Group Title: BMC Surgery
Title: Radical Prostatectomy : Hospital volumes and surgical volumes - does practice make perfect?
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Title: Radical Prostatectomy : Hospital volumes and surgical volumes - does practice make perfect?
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Creator: Urbanek, Cydney
Turpen, Ryan
Rosser, Charles
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Publication Date: 2009
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Abstract: BACKGROUND:Between the years 1993 and 2003, more than 140,000 men underwent radical prostatectomy (RP), thus making RP one of the most common treatment options for localized prostate cancer in the United States.DISCUSSION:Localized prostate cancer treated by RP is one of the more challenging procedures performed by urologic surgeons. Studies suggest a definite learning curve in performing this procedure with optimal results noted after performing >500 RPs. But is surgical volume everything? How do hospital volumes of RP weigh in? Could fellowship training in RP reduce the critical volume needed to reach an 'experienced' level?SUMMARY:As we continue to glean data as to how to optimize outcomes after RP, we must not only consider surgeon and hospital volumes of RP, but also consider training of the individual surgeon.
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Debate

Radical Prostatectomy: Hospital volumes and surgical volumes -
does practice make perfect?
Cydney Urbanek, Ryan Turpen and Charles J Rosser*


Address: Department of Urology, University of Florida, Gainesville, Florida, USA
Email: Cydney Urbanek cydney.urbanek@urology.ufl.edu; Ryan Turpen ryan.turpen@urology.ufl.edu;
Charles J Rosser* charles.rosser@urology.ufl.edu
* Corresponding author


Id Central


Published: 6 June 2009
BMC Surgery 2009, 9:10 doi:10.1186/1471-2482-9-10


Received: 10 February 2009
Accepted: 6 June 2009


This article is available from: http://www.biomedcentral.com/1471-2482/9/10
2009 Urbanek et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.ore/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
Background: Between the years 1993 and 2003, more than 140,000 men underwent radical
prostatectomy (RP), thus making RP one of the most common treatment options for localized
prostate cancer in the United States.
Discussion: Localized prostate cancer treated by RP is one of the more challenging procedures
performed by urologic surgeons. Studies suggest a definite learning curve in performing this
procedure with optimal results noted after performing >500 RPs. But is surgical volume everything?
How do hospital volumes of RP weigh in? Could fellowship training in RP reduce the critical volume
needed to reach an 'experienced' level?
Summary: As we continue to glean data as to how to optimize outcomes after RP, we must not
only consider surgeon and hospital volumes of RP, but also consider training of the individual
surgeon.


Background
One out of every six men in the US will be diagnosed with
prostate cancer making it the second most commonly
diagnosed cancer among American males over the age of
45 years [1]. The most common treatment for localized
prostate cancer remains radical prostatectomy (RP) [2].
Over the past 30 years, RP has significantly transformed
from what Dr. Hugh Hampton Young first described in
1904. Early prostatectomies were fraught with significant
morbidity and mortality, until Walsh and others reported
on the anatomic, nerve sparing RP in 1982. The anatomic,
nerve sparing RP was associated with less blood loss and
reduced incidence of erectile dysfunction [3]. Several
reports documented more favorable outcomes in physi-
cians who had performed more than 500 RPs. For exam-
ple, in Catalona et al's report of 1,870 men undergoing


RP, postoperative complications were less likely with
increasing surgeon experience [4].

Prostatectomy is a challenging radical surgery performed
in appropriately selected men for prostate cancer. Though
cancer control is the key for this procedure, we must strive
for favorable post operative quality of life outcomes (e.g.,
urinary continence, bowel continence, and erectile func-
tion). More so than with other genitourinary malignan-
cies, these quality of life outcomes are extremely
important since some of these tumors are non-life threat-
ening.

Previous research has linked outcomes from RP to hospi-
tal volume, surgeon volume and the level of surgical train-
ing. Many studies suggest that these volume-outcome


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relationships exist because of the perceived favorable
trends associated with volumes and outcomes (i.e., out-
comes must inevitably improve as surgeon's and hospi-
tal's volume increase) [5]. Prompted by such reports, this
manuscript aims to review literature related to training
and volume as it relates to outcomes of RP.

Discussion
Hospital volume
Numerous studies have evaluated the relationship
between the number of RPs performed at hospitals to the
clinical outcomes [3,4]. These studies have varied signifi-
cantly in the hospital volumes. Currently, there is no uni-
versally accepted definition for what is considered to be a
high or low volume center. Table 1 shows the distribution
of some of these studies that assessed RP outcomes based
on hospital volume. Results from these retrospective stud-
ies are mixed in regards to outcomes and have used vari-
ous endpoints to critically evaluate differences in these
centers. Outcomes measured have included everything
from length of stay to mortality. Whereas mortality asso-
ciated with RP should not be the sole endpoint to monitor
since the overall reported mortality rate for the procedure
is < 1%, other endpoints such as oncologic outcomes and
quality of life related outcomes have significant implica-
tions in patient care [6].

In one study, high volume hospitals were associated with
reduction in length of stay and in-hospital mortality [7].
However, Begg and others noted no significant difference
in mortality between low and high volume hospitals. This
study did demonstrate a higher risk of post-operative uri-
nary complications at low volume hospitals [8]. Similarly,
Hu and colleagues showed that high volume hospitals
reported fewer urethral anastomatic strictures while low
volume centers had an increased stricture rate. In regards
to long-term incontinence, despite the significant differ-
ence in stricture rates, there was no statistically significant
difference between low volume and high volume centers
[9]. Furthermore, in a large study from England com-
prised of over 18,000 men who underwent RPs, there was
only a slight difference in the rate of post-operative com-
plications between low volume and high volume centers,
2.3% vs. 1.2%, respectively [10].

Confounding many of these studies comparing high and
low volume centers is the fact that high volume centers
tend to see more high surgical risk patients and high risk
prostate cancer patients in regards to grade and stage of
the disease being treated compared to the low volume
centers [11]. Many hospitals have implemented clinical
care pathways as a means to reduce hospital stay, post-
operative complication, and overall cost. After imple-
menting the clinical care pathway, Chang and others
shorten length of stay from 3 days to 2 days without com-


promising the quality of care [12]. In addition, regionali-
zation of RP from low volume to high volume hospitals
can also decrease the length of stay post RP [1]. Ellison
and colleagues sought to identify a relationship between
hospital RP volume and oncologic outcomes. They
reported that in low volume hospitals, 25% more of the
patients deemed to have low risk prostate cancer (i.e., low
grade and low stage disease) require some form of post
operative adjuvant therapy [11]. It must be noted that
these studies that report on volumes are heterogeneous
with varied methodology in data analysis.

Volume-outcome studies done by general surgery or gyne-
cology such as pyloromyotomy, pancreatectomy,
esophagectomy, pneumonectomy, liver resection, and
pelvic exenteration have shown compelling results that
support the theory that high volume hospitals offer better
quality of care than low volume hospitals [13,14]. One
must remember that the high volume hospitals may have
access to state of the art equipment and facilities as well as
more staff with specialty training. With this in mind,
healthcare providers may be more likely to refer their
patients to these better equipped, high volume hospitals
expecting superior outcomes.

Surgeon volume
Several reports documented more favorable outcomes in
surgeons who have performed more than 500 RPs. For
example, Catalona reported his results of 1,870 men
undergoing RP and found postoperative complications
were less likely with increasing surgeon experience [4].
Recently, two large studies reported patient outcomes as
related to surgeon's volumes [15,16]. Neither study
reported an increase in the relative risk of surgery related
death associated with surgeon volume. Taking into con-
sideration patient age and comorbidities, an increase risk
of post-operative complications was noted among sur-
geons who performed fewer than 40 RP per year. Even
more startling was a significantly higher transfusion rate
when surgeons performed less than 15 RP per year. Fur-
thermore, surgeons who performed more than 15 RP per
year had shorter hospital length of stay [15,16].

Regarding quality of life outcomes and oncologic out-
comes, association with surgeon volumes is varied. In a
study by Begg and others, high volume surgeons, defined
as those who performed a minimum of 20 procedures
during the five-year study, had fewer late urinary compli-
cations. However, there was no difference in the rate of
positive surgical margins between the surgeons [8]. Simi-
larly, Chun and others reported the association of surgical
margins in 2,402 men with localized prostate cancer
treated with RP by 11 highly trained surgeons. High vol-
ume surgeons were noted to have a statistically significant
lower rate of positive surgical margin (18.9% vs. 22.6%).


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Table I: Studies of effect of hospital and surgeon volume on outcomes


Hospital
Volumes
Hu et al.
In hospital
complications
adjusted OR
(95% Cl)
Length of stay
parameter
estimate
(95% Cl)
Anastomati c
stricture rate
adjusted OR
(95% Cl)
Begg et al

% 30 day
mortality
% 60 day
mortality
% post-op
complications
% late urinary
complication
% long-term
incontinence
Ellison et al

In hospital
mortality
adjusted OR
(95% Cl)
Ave length of
stay (days)
Yao et al

% 30 day
mortality
(95% Cl)
% 60 day
mortality
(95% Cl)
% overall
complications
(95% Cl)
Mean day
length of stay
(95% Cl)
Surgeon
Volume
Hu et al.
In hospital
complications
adjusted OR
(95% Cl)
Length of stay
parameter
estimate
(95% Cl)
Anastomati c
stricture rate
adjusted OR
(95% Cl)
Begg et al


< 60 RP/yr
1.0


Low (I-33)


> 60 RP/yr
0.84 (0.59-1.19)



-0.42 (-0.89-0.03)



0.72 (0.49-1.04)


Medium (34-61)


High (62-107)


Very High
(114-252)
0.5


0.01


Low, < 25 RP/yr

1.78 (1.2-2.7)


Low, < 38/yr

0.63 (0.53-0.73)


5.0 (4.7-5.3)


31.3 (30.8-31.9)


8.51 (8.47-8.56)


Low 1-10 RP/yr


Medium, 26-54
RP/yr
1.71 (1.2-2.6)


Medium-low, 39-
74 RP/yr
0.59 (0.49-0.68)


High, > 54 RP/yr

1.0


Medium high, 75-
140
0.56 (0.47-0.66)


High > 140 RP/yr

0.39 (0.31-0.46)


4.5 (4.3-4.8) 4.3(4.0-4.5)


28.7 (28.2-29.3)


8.18 (8.14-8.22)


Low, < 40 RP/yr
1.0


Medium I 1-19
RP/Yr


<0.001



<0.000 I1



0.0015


4.1 (3.8-4.3) 0.03


27.8 (27.2-28.3)


7.70 (7.66-7.74)


High, > 40 RP/yr
0.53 (0.32-0.89)



0.68 (1.26-0.06)



0.89 (0.55-1.44)



High 20-32 RP/yr


26.3 (25.8-26.9)


7.81 (7.77-7.85)


0.02


0.0001


0.02


Very High, >33
RP/yr


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Table I: Studies of effect of hospital and surgeon volume on outcomes (Continued)
% 30 day 0.4 0.5 0.5
mortality
% 60 day 0.5 0.5 0.6
mortality
% post-op 32 31 30
complications
% late urinary 28 26 27
complication
% long-term 20 20 19
incontinence


<0.001


(Modified, Nuttall, J Urol 2004)


However, when assessed in a multivariate analysis with
low and intermediate volume surgeons, the association
between a reduction of positive surgical margins in high
volume surgeons diminished [15], thus possibly illustrat-
ing the importance of another factor (e.g., surgical train-
ing) in this complex procedure.

In a study by Bianco and colleagues, 10,737 patients who
underwent RP by 999 surgeons were analyzed. In this


study, expected outcomes in major post-operative compli-
cations, late urinary complications and long-term inconti-
nence were compared with the observed outcomes of
these three domains. For all three outcomes, the variation
among surgeons in the rate of complications was signifi-
cantly greater than that expected by chance after adjust-
ment of covariates. Furthermore, surgeons with better
results with regard to one outcome were likely to have bet-
ter results with regard to the other two outcome measures


Figure 1.

0 Expected U Observed


40

35'

30

O 25
C
3 20 ------- ------
L.
U-
10

5 --
0




% Postoperative Complications


Figure I
Histograms juxtapose observed and expected number of surgeons' postoperative complications. More outliers
on right side of histogram in observed vs. expected plot highlight providers achieving poor outcomes. On the other hand, out-
liers toward left in observed vs. expected plots indicate surgeons achieving more favorable outcomes (From Bianco, J Urol,
2005, copyright permission).




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(Figures 1 &2). The authors concluded that outcomes
might very well be related to surgical technique and not
strictly surgical volume [16]. In a sense, they are implying
that practice does not necessarily make perfect.

But if a surgeon's volume is truly felt to be the major cul-
prit in suboptimal outcomes, perhaps a minimum vol-
ume threshold (MVT) should be required for difficult
cases. Three hundred and seven urologists were queried as
to their thoughts on a MVT for such procedures as radical
nephrectomy, radical cystectomy and radical prostatec-
tomy. The majority of the surgeons were in favor of MVTs.
Interestingly enough, the most complex surgeries were
given the lowest MVT based on their frequency. For exam-
ple, radical cystectomy with continent urinary diversion
had the lowest MVT (1-5/yr), while RP, considered to be
the third most complex surgery, was given the highest
MVT (>20/yr) [17]. With this said, volume thresholds
based on frequency of procedure instead of complexity of
procedure may not correlate with the best outcomes for
patients due to the fact that increasing volume does not
guarantee improvements in outcome since low and high
volume surgeons can produce both good and poor out-
comes.


Fellowship Training
Everything that has been discussed so far hinges on the
premise that practice makes perfect (or increase volume
leads to superior outcomes). Previous reports from expe-
rienced surgeons reporting on pathologic outcomes, and
overall complication rates hinted that as many as 200-
500 RPs must be performed before a surgeon reaches the
expert portion of the learning curve [4,18,19]. Though
attention should be on volumes, perhaps there are other
factors that can influence outcomes, specifically addi-
tional training (i.e., urologic oncology fellowship).

The ultimate goal of RP is cancer control with little to no
morbidity. The specialized training obtained during a uro-
logic oncology fellowship affords surgeons an opportu-
nity to study in depth the art and science of prostate
cancer treatment and thus achieve cancer control rates and
surgical outcomes similar to those of more experienced
surgeons. In a recent study, two recently graduated uro-
logic oncologists reported the outcomes of their first 66
RP. Operative time, estimated blood loss, transfusion
rates, and post-operative complications [20] were similar
to those previously reported by more experienced sur-
geons [21,22]. Furthermore, postoperative complications


Figure 2
Histograms juxtapose observed and expected number of surgeons' long-term incontinence. More outliers on
right side of histogram in observed vs. expected plot highlight providers achieving poor outcomes. On the contrary, outliers
toward left in observed vs. expected plots indicate surgeons achieving more favorable outcomes (From Bianco, J Urol, 2005,
copyright permission).



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Figure 2.

S Expected 0 Observed
45-
40-
35-
> 30-
25
2 0
Lu 15
10
5
0




% Long Tenn Incontinence Complications


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were similar in nature and frequency to those previously
documented in the literature. More important, the patho-
logic outcomes (i.e., the ability to correctly perform this
oncologic procedure) were similar to those previously
reported by more experienced surgeons. On the basis of
the study reported here, it is believed that the patient vol-
ume and practice necessary to achieve the outcomes seen
by more experienced surgeons may be obtained during a
urologic oncology fellowship training program.

Recently, Klein and others reported the results of a collab-
orative study which hypothesized that surgeon's experi-
ence is more important to ensuring favorable outcomes
than certain preoperative patient risk factors (serum PSA,
clinical stage, and Gleason score). Their results showed a
statistically significant association between biochemical
recurrence and surgeon's experience such that patients
receiving treatment from a surgeon with 10 versus 250
prior RPs would have an absolute risk difference of 6.6%,
12.0% and 9.7% for low, intermediate, and high risk pros-
tate cancer. Moreover, the data illustrated that the most
experienced surgeons had an almost zero percent 5-year
biochemical relapse rate for low risk prostate cancer
patients. Such a substantial cancer control rate suggests
that the primary cause for recurrence would most likely be
poor surgical technique [23].

The notion of better outcomes observed in fellowship
trained practitioners is not unique to the treatment of
prostate cancer. In fact, the gynecological and general sur-
gical literature have extensively reported on this concept
[24-28]. Thus, being fellowship trained in an environ-
ment where an experienced surgeon serves as first assist-
ant to the trainee in a manner committed to perfect his/
her skills, might be one way to reduce the surgeon volume
or MVT needed to obtain acceptable outcomes with RP.

Summary
A look in the literature regarding the learning curve for
prostatectomies clearly illustrates that surgical volume,
hospital volume, and surgical training are integral to suc-
cessful outcomes. Some have even defined a MVT of 200-
500 cases that must be performed before one achieves the
expertise level. The importance of dedicated oncologic fel-
lowship training would seemingly become an integral, if
not necessary ingredient in developing experienced pros-
tatectomists, capable of performing RPs with maximal
outcomes.

Although there is increasing evidence that high volume
hospitals and high volume surgeons produce more favo-
rable outcomes, caution is still advised when interpreting
the overall results. Most short-term outcomes such as hos-
pital length of stay and post operative complications are
reduced in settings of a high volume center/surgeon; how-


ever, the real concern lies within the long-term outcomes,
i.e., cancer control, continence and potency. Even in expe-
rienced hands, achieving successful outcomes in all three
of these domains is extremely difficult. However, initia-
tives are in the pipeline to link procedural reimburse-
ments with the performance (or outcomes) associated
with the surgeons. This is more impetus for surgeons to
critically review their outcomes to improve their perform-
ance and maximize patient benefit.

Abbreviations
RP: radical prostatectomy; MVT: minimum volume
threshold.

Competing interests
The authors declare that they have no competing interests.

Authors' contributions
CU collected data and drafted the manuscript. RT assisted
in collecting data and revising the manuscript. CJR con-
ceived the project, and participated in its design and coor-
dination. All authors read and approved the final
manuscript.

Acknowledgements
NONE

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