Surgical experience, caseload, and short-term complications at radical prostatectomy


No data have previously been available on the relationship between surgical experience, surgical volume and complication and transfusion rates in patients undergoing minimally invasive forms of radical prostatectomy (e.g., laparoscopic radical prostatectomy with or without robot assistance).

Budäus et al. have now reported data from > 2,500 patients who received a minimally invasive radical prostatectomy in Florida between 2002 and 2008. To understand the implications of their report, you need some definitions:

  • Surgical experience (SE) is the number of procedures performed by an individual surgeon from the beginning of the study until each specific minimally invasive procedure. (It inevitably goes up by one after each procedure carried out.)
  • Annual caseload (AC) is the number of operations carried out by an individual surgeon in any one year.

Budäus et al. wanted to see if there was any specific series of trends that associated SE, AC, and in-hospital complication and transfusion rates (i.e., short-term complications of surgery). We need to be clear that this study was not designed to assess longer-term outcomes and complications such as incontinence or ED.

The authors appear to have categorized surgeons into three groups based on their annual caseload:

  • Surgeons with a low AC do less than 16 minimally invasive procedures in a year.
  • Surgeons with an intermediate AC do between 16 and 76 minimally invasive procedures in a year.
  • Surgeons with a high AC do more than 76 minimally invasive procedures in a year.

Here are the results of their analysis:

  • Overall AC ranged from 1 to 171.
  • Overall SE ranged from 1 to 500.
  • Between 2002 and 2005
    • Nearly all surgeons (94-100 percent) fell into the low AC group.
    • Surgeons in the low AC group carried out between 46 and 100 percent of all minimally invasive procedures.
  • Between 2006 and 2008
    • At least three-quarters of surgeons (76-82 percent) still fell into the low AC group.
    • Surgeons in the low AC group carried out only 27 to 32 percent of all minimally invasive procedures.
  • Short-term complication rates were
    • 68 percent less likely for patients operated on by surgeons in the high AC group that by surgeons in the low AC group.
    • 51 percent less likely for patients operated on by surgeons in the intermediate AC group that by surgeons in the low AC group.
  • Blood transfusions were
    • 83 percent less likely for patients operated on by surgeons in the high AC group that by surgeons in the low AC group.
    • 80 percent less likely for patients operated on by surgeons in the intermediate AC group that by surgeons in the low AC group.

The authors draw three specific conclusions:

  • Higher levels of surgical experience with minimally invasive forms of radical prostatectomy reduce patient risk for short-term complications and blood transfusions.
  • Even in 2008, most of the surgeons (82 percent) were in the low AC group.
  • In 2008 surgeons in the low AC group still carried out 32 percent of all minimally invasive radical prostatectomies in Florida.

The authors also state that, “These findings should be considered at informed consent.” In other words, patients need to be advised, prior to surgery, whether their surgeons meet criteria for low, intermediate, or high levels of surgical experience and annual caseload.

It is worth noting that, for surgeons who are in the low AC group, even if they did the maximum number of procedures every year for a surgeon in that group, i.e., 15 procedures a year, it would take them about 15 years to reach the generally recognized basic level of sufficient skill to get good, reliable outcomes. Another new paper by Secin et al. has just confirmed that a surgeon needs to carry out at least 200 to 250 laparoscopic radical prostatectomies (LRPs) to reach a plateau level for minimal risk of positive surgical margins (regardless of prior experience carrying out open surgeries). Every patient who allows himself to be given a minimally invasive radical prostatectomy by a surgeon with a low SE and a low AC may, quite literally, be placing his life in that surgeon’s hands.

2 Responses

  1. Sounds like a riddle. How can surgeons gain the experience if patients only go to the most experienced surgeons?

  2. In the UK the National Health Service has concentrated radical prostatectomies in fewer hospitals to increase surgeon AC. Even so AC levels are often low. In my case a low SE and low AC surgeon left me with a positive margin. Although this can happen with any surgeon, I feel it would have been more ethical if my surgeon had been completely forthcoming about the widely held view that 250 procedures are required to achieve optimum results.

    Yes, new surgeons need to start somewhere, but their patients should be made fully aware of the implications, which I wasn’t. Interestingly the most experienced surgeons seem to be the most open about the possibility of positive margins, even in the most experienced hands — perhaps because they feel more secure. As patients we do not expect miracles, just complete honesty at the outset.

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