Heterogeneity of outcomes after radical prostatectomy: the surgeon is a factor


It will come as no surprise to regular readers of this blog that there is variation among surgeons in the overall quality of their patients’ outcomes after radical prostatectomy. However, a newly published and large study of outcomes among surgeons in Sweden does expand our knowledge on this topic.

An article by Carlsson et al. entitled “Effects of surgeon variability on oncologic and functional outcomes in a population-based setting” was initially published in BMC Urology earlier this year and has been reprinted in full on the Medscape Oncology web site. This study is a follow-up study to research into outcomes among surgeons operating at the Memorial Sloan-Kettering Cancer Center just a few years ago.

Carlsson and her colleagues looked at data from 1,280 men, all of whom were given an open, retropubic, radical prostatectomy by one of nine surgeons at an academic institution in Sweden between 2001 and 2008. Surgeons had to have done at least 20 procedures during the study period to be included in the analysis.

All patients were evaluated for biochemical recurrence of their disease post-surgery (i.e., a PSA value > 0.2 ng/ml with at least one confirmatory rise); they were also asked to complete patient-administered questionnaires before surgery and at 6, 18, and 36 months post-surgery to evaluate potency and continence outcomes.

The core findings of the study are as follows:

  • 679/1,280 men (53.0 percent) were potent at baseline.
  • 647/679 men who were potent at baseline (95.3 percent) provided potency data at 18 months post-surgery.
  • Patients reporting use of alprostadil injections for erectile aid were all categorized as impotent (222 men at 18 months, and 198 men at 36 months).
  • Men reporting use of PDE5-inhibitors (e.g., sildenafil or tadalafil) were included in the analysis.
  • 122/647 men who were potent at baseline (19 percent) reported being potent at 18 months.
  • Crude potency rates at 18 months were higher for men given a bilateral, nerve-sparing, radical prostatectomy (31.8 percent) and for those < 60 years of age (45.7 percent).
  • There was no evidence of heterogeneity of potency outcomes between surgeons (P = 1). In other words, neither the skill nor the experience of the surgeon had impact on the probability of post-surgical potency!
  • 979/1,280 patients (76.5 percent) provided continence data at 18 months post-surgery.
  • 836/979 patients who reported continence data at 18 months post-surgery (85.4 percent) reported being continent.
  • There was statistically significant heterogeneity between surgeons (P = 0.001) with regard to continence. In other words, with regard to continence, it appears that some patients were certainly receiving sub-optimal care.
  • There was no evidence of any association between surgeons’ adjusted probabilities of functional recovery and 5-year probability of freedom from biochemical recurrence.

The “New” Prostate Cancer InfoLink is in no way surprised by the finding with respect to continence, but we are surprised by the finding with regard to potency. However, this does not mean that it is impossible for any surgeon to be able to get better outcomes with regard to potency that his peers. On the other hand, it does seem to mean that for any one surgeon to be getting better outcomes than his peers with regard to post-operative potency in this group of patients, he or she almost certainly would need to be doing something very different than his or her peers in order to protect the patient from loss of potency, and that just “doing the same operation a little better” is not going to be enough to change outcomes.

Having said that, Carlsson et al. are careful to note that the lower rate of potency post-surgery in this study can be explained by the fact that the men in this study were, on average, about 6 years older than those in a large study of surgeons at Memorial Sloan-Kettering Cancer Center a few years ago. Furthermore,

the study cohort was derived from a population-based sample in an area where active surveillance is frequently used, implying that only the most aggressive tumors are treated; this likely results in more advanced tumor features leading to more radical surgery with wider resection and lower potency rates.

Only one-third of the patients in this Swedish cohort underwent a bilateral nerve-sparing procedure.

So, we cannot conclude with certainty that surgical skill and experience are unable to improve the probability of potency in a defined group of patients, but we can conclude that other factors have a crucial level of importance, in that if the patients are older, or less likely to have nerve sparing, then that will, per se, affect the probability of recovery of potency. (This is hardly a surprising observation.)

3 Responses

  1. Having met and spoken with Sigrid Carlsson I remain absolutely certain beyond reasonable doubt that he is a she. http://www.akademiliv.se/en/2014/01/16165/

    She spoke at ASCO last year about the desperate need to slow down treatment for prostate cancer in the US while focusing on improvement in quality of life decision making. By this she pointed out that data patients are given is biased to the physicians thinking and it needs to be improved.

    I am certain this research is tied to that objective. All along we have been told the physician skill would reduce side effects, and in many ways it does. But we also were led to believe that the better the surgeon the better the sex life after RP. This throws a wrench in that thinking.

  2. Ooops … Mea culpa … Duly corrected.

  3. I agree with this point: “I am certain this research is tied to that objective. All along we have been told the physician skill would reduce side effects, and in many ways it does. But we also were led to believe that the better the surgeon the better the sex life after RP. This throws a wrench in that thinking.”

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