Short-term outcomes after radical prostatectomy and surgeon training/practice site

Now here’s some data that may cause a bit of a furore … so before the US-based urologists get upset, we’d like to point out that this is a Canadian study based on data from members of the Canadian urology community in a single, unidentified Canadian province!

Nayak et al. looked at pathological outcomes data after radical prostatectomy for 15 different urologists working in that one province (which might well be Manitoba). They divided the urologists into three categories, as follows:

  • Group A: Fellowship-trained, academic urologists (n = 2)
  • Group B: Non-fellowship trained, academic urologists (n = 3)
  • Group C: Non-academic (community-based) urologists (n = 10)

The authors then conducted a population-based, retrospective chart review of men diagnosed with prostate cancer between 2003 and 2008 and treated by these 15 urologists.

Here are the key results of the study:

  • 1,294 patients were initially identified as meeting the study criteria.
  • 1,075 patients were ultimately deemed eligible and included in the full modeling analysis.
  • The median age of the study population was 62 years.
  • > 99 percent of the patients were treated by open radical prostatectomy during this study period (because robot-assisted laparoscopic radical prostatectomies were not being carried out in this Canadian province within the period 2003 to 2008).
  • The average number of annual radical prostatectomies per group was
    • 20.5  (range, 13.4 to 27.6) for the surgeons in Group A
    • 4.3 (range, 0.2 to 11.4) for the surgeons in Group B
    • 12.1 (range, 0.2 to 51.6) for the surgeons in Group C
  • 7/15 surgeons (47 percent) averaged less than 5 radical prostatectomies per year (0/2 in Group A, 2/3 in Group B, and 5/10 in Group C).
  • 70.1 percent of the radical prostatectomies were performed at non-academic centers.
  • Pathological outcomes reported were that
    • 71.5 percent of patients had organ-confined disease (with a median Gleason score of 7 in 60.5 percent of the patients).
    • 3.1 percent of patients had positive lymph nodes.
    • Overall rates of positive surgical margins for patients with organ-confined disease were
      • 28.1 percent for surgeons in Group A
      • 49.2 percent for surgeons in Group B
      • 47.9 percent for surgeons in Group C
  • On univariable analysis, age, pathological stage, Gleason score, and surgeon group were all statistically significant predictors of risk for positive surgical margins.
  • With respect to multivariable analysis
    • Surgeon volume was an independent predictor of margin positivity.
    • Pathological stage and Gleason sum were also independent predictors of positive surgical margins.
  • Surgeons in Group B had a higher rate of positive surgical margins than surgeons in Group A (odds ratio [OR] = 2.5; p = 0.001).
  • Surgeons in Group C had a higher rate of positive surgical margins than surgeons in Group A (OR = 2.1; p < 0.001).
  • Surgeons in Groups B and C had comparable rates of positive surgical margins (OR = 1.09;  p = 0.492).

For whatever it is worth, these data do tend to confirm prior studies suggesting that experienced, skilled, and well-trained surgeons with a relatively high caseload compared to their peers are “better” at radical prostatectomy than other urologic surgeons. However, it has to be pointed out that the caseloads of the 15 surgeons included in this study are all small by comparison with the caseloads of specialized prostate cancer surgeons here in the USA (who would customarily expect to conduct in excess of 100 radical prostatectomies a year). As a consequence, it would probably be a serious mistake to try to project these Canadian results from a single province on to the US urology community unless one took the differences in caseload into account.

5 Responses

  1. Experience counts in surgery. Not an amazing finding.

    From the study’s “Discussion” section: ‘In addition, there is a paucity of population-based literature examining pathological outcomes following RP and we have also shown that PSM rates are likely higher in “real-life” …’.

    Logic indicates a surgeon doing low volumes is working with a pathologist also doing low volumes. “Experience counts in pathology” is probably true as well. Is there a tendency to call a close 6 as cancer when doing low volumes?

    With a rejection rate of 1,075 of 1,294 and the above, this study shows even less than claimed.

  2. Dear Mike:

    I would just note that the “rejection rate” (i.e., the number of patients who were cut from the analysis for various reasons after initial identification of 1,294 potentially eligible patients) was actually only 1,294 – 1,075 = 219 (16.9%) and not 1,075.

  3. Thank you, I did mean retention rate remaining after the second cut.

    What is left out of the report: total starting pool to reach the 1,294 level, and the percentage of all patients within the A, B, C groupings actually analyzed. Fairly consistent retention or highly weighted between groups? Those figures may or may not be relevant to the validity of the findings.

  4. Thank you for posting this article with the Medscape link.

    While it is true that the fellowship-trained (FT) surgeons had almost half the PSM rates as the other surgeons, isn’t 28% PSM still way too high?

    Does this means these RARP surgeons need to have more surgeries under their belt before being called proficient at RARP. At least 250 RARP surgeries is often quoted, but the M. D. Anderson report may mean 100 RARPs may be enough in some circumstances.

    Individual surgeons who have personally done thousands of RARP procedures report way lower rates of PSMs. The rates also vary significantly with the cancer stage.

    One wonders what the cost of the fewer PSMs in the FT trained surgeons is for these patients in terms of post-op side effects, like impotence and incontinence, as fewer PSMs usually comes at a relative risk of more complications?

    One of the things that is only occasionally mentioned with to regard to RARP’s is what happens if the robot fails during the RARP which has been estimated to occur in up to 5% of cases. This is a situation in which the urologist who was originally trained to do open RP and switched to doing RARP is at a distinct advantage, compared to a recent FT urologist who only knows how to do a RARP.

    One of the pre-surgery questions every patient undergoing a RARP needs to ask is: What is the game plan in the unlikely event of the robot failing during the procedure? Are you (the surgeon) trained to do an open RP, and if not, who will be available to help you complete the RP surgery if the robot fails?

  5. Dear Walter:

    One cannot take general data like these and apply them to specific surgeons. For example, a study done a few years ago showed that one FT surgeon still completing his fellowship at Memorial Sloan-Kettering Cancer Center had a simply outstandingly high quality of surgery rate after completion of only about 50 procedures, and at the other end of the scale there are surgeons who have done thousands of radical prostatectomies but are not considered (by their peers) to be particularly good prostate cancer surgeons.

    All any data like these can ever offer us as patients is some general guidance: FT surgeons in general are probably going to be better that those who aren’t fellowship-trained; doing more surgeries is generally likely to make you a better surgeon (assuming you are still trying to become a better surgeon). However, trying to put specific numbers to any of this as an absolute is simply not realistic.

    With regard to robots going wrong, I think this is less likely today than it was a few years ago, but yes, it happens, and asking what will happen if the robot does malfunction during a procedure is certainly a wise precaution.

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