Surgical experience, caseload, and short-term complications at radical prostatectomy
Posted Nov 10 2010 12:00am
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
Between 2006 and 2008
Short-term complication rates were
Blood transfusions were
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.