Impact Of Surgeon And Hospital Volume On Outcomes Of Radical Prostatectomy

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology
Article Date: 15 Jun 2009 - 0:00 PDT

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UroToday.com - In the online edition of Urologic Oncology, Dr. Michael Cookson and his colleagues at Vanderbilt University reviewed the impact of surgeon and hospital volume on outcomes of radical prostatectomy (RP). They concluded that better outcomes are associated with higher volume surgeons and centers.

The report is a literature review. Regarding hospital volume, there were no randomized trials identified, but 13 papers addressed the topic. Eight of the 13 addressed length of hospital stay, and all found that high-volume hospitals had a shorter mean length of stay. One meta-analysis reported a length of stay decrease of 0.9 days in high-volume centers. Another large multi-institution database found a 3.8 day LOS and 18.6% ICU admission rate in low-volume centers compared to 2.1 day LOS and 1.3% ICU admission rate in high-volume centers. Hospital readmission rates were also higher in the lowest volume quartile hospitals compared to the highest quartile. Five of 6 studies that evaluated complication rates found decreased peri-operative complication rates in high-volume hospitals, one study reporting 27% in these institutions compared with 32% in low-volume institutions. The difference in one multi-institutional cohort was 10%. The meta-analysis found a 1.21% decrease in complications for every additional 10 cases performed per year. Death was also lower in high volume hospitals; 0.04% in the highest volume quartile compared with 0.3% in the lowest volume decile. After adjusting for clinical variables, the oncologic efficacy of RP in higher volume hospitals was superior, with longer time to recurrence and lower incidence of secondary cancer treatments.

Eight studies reported on the impact of surgeon volume on RP outcomes. Higher surgeon volume is associated with lower complication rates (26% vs. 32%), shorter LOS, lower incontinence rates (by 4%). Surgical margin rates in a single institutional study were lower with increasing surgical experience. However, individual surgeon was also an independent predictor of margins status, suggesting that volume alone is not the sole factor involved. The likelihood of biochemical recurrence was 17.9% for a surgeon who had performed only 10 prior cases and 10.7% for surgeons who had performed 250 prior cases. This suggested that 250 may represent a volume threshold, as no significant decrease in BCR was noted after this number of cases. Regarding annual volume, one study showed that a surgeon performing at least 20 cases in the 2 years before surgery had a higher progression-free survival rate than men treated by surgeons who had 10-19 cases or 0-9 cases in the 2 years before surgery. All these data may drive changes in care of radical prostatectomy patients at the individual surgeon and hospital level or via regionalization of certain procedures at high-volume centers.

Barocas DA, Mitchell R, Chang SS, Cookson MS
Urol Oncol. 2009 Apr 21. (Epub ahead of print)
10.1016/j.urolonc.2009.03.001

Written by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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