A Systematic Review of the Impact of Surgeon and Hospital Caseload Volume on Oncological and Nononcological Outcomes After Radical Prostatectomy for Nonmetastatic Prostate Cancer

Evaluation of short term surgical outcomes of radical prostatectomy in the decade following the introduction of minimum volume standards in the Netherlands

INTRODUCTION

A minimum volume standard (MVS) of 20 radical prostatectomies (RPs) per institution per year was implemented in the Netherlands in 2014, and raised to 50 RPs in 2018 and 100 in 2019. This study aimed to evaluate the effects of implementing a MVS on the extent of care centralization and short term surgical outcomes.

METHODS

All patients who underwent RP between 2014 and 2022 were identified in the nationwide Netherlands Cancer Registry. Short term surgical outcomes included positive surgical margins (PSMs), PSA persistence (failure to achieve a PSA value <0.1 ng/mL within 6 months after RP) and complications (Clavien-Dindo grade ≥3) up to 30 days after RP. Multivariable logistic regression analyses were performed to evaluate surgical outcomes over time.

RESULTS

Between 2014 and 2022, 24,576 RPs were performed and the number of hospitals performing RPs decreased substantially from 40 in 2014 to 14 in 2022, whereas the median number of RPs per hospital per year increased from 85 (IQR: 57-139) to 189 (IQR: 157-393). PSM-rate decreased from 51.6% to 45.7% for pT3-4 (OR = 0.95, 95% CI 0.93-0.98) and 23.6% to 17.6% for pT2 (OR = 0.93, 95% CI 0.91-0.96) prostate cancer. A decline was observed in PSA persistence from 14.0% to 7.7% (OR = 0.84, 95% CI 0.82-0.87). Also the grade ≥3 complication-rate slightly decreased from 3.9% to 3.0% (OR = 0.94, 95% CI 0.90-0.98).

CONCLUSION

Introduction of a MVS resulted in a substantial centralization of RP-care in the Netherlands. A gradual, but moderate, improvement was observed in complications, PSMs and PSA persistence after RP.

Does the surgeon's learning curve impact pentafecta outcomes in radical prostatectomy? a systematic review and meta-analysis

INTRODUCTION

Radical prostatectomy is a key treatment for prostate cancer. However, the impact of the learning curve of the surgeon has on the pentafecta is unclear. This meta-analysis aims to determine the impact of a procedure being performed in the initial learning curve has on the surgical results.

MATERIALS AND METHODS

A systematic review of MEDLINE, Embase, Scopus, Web of Science, and Google Scholar was conducted up to March 2024, focusing on learning curves in prostatectomy. Primary outcome was biochemical recurrence rate (BCR); secondary outcomes included positive surgical margin (PSM) rate, continence, potency, operative time, blood loss, and complications (Clavien-Dindo classification). Bias was assessed using the ROBINS-I tool, and statistical analysis was done via Review Manager 5.4.

RESULTS

Sixteen studies with 21,851 patients were included. No significant difference in BCR rates was found between initial and advanced learning curves (OR1.44;95%CI0.97,2.13;p = 0.07;I²=74%). No significant difference in continence rates was also observed. (RD-0.05;95CI-0.10,0.01;p = 0.08;I²=86%). However, advanced learning curves showed lower PSM rates (OR1.61;95%CI1.19,2.17;p = 0.002;I²=88%), higher potency, less blood loss, shorter operative time, and fewer complications. Although randomized trials are unlikely in this context, further high-quality prospective studies are needed to validate these findings.

CONCLUSION

This meta-analysis highlights that achieving favorable outcomes in key pentafecta parameters-particularly potency, continence, and complication rates-increases with surgical experience. These findings emphasize the value of structured mentorship and establishing surgical volume benchmarks in training programs. Our analysis suggests that reaching a threshold of 100 cases may be necessary to consistently attain optimal functional and perioperative results.

Rectal Injury During Radical Prostatectomy: Incidence, Management, and Outcomes in Single-Center Experience

Background: Rectal injury (RI) is a rare yet serious complication of radical prostatectomy (RP). In this study, we aimed to assess the incidence, risk factors, management strategies, and outcomes of RI during RP. Methods: A retrospective analysis was conducted on 382 patients who underwent RP between 2012 and 2024. Cases of RI were identified intraoperatively, and repair techniques, including two-layer rectal wall closure and vesicourethral anastomosis, were recorded. Risk factors, such as prior pelvic surgery and high-risk pathological features, were also analyzed. Postoperative continence status at 12 months was evaluated using daily pad count, and erectile dysfunction was evaluated using the International Index of Erectile Function (IIEF-5) Results: RI was observed in 2.4% of patients (n = 9), and repairs were successfully completed intraoperatively in all cases. During multivariate analysis, the BMI was found to be protective against RI. Among RI patients, one patient developed a rectourethral fistula, which required reoperation and diversion colostomy; however, six months after the closure colostomy, the fistula persisted, and the patient suffered from severe incontinence. The postoperative 12-month IIEF-5 median score was 7. Conclusions: This study highlights the importance of early intraoperative detection and meticulous surgical repair of RI during RP. Diagnostic measures, such as pneumatic testing and rectal wall monitoring, can mitigate postoperative complications. Our findings contribute to a better understanding of RI management and underscore the importance of individualized surgical approaches for high-risk patients.

Higher surgical volumes are associated with improved perioperative outcomes for vestibular schwannomas

BACKGROUND

Surgical resection remains a primary treatment for vestibular schwannomas (VS). In neuro-oncology, surgical outcomes tend to be better at higher volume centers, but this remains understudied for VS. This study aims to investigate the association of hospital neurosurgical volume with perioperative VS outcomes.

METHODS

The National Inpatient Sample (NIS) database was queried from 1998 to 2014 for patients undergoing VS resection. Hospitals were classified by quartile of annual surgical VS volume across the study period. Odds ratios (OR) were calculated using a logistic regression model with covariates assessed to be clinically relevant.

RESULTS

Patients in the highest quartile of VS resection surgical volume had a lower rate of overall complications (29.4 % vs. 50.2 %, p < 0.001), including neurosurgical complications (26.1 % vs. 46.3 %, p < 0.001) when compared to the lowest quartile. The highest quartile had an OR of 0.46 (p < 0.001) for overall complications and 0.43 (p < 0.001) for any neurosurgical complications, compared to the lowest quartile. The highest quartile also had a lower OR for facial paralysis, vocal cord paralysis, and dysphagia. In addition, overall complications decreased as surgical volume increased, with the lowest odds of complications seen in the 30-40 cases/year group.

CONCLUSIONS

Hospital neurosurgical volume was inversely related to perioperative surgical and medical complications for patients undergoing VS resection, suggesting surgeons at high volume hospitals may have more experience and skills in performing these surgeries. Long-term investigations are necessary to further quantify the relationship between surgical volume and peri-operative outcomes for patients with VS.

Innate Versus Acquired: A Review of Predictive Technical Aptitude Assessments in Surgical Trainee Selection

PURPOSE OF REVIEW

The evaluation and selection process of similarly qualified applicants for surgical residency positions in the United States (US) is challenging. Technical aptitude assessments may provide an opportunity to improve the selection process by offering insight into a candidate's technical skills. The use of these assessments prompts consideration of the degree to which technical aptitude in surgery is innate versus acquired. In this narrative review, we review the state of these assessments and the limitations of developing and validating these instruments.

RECENT FINDINGS

Recent evidence suggests that technical aptitude can be quantified in medical students prior to selection for surgical training; however, both technical aptitude and dedicated practice of technical skills influence operative performance. In the US, technical aptitude assessments are inconsistently used in selecting candidates for surgical residency. Internationally, few countries have implemented standardized technical aptitude assessments in their surgical trainee selection processes. The development of technical aptitude assessments is ongoing worldwide. Technical aptitude assessments may help identify individuals particularly well-suited for a surgical career or those who might benefit from additional practice or remediation. The potential role of technical aptitude assessments in the selection process for surgical trainees remains uncertain. Consideration of these instruments requires an understanding of meaningful outcomes associated with particular technical assessments as well as the assessments' limitations.

Teaching Hospitals and Textbook Outcomes After Major Urologic Cancer Surgery

OBJECTIVE

To assess textbook outcomes by hospital teaching status following major surgery for urologic cancers.

METHODS

We used 100% national Medicare Provider Analysis and Review files from 2017-2020 to assess rates of textbook outcomes in patients undergoing bladder (ie, radical cystectomy), kidney (ie, radical or partial nephrectomy), and prostate (ie, radical prostatectomy) surgery for genitourinary malignancies. The extent of integration of learners into each hospital's workforce-defined as major, minor, and non teaching hospitals-was the primary exposure. A textbook outcome, measured at the patient level, was defined as the absence of in-hospital mortality and mortality within 30days of surgery, no readmission 30days following discharge, no postoperative complication, and no prolonged length of stay.

RESULTS

Textbook outcomes were achieved in 51% (8564/16,786) of patients after bladder cancer surgery, 70% (39,938/57,300) of patients after kidney cancer surgery, and 82% (50,408/61,385) of patients after prostate cancer surgery. After adjusting for patient- and hospital-level characteristics, teaching hospitals had higher rates of textbook outcomes in those undergoing bladder (50.7% vs 44.0%; P = .001), kidney (72.0% vs 69.7%; P = .02), and prostate (85.3% vs 81.0%; P <.001) surgery. This effect was attenuated, but not eliminated, by surgical volume in additional sensitivity analyses for bladder (OR: 1.20, 95% CI: 1.00-1.42; P = .04) and prostate (OR: 1.15, 95% CI: 1.00-1.32; P = .04) surgery. There were no significant differences in kidney cancer surgery outcomes after adjusting for hospital volume (OR: 1.03, 95% CI: 0.93-1.14; P = .6).

CONCLUSION

Undergoing major cancer surgery at a teaching hospital was associated with an increased likelihood of achieving a textbook outcome. This effect was attenuated by volume but persisted for bladder and prostate surgery.

Development of preoperative nomograms to predict the risk of overall and multifocal positive surgical margin after radical prostatectomy

OBJECTIVE

To develop preoperative nomograms using risk factors based on clinicopathological and MRI for predicting the risk of positive surgical margin (PSM) after radical prostatectomy (RP).

PATIENTS AND METHODS

This study retrospectively enrolled patients who underwent prostate MRI before RP at our center between January 2015 and November 2022. Preoperative clinicopathological factors and MRI-based features were recorded for analysis. The presence of PSM (overall PSM [oPSM]) at pathology and the multifocality of PSM (mPSM) were evaluated. LASSO regression was employed for variable selection. For the final model construction, logistic regression was applied combined with the bootstrap method for internal verification. The risk probability of individual patients was visualized using a nomogram.

RESULTS

In all, 259 patients were included in this study, and 76 (29.3%) patients had PSM, including 40 patients with mPSM. Final multivariate logistic regression revealed that the independent risk factors for oPSM were tumor diameter, frank extraprostatic extension, and annual surgery volume (all p < 0.05), and the nomogram for oPSM reached an area under the curve (AUC) of 0.717 in development and 0.716 in internal verification. The independent risk factors for mPSM included the percentage of positive cores, tumor diameter, apex depth, and annual surgery volume (all p < 0.05), and the AUC of the nomogram for mPSM was 0.790 in both development and internal verification. The calibration curve analysis showed that these nomograms were well-calibrated for both oPSM and mPSM.

CONCLUSIONS

The proposed nomograms showed good performance and were feasible in predicting oPSM and mPSM, which might facilitate more individualized management of prostate cancer patients who are candidates for surgery.

Real-life Perioperative Outcomes of Radical Prostatectomy using the French National Registry: A Plea for Promotion of Centralized Care and Access to Minimally Invasive Approaches

Radical prostatectomy (RP) can be performed using an open (ORP), laparoscopic (LRP) or robotic (RARP) approach. Most studies, even in experienced centers, have not provided solid evidence demonstrating better outcomes when using the robotic approach. In addition, one of the remaining concerns about RARP is its cost effectiveness, leading to no reimbursement for this surgical technique in some countries and thus health care inequality. We used data from a French national registry to improve knowledge of RP outcomes in a real-world scenario in order to guide and inform health care decision-makers. A total of 21 213 RP procedures were performed in 645 French centers in 2021 (ORP 20%, LRP 25%, and RARP 55% of cases). ORP was associated with longer hospital stay (p < 0.001), higher rates of postoperative complications (p < 0.001), fewer days out of hospital within 90 d of surgery (81.7 vs 83.6 vs 84.9 d for ORP vs LRP vs RARP; p < 0.00), and higher hospitalization costs (€2424 vs €1789 vs €1302). RARP is an optimal and cost-effective approach, with several advantages over ORP. Our data can be used by health care decision-makers to facilitate access to and reimbursement for the robotic approach for RP indications. PATIENT SUMMARY: For men with prostate cancer for whom surgery is recommended, surgeons can remove the prostate using open surgery or a keyhole approach with or without robot assistance. Open surgery has higher costs, more complications, and longer hospital stays.

Individualized center-based analysis of urinary and sexual functional outcome after radical prostatectomy based on the prostate cancer outcome study: a post hoc pathway to patient outcome measurement analysis for quality improvement

PURPOSE

We evaluate differences of patient-reported outcome measurements (PROM) based urinary continence and sexual function 12 months after radical prostatectomy (RPE) based on perioperative, surgical, and patient-specific characteristics in a large European academic urology center.

MATERIALS AND METHODS

All men enrolled in the Prostate Cancer Outcome Study (PCO) study who were treated with RPE between 2017 and 2021 completed EPIC-26 information surveys before and 12 months after RPE. Survey data were linked to clinical data of our institution. Logistic regression analyses were performed to examine the correlation between individual surgeons, patient characteristics, patient clinical data, and their urinary continence and sexual function.

RESULTS

In total, data of 429 men were analyzed: unstratified mean (SD) EPIC-26 domain score for urinary function decreased from 93.3 (0.7) to 60.4 (1.5) one year after RPE, respectively for sexual function from 64.95 (1.6) to 23.24 (1.1). Patients with preoperative adequate urinary function (EPIC-26 score > 80) reported significantly different mean urinary function scores between 53.35 (28.88) and 66.25 (25.15), p= 0.001, stratified by surgeons experience. On binary logistic regression analyses, only nerve sparing techniques (OR: 1,83, 95% CI: 1.01;3.21; p = 0.045) and low body mass index (OR: 0.91, CI: 0.85;0.99, p= 0.032) predicted adequate postoperative urinary function.

CONCLUSIONS

The results show how using provider-specific data from a larger cohort study enables to develop institution-specific analysis for functional outcomes after RPE. These models can be used for internal quality improvement as well as enhanced and provider-specific patient communication and shared decision making.

Validation of Claims Data for Absorbing Pads as a Measure for Urinary Incontinence after Radical Prostatectomy, a National Cross-Sectional Analysis

The use of healthcare insurance claims data for urinary incontinence (UI) pads has the potential to serve as an objective measure for assessing post-radical prostatectomy UI rates, but its validity for this purpose has not been established. The aim of this study is to correlate claims data with Patient Reported Outcome Measures (PROMs) for UI pad use. Patients who underwent RP in the Netherlands between September 2019 and February 2020 were included. Incontinence was defined as the daily use of ≥1 pad(s). Claims data for UI pads at 12-15 months after RP were extracted from a nationwide healthcare insurance database in the Netherlands. Participating hospitals provided PROMS data. In total, 1624 patients underwent RP. Corresponding data of 845 patients was provided by nine participating hospitals, of which 416 patients were matched with complete PROMs data. Claims data and PROMs showed 31% and 45% post-RP UI (≥1 pads). UI according to claims data compared with PROMs had a sensitivity of 62%, specificity of 96%, PPV of 92%, NPV of 75% and accuracy of 81%. The agreement between both methods was moderate (κ = 0.60). Claims data for pads moderately align with PROMs in assessing post-prostatectomy urinary incontinence and could be considered as a conservative quality indicator.

Does Centralization of Radical Prostatectomy Reduce the Incidence of Postoperative Urinary Incontinence?

Background

On the basis of previous analyses of the incidence of urinary incontinence (UI) after radical prostatectomy (RP), the hospital RP volume threshold in the Netherlands was gradually increased from 20 per year in 2017, to 50 in 2018 and 100 from 2019 onwards.

Objective

To evaluate the impact of hospital RP volumes on the incidence and risk of UI after RP (RP-UI).

Design setting and participants

Patients who underwent RP during 2016-2020 were identified in the claims database of the largest health insurance company in the Netherlands. Incontinence was defined as an insurance claim for ≥1 pads/d.

Outcome measurements and statistical analysis

The relationship between hospital RP volume (HV) and RP-UI was assessed via multivariable analysis adjusted for age, comorbidity, postoperative radiotherapy, and lymph node dissection.

Results and limitations

RP-UI incidence nationwide and by RP volume category did not decrease significantly during the study period, and 5-yr RP-UI rates varied greatly among hospitals (19-85%). However, low-volume hospitals (≤120 RPs/yr) had a higher percentage of patients with RP-UI and higher variation in comparison to high-volume hospitals (>120 RPs/yr). In comparison to hospitals with low RP volumes throughout the study period, the risk of RP-UI was 29% lower in hospitals shifting from the low-volume to the high-volume category (>120 RPs/yr) and 52% lower in hospitals with a high RP volume throughout the study period (>120 RPs/yr for 5 yr).

Conclusions

A focus on increasing hospital RP volumes alone does not seem to be sufficient to reduce the incidence of RP-UI, at least in the short term. Measurement of outcomes, preferably per surgeon, and the introduction of quality assurance programs are recommended.

Patient summary

In the Netherlands, centralization of surgery to remove the prostate (RP) because of cancer has not yet improved the occurrence of urinary incontinence (UI) after surgery. Hospitals performing more than 120 RP operations per year had better UI outcomes. However, there was a big difference in UI outcomes between hospitals.

Association of hospital volume and long-term survival after esophagectomy: A systematic review and meta-analysis

Background

It remains controversial whether esophageal cancer patients may benefit from esophagectomy in specialized high-volume hospitals. Here, the effect of hospital volume on overall survival (OS) of esophageal cancer patients post esophagectomy was assessed.

Methods

PubMed, Embase, and Cochrane Library were systematically searched for relevant published articles between January 1990 and May 2022. The primary outcome was OS after esophagectomy in high- vs. low-volume hospitals. Random effect models were applied for all meta-analyses. Subgroup analysis were performed based on volume grouping, sample size, study country, year of publication, follow-up or study quality. Sensitivity analyses were conducted using the leave-one-out method. The Newcastle-Ottawa Scale was used to assess the study quality. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidance, and was registered (identifier: INPLASY202270023).

Results

A total of twenty-four studies with 113,014 patients were finally included in the meta-analysis. A significant improvement in OS after esophagectomy was observed in high-volume hospitals as compared to that in their low-volume counterparts (HR: 0.77; 95% CI: 0.71-0.84, P < 0.01). Next, we conducted subgroup analysis based on volume grouping category, consistent results were found that high-volume hospitals significantly improved OS after esophagectomy than their low-volume counterparts. Subgroup analysis and sensitivity analyses further confirmed that all the results were robust.

Conclusions

Esophageal cancer should be centralized in high-volume hospitals.

Erectile Dysfunction in Pelvic Cancer Survivors and Current Management Options

Pelvic malignancies, including prostate, rectal, and bladder cancers, are among the most frequent malignancies found in the male population. These issues are most effectively and commonly treated with radiotherapy and/or surgery. However, these treatments can cause collateral damage, resulting in significant impacts on quality of life, with erectile dysfunction being one of the most frequent postoperative complications. Currently, there are several treatment options for erectile dysfunction, including oral phosphodiesterase type 5 inhibitors, vacuum erection devices, intracorporeal injections, and penile prosthesis. The latter has shown to be an effective and safe technique, with results comparable to those obtained by patients without pelvic surgery or radiotherapy. The results of early penile rehabilitation programs are promising and they have been incorporated into a greater proportion of treatment plans more recently, with varying degrees of success. In this narrative review, we summarize the literature on erectile dysfunction after pelvic cancer treatments and its management.

Impact of Cancer Care Regionalization on Patient Volume

BACKGROUND

Cancer centers are regionalizing care to expand patient access, but the effects on patient volume are unknown. This study aimed to compare patient volumes before and after the establishment of head and neck regional care centers (HNRCCs).

METHODS

This study analyzed 35,394 unique new patient visits at MD Anderson Cancer Center (MDACC) before and after the creation of HNRCCs. Univariate regression estimated the rate of increase in new patient appointments. Geospatial analysis evaluated patient origin and distribution.

RESULTS

The mean new patients per year in 2006-2011 versus 2012-2017 was 2735 ± 156 patients versus 3155 ± 207 patients, including 464 ± 78 patients at HNRCCs, reflecting a 38.4 % increase in overall patient volumes. The rate of increase in new patient appointments did not differ significantly before and after HNRCCs (121.9 vs 95.8 patients/year; P = 0.519). The patients from counties near HNRCCs, showed a 210.8 % increase in appointments overall, 33.8 % of which were at an HNRCC. At the main campus exclusively, the shift in regional patients to HNRCCs coincided with a lower rate of increase in patients from the MDACC service area (33.7 vs. 11.0 patients/year; P = 0.035), but the trend was toward a greater increase in out-of-state patients (25.7 vs. 40.3 patients/year; P = 0.299).

CONCLUSIONS

The creation of HNRCCs coincided with stable increases in new patient volume, and a sizeable minority of patients sought care at regional centers. Regional patients shifted to the HNRCCs, and out-of-state patient volume increased at the main campus, optimizing access for both local and out-of-state patients.

Utilizing clinical, pathological and radiological information to guide postoperative radiotherapy in prostate cancer

INTRODUCTION

A detectable and rising PSA following radical prostatectomy is indicative of recurrent prostate cancer. Salvage radiotherapy (SRT) with/without androgen deprivation therapy represents the main treatment option for these patients and has been historically associated with a biochemical control rate of ~70%. To determine the optimal timing, diagnostic workup, radiotherapy dosefractionation, treatment volume, and use of systemic therapy, several informative studies have been conducted in the last decade.

AREAS COVERED

This review examines the recent evidence to guide radiotherapy decision making in the SRT setting. Key topics include adjuvant vs salvage RT, utilization of molecular imaging and genomic classifiers, length of androgen deprivation therapy, inclusion of elective pelvic volume, and emerging role for hypofractionation.

EXPERT OPINION

Recently reported trials, conducted in an era prior to the routine use of molecular imaging and genomic classifiers, have been pivotal in establishing the current standard of care for SRT in prostate cancer. However, decisions about radiation treatment and systemic therapy may be tailored based on available prognostic and predictive biomarkers. Data from contemporary clinical trials are awaited to define and establish individualized, biomarker-driven approaches for SRT.

Hepatopancreatic Surgeons Versus Pancreatic Surgeons: Does Surgical Subspecialization Impact Patient Care and Outcomes?

BACKGROUND

Hepatopancreatic (HP) surgeon and hospital procedural volume may vary relative to liver or pancreas cases. We sought to investigate the impact of surgeon and hospital pancreatic subspecialization on patient outcomes.

METHODS

Patients who underwent pancreatic surgery between 2013-2017 were identified from the Medicare Standard Analytic Files. The surgery subspecialization index (SSI) was calculated to signify surgeon and hospital pancreatic subspecialization, and categorized as low, intermediate, and high SSI. The association of SSI with Textbook Outcome (TO) and its components, failure to rescue (FTR), discharge to home and index admission expenditures was assessed with mixed-effects multivariable logistic regression.

RESULTS

Among 19,625 patients, most pancreatic procedures were characterized by high SSI (Low SSI: 27.7%, Intermediate SSI: 34.7%, High SSI: 37.7%). Notably, higher SSI was associated with greater odds of achieving a TO [Intermediate SSI: OR 1.16 (95%CI 1.06-1.27); High SSI: OR 1.23 (95%CI 1.11-1.35)] as well as being discharged home, and  lower odds of experiencing FTR. Furthermore, this association persisted in both low-volume [referent: Low SSI; Intermediate SSI: OR 1.14 (95%CI 1.01-1.28); High SSI: OR 1.15 (95%CI 1.02-1.31)] and high-volume hospitals [referent: Low SSI; Intermediate SSI: OR 1.16 (95%CI 1.01-1.32); High SSI: OR 1.26 (95%CI 1.09-1.45)].

CONCLUSIONS

Greater pancreatic subspecialization was associated with improved postoperative outcomes following pancreatic resection. Amidst increasing efforts to improve quality of care, surgical subspecialization may play a role in determining patient outcomes regardless of total surgeon or hospital volume.

Radical prostatectomy readmissions: Causes, risk factors, national rates, & costs

INTRODUCTION

Readmissions have substantial clinical and financial impacts on the healthcare system. Radical prostatectomy (RP) is considered a standard treatment in the management of clinically localized prostate cancer. Yet, there is a paucity of research evaluating readmissions for RP in a national dataset.

PATIENTS AND METHODS

Patients with histologically confirmed prostate cancer managed with RP were identified within the 2016 to 2018 Nationwide Readmissions Database. Patient factors, facility factors, and surgical characteristics were evaluated for associations with readmission using univariable and multivariable analyses.

RESULTS

A total of 133,727 patients receiving RP were identified. Early (30-day) and late (31-90-day) readmission rates were 4.2% and 1.8% respectively. The most common cause of early readmission was postoperative digestive system complication (10%) and the most common cause of late readmission was septicemia (13%). On multivariable logistic regression, factors associated with both early and late readmission include nonroutine discharge at index (early: OR 1.877, 95% CI 1.667-2.113; late: OR 1.801, 95% CI 1.490-2.183), and circulatory system comorbidity (early: OR 1.29, 95% CI 1.082-1.538); late: OR 1.515, 95% CI 1.157-1.984).

CONCLUSIONS

Our findings regarding factors associated with readmission provide insight for RP counseling and may inform postoperative care pathways. Elucidation of readmission trends may allow the identification and proactive management of patients at higher risk for readmission.

Mapping European Association of Urology Guideline Practice Across Europe: An Audit of Androgen Deprivation Therapy Use Before Prostate Cancer Surgery in 6598 Cases in 187 Hospitals Across 31 European Countries

BACKGROUND

Evidence-practice gaps exist in urology. We previously surveyed European Association of Urology (EAU) guidelines for strong recommendations underpinned by high-certainty evidence that impact patient experience for which practice variations were suspected. The recommendation "Do not offer neoadjuvant androgen deprivation therapy (ADT) before surgery for patients with prostate cancer" was prioritised for further investigation. ADT before surgery is neither clinically effective nor cost effective and has serious side effects. The first step in improving implementation problems is to understand their extent. A clear picture of practice regarding ADT before surgery across Europe is not available.

OBJECTIVE

To assess current ADT use before prostate cancer surgery in Europe.

DESIGN, SETTING, AND PARTICIPANTS

This was an observational cross-sectional study. We retrospectively audited recent ADT practices in a multicentre international setting. We used nonprobability purposive sampling, aiming for breadth in terms of low- versus high-volume, academic, versus community and public versus private centres.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Our primary outcome was adherence to the ADT recommendation. Descriptive statistics and a multilevel model were used to investigate differences between countries across different factors (volume, centre type, and funding type). Subgroup analyses were performed for patients with low, intermediate, and high risk, and for those with locally advanced prostate cancer. We also collected reasons for nonadherence.

RESULTS AND LIMITATIONS

We included 6598 patients with prostate cancer from 187 hospitals in 31 countries from January 1, 2017 to May 1, 2020. Overall, nonadherence was 2%, (range 0-32%). Most of the variability was found in the high-risk subgroup, for which nonadherence was 4% (range 0-43%). Reasons for nonadherence included attempts to improve oncological outcomes or preoperative tumour parameters; attempts to control the cancer because of long waiting lists; and patient preference (changing one's mind from radiotherapy to surgery after neoadjuvant ADT had commenced or feeling that the side effects were intolerable). Although we purposively sampled for variety within countries (public/private, academic/community, high/low-volume), a selection bias toward centres with awareness of guidelines is possible, so adherence rates may be overestimated.

CONCLUSIONS

EAU guidelines recommend against ADT use before prostate cancer surgery, yet some guideline-discordant ADT use remains at the cost of patient experience and an additional payer and provider burden. Strategies towards discontinuation of inappropriate preoperative ADT use should be pursued.

PATIENT SUMMARY

Androgen deprivation therapy (ADT) is sometimes used in men with prostate cancer who will not benefit from it. ADT causes side effects such as weight gain and emotional changes and increases the risk of cardiovascular disease, diabetes, and osteoporosis. Guidelines strongly recommend that men opting for surgery should not receive ADT, but it is unclear how well the guidance is followed. We asked urologists across Europe how patients in their institutions were treated over the past few years. Most do not use ADT before surgery, but this still happens in some places. More research is needed to help doctors to stop using ADT in patients who will not benefit from it.

Learning curve and functional outcomes after laser enucleation of the prostate for benign prostate hyperplasia according to surgeon's caseload

PURPOSE

To evaluate the impact of surgical caseload on safety, efficacy, and functional outcomes of laser enucleation of the prostate (LEP) applying a structured mentoring program.

METHODS

Patient characteristics, perioperative data, and functional outcomes were analyzed descriptively. Linear and logistic regression models analyzed the effect of caseload on complications, functional outcomes and operative speed. Within the structured mentoring program a senior surgeon was present for the first 24 procedures completely, for partial steps in procedures 25-49, and as needed thereafter.

RESULTS

A total of 677 patients from our prospective institutional database (2017-2022) were included for analysis. Of these, 84 (12%), 75 (11%), 82 (12%), 106 (16%), and 330 patients (49%) were operated by surgeons at (A) < 25, (B) 25-49, (C) 50-99, (D) 100-199, and (E) ≥ 200 procedures. Preoperative characteristics were balanced (all p > 0.05) except for prostate volume, which increased with caseload. There was no significant difference in change of IPSS, Quality of life, ICIQ, pad usage, peak urine flow, residual urine, and major complications (Group A: 8.3 to E: 7.6%, p = 0.2) depending on the caseload. Caseload was not associated (Odds ratio: 0.7-1.4, p > 0.2) with major complications in the multivariable logistic regression model. Only operating time was significantly shorter with increasing caseload in the multivariable analysis (111-55 min, beta 23.9-62.9, p < 0.001).

CONCLUSION

With a structured mentoring program, the safety and efficacy of LEP can be ensured even during the learning curve with very good outcome quality. Only the operating time decreases significantly with increasing experience of the surgeon.

Rectal Perforation During Pelvic Surgery

Rectal perforations during pelvic surgery are rare but serious complications. The occurrence of rectal involvement is generally lower than that of the involvement of other portions of the bowel. The urologic field is responsible for the majority of iatrogenic rectal injuries from pelvic surgery; general and gynecologic surgeries are prone to the occurrence as well, the latter especially in the case of rectal shaving for deep infiltrating endometriosis. Attention should be posed to the prevention of rectal injuries, especially in case of challenging or salvage procedures; some tricks may be recommended to avoid thermal and mechanical damages and to realize a safe dissection. Intraoperative detection of rectal injuries is of paramount importance; once confirmed, immediate management with the closure of the defect is recommended. In general, rectal injuries diagnosed after surgery are liable to significantly worse outcomes than those detected and managed intraoperatively.

Patient summary

Rectal perforation is a rare but possible complication of pelvic surgeries. The more challenging the procedure (ie, surgery for locally advanced tumors or after radiation therapy), the higher the risk of rectal lesion. Intraoperative management of the injury should be attempted, with direct repair of the defect with or without fecal diversion.

Low annual hospital volume of anterior cruciate ligament reconstruction is not associated with higher revision rates

PURPOSE

Surgery performed in low-volume centres has been associated with longer operating time, longer hospital stays, lower functional outcomes, and higher rates of revision surgery, complications and mortality. This has been reported consistently in the arthroplasty literature, but there is a paucity of data regarding the relationship between surgical volume and outcome following anterior cruciate ligament (ACL) reconstruction. The purpose was to compare ACL reconstruction failure rates between hospitals performing different annual surgical volumes.

METHODS

All patients from the Norwegian Knee Ligament Register having primary autograft ACL reconstruction between 2004 and 2016 were included. Hospital volume was divided into quintiles based on the number of ACL reconstructions performed annually, defined arbitrarily as: 1-12 (V1), 13-24 (V2), 25-49 (V3), 50-99 (V4) and ≥ 100 (V5) annual procedures. Kaplan-Meier estimated survival curves and survival percentages were calculated with revision ACL reconstruction as the end point. Secondary outcome measures included (1) mean change in Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (QoL) and Sport subsections from pre-operative to 5-year follow-up and (2) subjective failure defined as KOOS QoL < 44.

RESULTS

Twenty thousand eight hundred and fifty patients met the inclusion criteria and 1195 (5.7%) underwent subsequent revision ACL reconstruction over the study period. Revision rates were lower in the lower volume hospitals compared with the higher volume hospitals (p < 0.001). There was no clinically significant difference in improvement between pre-operative and 5-year follow-up KOOS scores between hospital volume categories, but a higher proportion of patients having surgery at lower volume hospitals reported a subjective failure. Patients in the lower volume categories (V1-3) were more often male and older compared to the higher volume hospitals (V4-5). Concomitant meniscal injuries and participation in pivoting sports were most common in V5 compared with V1 (p < 0.001). Median operative time decreased as hospital volume increased, ranging from 90 min at V1 hospitals to 56 min at V5 hospitals (p < 0.001).

CONCLUSION

Patients having ACL reconstruction at lower volume hospitals had a lower rate of subsequent revision surgery relative to higher volume hospitals. However, complications occurred more frequently, operative duration was longer, and the number of patients reporting a subjective failure of ACL reconstruction was highest at these lower volume hospitals.

LEVEL OF EVIDENCE

Level III.

Risk model based on MRI fusion biopsy characteristics predicts biochemical recurrence after radical prostatectomy

BACKGROUND

To determine the prostate cancer biochemical recurrence-related fusion biopsy characteristics before radical surgery and to establish the risk prediction model of biochemical recurrence of prostate cancer.

METHODS

Three hundred and four patients undergoing radical surgery for prostate cancer at Huadong Hospital affiliated to Fudan University between 2009 and 2020 for preoperative magnetic resonance imaging (MRI) before biopsy with suspicious prostate cancer lesions. Each case was followed by a 10 + x needle combination of targeted biopsy (intentional or robotic fusion) with systematic biopsy. Prostate-specific antigen levels were measured at 1, 3, and 6 months postoperatively, followed by reexamination every 6 months. Survival analysis was performed by the Kaplan-Meier method, univariate and multivariate analysis by Cox, and Logistic risk regression models.

RESULTS

Higher Prostate Imaging Reporting And Data System (PI-RADS) scores (p < 0.001), suspicious extracapsular invasion (p < 0.001), and seminal vesicle invasion (p < 0.001) on MRI, the largest lesion diameter on MRI (p = 0.006), higher biopsy International Society of Urological Pathology (ISUP) grade group (p < 0.001) related to higher biochemical recurrence rates, higher pathological staging (p < 0.001), and a greater probability of local lymph node metastasis (p < 0.001). We accurately predicted the biochemical recurrence of prostate cancer after radical surgery based on preoperative features including the long diameter of the largest MRI lesion more than 23 mm, seminal vesicle invasion on MRI, and targeted fusion biopsy ISUP grade >3 Risk stratified classification (AUC = 0.729, p < 0.001). In our cohort, this risk stratification had a larger area under the curve than predictive models based only on magnetic resonance parameters and traditional risk scores.

CONCLUSIONS

In this cohort, seminal vesicle invasion on MRI, the long diameter of the largest MRI lesion, and targeted fusion biopsy ISUP grade grope are significantly predictive of pathologic features and biochemical recurrence after prostate surgery. The risk stratification integrating the three parameters could better predict the biochemical recurrence than the traditional model.

American Cancer Society's report on the status of cancer disparities in the United States, 2021

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

Same-day-discharge Robot-assisted Radical Prostatectomy: An Annual Countrywide Analysis

There are no countrywide data regarding the utilization of same-day-discharge (SDD) surgery for robot-assisted radical prostatectomy (RARP). We aimed to evaluate the annual number of SDD RARP procedures in France and to compare postoperative outcomes in SDD versus non-SDD centers. Data for all 9651 patients undergoing RARP in France in 2020 were extracted from the central database of the national healthcare system. Endpoints were length of hospital stay, patient age, center volume, lymph node dissection, and the hospital readmission rate. Overall, 184 SDD cases (1.9%) were reported in 14.2% of RARP centers. The annual RARP and SDD RARP caseload ranged from 41 to 485, and from one to 47, respectively, in SDD centers. SDD was significantly associated with higher-volume centers (p < 0.001). No difference in readmission rate (7.9% vs 5.1%; p = 0.141) was observed for SDD versus non-SDD centers. Direct stay costs were estimated at €1457 in SDD centers compared to €2021 in non-SDD centers. The main limitation is the lack of detailed patient characteristics and readmission causes. This annual nationwide analysis suggests that SDD RARP remains infrequently used in routine practice in France despite being associated with comparable short-term outcomes after RARP and potential cost benefits.

Patient summary

We evaluated the use of robot-assisted removal of the prostate (RARP) with same-day hospital discharge in France for men with prostate cancer. In 2020, only 1.9% of the 9651 RARP procedures involved same-day discharge, even though the data show that this approach has lower costs and comparable safety.

[Health care reality of selected pediatric urologic surgeries in Germany from 2006 to 2019]

BACKGROUND

The conservative and surgical treatment of children is a fundamental pillar of the urological specialist training program and represents one of the core competencies within urological healthcare. The loss of this expertise has been a reoccurring topic within urologic occupational policy. The aim of this study is to analyse actual case numbers and to compare the distribution and dynamics of pediatric urologic surgeries between the specialist departments of urology and pediatric surgery in Germany.

MATERIALS AND METHODS

We defined the surgical treatments of maldecensus testis, hypospadias, and vesicoureteral reflux (VUR) as index interventions. Using the tool reimbursement.INFO (RI Innovation GmbH, Hürth, Germany) we analysed publicly available quality report data of German hospitals between 2006 and 2019.

RESULTS

While orchidopexy was more commonly performed in the field of urology, the correction of hypospadias and the surgical treatment of VUR showed higher case numbers in the field of pediatric surgery. Proportionally, there was no relevant shift between urologic and pediatric surgical clinics for orchidopexy and surgical VUR therapy during the study period. For hypospadias corrections, the proportion of surgeries performed in pediatric surgical units is increasing (p < 0.0001). In pediatric surgery 84-93% of the analyzed procedures are performed in high-volume units, while this proportion is 56-73% in urology. In particular, a high proportion of VUR therapy in urology is performed as an occasional procedure (30% very low volume).

CONCLUSIONS

The quality report data enable the compilation of case numbers and the analysis of the distribution between urology and pediatric surgery in Germany. Merely the correction of hypospadias has shown a relevant shift towards pediatric surgery. The causes and possible consequences for professional policy of this preliminary investigation are complex and require further analysis.