
- Department of Urology, Emory University Hospital, Atlanta, GA
| | - Montse Ferrer
- Health Services Research Group, IMIM (Hospital del Mar Research Institute), Barcelona, Spain
| | - Jon Håvard Loge
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Alv A Dahl
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Eivind A S Steinsvik
- Department of ENT, Division of Surgery, Akershus University Hospital, Lorenskog, Norway
| | - Ferran Guedea
- Department of Radiation Oncology, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Milada Cvancarova
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Sophie D Fosså
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
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A manpower calculus: The implications of SUO fellowship expansion on oncologic surgeon case volumes. Urol Oncol 2014; 32:42.e7-12. [DOI: 10.1016/j.urolonc.2013.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/08/2013] [Accepted: 05/09/2013] [Indexed: 11/20/2022]
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Fode M, Sønksen J, Jakobsen H. Radical prostatectomy: initial experience with robot-assisted laparoscopic procedures at a large university hospital. Scand J Urol 2013; 48:252-8. [PMID: 24341725 DOI: 10.3109/21681805.2013.868514] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to compare oncological and functional outcomes between robot-assisted laparoscopic radical prostatectomy (RALP) and retropubic radical prostatectomy (RRP) during the initial phase with RALP at a large university hospital. MATERIAL AND METHODS Patient and tumour characteristics, surgeon, nerve sparing, surgical margins and blood loss were recorded prospectively in patients who underwent RRP or RALP between April 2008 and May 2012. Patients filled out the Danish Prostate Symptom Score (DAN-PSS) and International Index of Erectile Function 5 (IIEF-5) questionnaires before surgery and at follow-up and they were asked to report their use of pads/diapers. Potency was defined as an IIEF-5 score of at least 17 with or without phosphodiesterase-5 inhibitors. Patients using up to one pad daily for security reasons only were considered continent. Positive surgical margins, blood loss and functional outcomes were compared between groups. RESULTS Overall, 453 patients were treated with RRP and 585 with RALP. On multivariate logistic regression analyses, the type of surgery did not affect surgical margins (p = 0.96) or potency at 12 months (p = 0.7). Patients who had undergone RRP had an increased chance of reporting subjective continence at 12 months (odds ratio 2.6, p = 0.014). There was no difference in the proportion of RRP and RALP patients who underwent surgical treatment for incontinence (p = 0.57). On multivariate linear regression analysis, RALP was an independent predictor of a low perioperative blood loss (RRP:RALP ratio = 2.89, p < 0.0001). CONCLUSIONS RALP is a safe procedure with regard to perioperative and oncological results. However, it is important to be aware that functional outcomes may be compromised in the initial phase when introducing RALP.
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Affiliation(s)
- Mikkel Fode
- Department of Urology, Herlev Hospital , Herlev , Denmark
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