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Björklund J, Stattin P, Rönmark E, Aly M, Akre O. The 90-day cause-specific mortality after radical prostatectomy: a nationwide population-based study. BJU Int 2021; 129:318-324. [PMID: 34191407 DOI: 10.1111/bju.15533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the cause-specific mortality in the postoperative period after radical prostatectomy (RP) for prostate cancer (PCa). METHODS In the National Prostate Cancer Register of Sweden (NPCR), we identified all men who died within 90 days after RP performed 1998-2018 and we assessed cause of death in a chart review. We compared the adjudications of death from our medical record review with those in in the Swedish Cause of Death Registry (CDR). RESULTS Out of 44 635, 58 (0.13%) men who had undergone RP from 1998 through 2018 died within 90 days after RP. Per medical record review the most common causes of death were cardiac disease (30%) and venous thromboembolic events (VTE; 21%). No men died of metastatic PCa as was first indicated in the CDR. After robot-assisted RP (RARP) or open retropubic RP (RRP), the postoperative mortality was 0.09% (19/21 520) and 0.19% (37/19 635), respectively. The effect off modality was confounded mainly by year of surgery, age at surgery, Charlson Comorbidity Index score and the concomitant pelvic lymph node dissection. CONCLUSION The validated absolute 90-day mortality after RP was 1.3/1000 during the 21-year study period. Cardiovascular diseases were the most common causes of death after RP. Our validation of the CDR refuted the occurrence of postoperative deaths from metastatic PCa. There were differences in rates and type of mortality between RRP and RARP, but the RARP cohort was more recent than the RRP cohort, which likely explain the differences.
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Affiliation(s)
- Johan Björklund
- Urology, The Institution for Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Erik Rönmark
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Markus Aly
- Urology, The Institution for Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Akre
- Urology, The Institution for Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
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Kennedy GT, McMillan MT, Maggino L, Sprys MH, Vollmer CM. Surgical experience and the practice of pancreatoduodenectomy. Surgery 2017; 162:812-822. [DOI: 10.1016/j.surg.2017.06.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/13/2017] [Accepted: 06/25/2017] [Indexed: 01/10/2023]
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3
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Björklund J, Folkvaljon Y, Cole A, Carlsson S, Robinson D, Loeb S, Stattin P, Akre O. Postoperative mortality 90 days after robot-assisted laparoscopic prostatectomy and retropubic radical prostatectomy: a nationwide population-based study. BJU Int 2016; 118:302-6. [PMID: 26762928 DOI: 10.1111/bju.13404] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess 90-day postoperative mortality after robot-assisted laparoscopic radical prostatectomy (RARP) and retropubic radical prostatectomy (RRP) using nationwide population-based registry data. PATIENTS AND METHODS We conducted a cohort study using the National Prostate Cancer Register of Sweden, including 22 344 men with localized prostate cancer of clinical stage T1-T3, whose prostate-specific antigen levels were <50 μg/mL and who had undergone primary radical prostatectomy in the period 1998-2012. Vital status was ascertained through the Total Population Register. The rates for 90-day postoperative mortality were analysed using logistic regression analysis, and comparisons of 90-day mortality with the background population were made using standardized mortality ratios (SMRs). RESULTS Of the 14 820 men who underwent RRP, 29 (0.20%) died, and of the 7 524 men who underwent RARP, 10 (0.13%) died. Mortality in the cohort during the 90-day postoperative period was lower than in an age-matched background population: SMR 0.57 (95% confidence interval [CI] 0.39-0.75). There was no statistically significant difference in 90-day mortality according to surgical method: RARP vs RRP odds ratio (OR) 1.14; 95% CI 0.46-2.81. Postoperative 90-day mortality decreased over time: 2008-2012 vs 1998-2007 OR 0.44; 95% CI 0.21-0.95, mainly because of lower mortality after RARP. CONCLUSION The 90-day postoperative mortality rates were low after RARP and RRP and there was no statistically significant difference between the methods. Given the long life expectancy among men with low- and intermediate-risk prostate cancer, very low postoperative mortality is a prerequisite for RP, which was fulfilled by both RRP and RARP. The selection of healthy men for RP is highlighted by the lower 90-day mortality after RP compared with the background population.
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Affiliation(s)
- Johan Björklund
- Department of Urology, Karolinska University Hospital, Solna, Sweden
| | - Yasin Folkvaljon
- Regional Cancer Centre, Uppsala University Hospital, Uppsala, Sweden
| | - Alexander Cole
- Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefan Carlsson
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - David Robinson
- Department of Urology, Ryhov County Hospital, Jönköping, Sweden.,Department of Surgery and Perioperative Sciences, Urology and Andrology, Umeå University Hospital, Umeå, Sweden
| | - Stacy Loeb
- Department of Urology Population Health, the Laura and Isaac Perlmutter Cancer Center, New York University, New York, NY, USA
| | - Pär Stattin
- Department of Surgery and Perioperative Sciences, Urology and Andrology, Umeå University Hospital, Umeå, Sweden.,Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Olof Akre
- Department of Urology, Karolinska University Hospital, Solna, Sweden.,Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Hansen J, Gandaglia G, Bianchi M, Sun M, Rink M, Tian Z, Meskawi M, Trinh QD, Shariat SF, Perrotte P, Chun FKH, Graefen M, Karakiewicz PI. Re-assessment of 30-, 60- and 90-day mortality rates in non-metastatic prostate cancer patients treated either with radical prostatectomy or radiation therapy. Can Urol Assoc J 2014; 8:E75-80. [PMID: 24554978 DOI: 10.5489/cuaj.749] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION It is customary to consider deaths that occur within 90 days of surgery as caused by that surgery. However, such practice may overestimate the true short-term mortality rates after radical prostatectomy (RP). Indeed, treatment-unrelated events might affect short-term mortality rates. We assess RP-specific excess short-term mortality. METHODS We performed a retrospective analysis of a population-based cohort of 59 010 patients (RP = 28 281 and external beam radiation therapy [EBRT] as reference group, n = 30 729) who were treated between 1998 and 2005 for non-metastatic prostate cancer. Using univariate and multivariate logistic regression analyses, we assessed the rates of 30-, 60- and 90-day mortality after either RP or EBRT. RESULTS Within the cohort, 30-, 60- and 90-day mortality rates were 0.2, 0.5 and 0.6%, and 0.1, 0.4 and 0.6% for RP and EBRT patients, respectively. This resulted in overall 30-, 60, and 90- day mortality differences of 0.1, 0.1 and 0%, respectively. After stratification according to age and Charlson comorbidity index (CCI), the magnitude of these differences increased up to 3.2% in favour of EBRT in patients aged >75 years with CCI ≥2. In multivariable analysis, rates of 30-, 60- and 90- day mortality were 5.2-, 1.8- and 1.3-fold higher after RP than EBRT, respectively. Our study is limited by its non-randomized design. CONCLUSION Overall, absolute short-term mortality rates after RP are comparable to those of EBRT. The difference decreases over time: 90 days <60 days <30 days. Nonetheless, their magnitude is far from trivial in the elderly and sickest patients.
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Affiliation(s)
- Jens Hansen
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC; ; Martini Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany
| | - Giorgio Gandaglia
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC; ; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Bianchi
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC; ; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy
| | - Maxine Sun
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC
| | - Michael Rink
- Department of Urology, University of Montreal Health Centre, Montreal, QC ; Department of Urology, Weill Medical College of Cornell University, New York, NY
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC
| | - Malek Meskawi
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC
| | - Quoc-Dien Trinh
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI
| | - Shahrokh F Shariat
- Department of Urology, Weill Medical College of Cornell University, New York, NY
| | - Paul Perrotte
- Department of Urology, Weill Medical College of Cornell University, New York, NY
| | | | - Markus Graefen
- Martini Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC; ; Department of Urology, University of Montreal Health Centre, Montreal, QC
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Trinh QD, Bjartell A, Freedland SJ, Hollenbeck BK, Hu JC, Shariat SF, Sun M, Vickers AJ. A systematic review of the volume-outcome relationship for radical prostatectomy. Eur Urol 2013; 64:786-98. [PMID: 23664423 PMCID: PMC4109273 DOI: 10.1016/j.eururo.2013.04.012] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Accepted: 04/09/2013] [Indexed: 01/09/2023]
Abstract
CONTEXT Due to the complexity and challenging nature of radical prostatectomy (RP), it is likely that both short- and long-term outcomes strongly depend on the cumulative number of cases performed by the surgeon as well as by the hospital. OBJECTIVE To review systematically the association between hospital and surgeon volume and perioperative, oncologic, and functional outcomes after RP. EVIDENCE ACQUISITION A systematic review of the literature was performed, searching PubMed, Embase, and Scopus databases for original and review articles between January 1, 1995, and December 31, 2011. Inclusion and exclusion criteria comprised RP, hospital and/or surgeon volume reported as a predictor variable, a measurable end point, and a description of multiple hospitals or surgeons. EVIDENCE SYNTHESIS Overall 45 publications fulfilled the inclusion criteria, where most data originated from retrospective institutional or population-based cohorts. Studies generally focused on hospital or surgeon volume separately. Although most of these analyses corroborated the impact of increasing volume with better outcomes, some failed to find any significant effect. Studies also differed with respect to the proposed volume cut-off for improved outcomes, as well as the statistical means of evaluating the volume-outcome relationship. Five studies simultaneously compared hospital and surgeon volume, where results suggest that the importance of either hospital or surgeon volume largely depends on the end point of interest. CONCLUSIONS Undeniable evidence suggests that increasing volume improves outcomes. Although it would seem reasonable to refer RP patients to high-volume centers, such regionalization may not be entirely practical. As such, the implications of such a shift in practice have yet to be fully determined and warrant further exploration.
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Affiliation(s)
- Quoc-Dien Trinh
- CRCHUM, Centre Hospitalier de l'Université de Montréal, Montreal, Canada; Cancer Prognostics and Health Outcomes Unit, Centre Hospitalier de l'Université de Montréal, Montreal, Canada; Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA.
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Harris I, Madan A, Naylor J, Chong S. Mortality rates after surgery in New South Wales. ANZ J Surg 2012; 82:871-7. [DOI: 10.1111/j.1445-2197.2012.06319.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2012] [Indexed: 12/17/2022]
Affiliation(s)
| | - Aman Madan
- Liverpool Hospital; South Western Sydney Clinical School, University of New South Wales; Liverpool; New South Wales; Australia
| | | | - Shanley Chong
- South Western Sydney Local Health District; Liverpool Hospital; Centre for Research; Evidence Management and Surveillance; Liverpool; New South Wales; Australia
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7
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Trinh QD, Sammon J, Jhaveri J, Sun M, Ghani KR, Schmitges J, Jeong W, Peabody JO, Karakiewicz PI, Menon M. Variations in the quality of care at radical prostatectomy. Ther Adv Urol 2012; 4:61-75. [PMID: 22496709 DOI: 10.1177/1756287211433187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Postoperative morbidity and mortality is low following radical prostatectomy (RP), though not inconsequential. Due to the natural history of the disease process, the implications of treatment on long-term oncologic control and functional outcomes are of increased significance. Structures, processes and outcomes are the three main determinants of quality of RP care and provide the framework for this review. Structures affecting quality of care include hospital and surgeon volume, hospital teaching status and patient insurance type. Process determinants of RP care have been poorly studied, by and large, but there is a developing trend toward the performance of randomized trials to assess the merits of evolving RP techniques. Finally, the direct study of RP outcomes has been particularly controversial and includes the development of quality of life measurement tools, combined outcomes measures, and the use of utilities to measure operative success based on individual patient priority.
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8
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Trinh QD, Schmitges J, Sun M, Shariat SF, Sukumar S, Tian Z, Bianchi M, Sammon J, Perrotte P, Rogers CG, Graefen M, Peabody JO, Menon M, Karakiewicz PI. Open radical prostatectomy in the elderly: a case for concern? BJU Int 2011; 109:1335-40. [DOI: 10.1111/j.1464-410x.2011.10554.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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9
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Hugosson J, Stranne J, Carlsson SV. Radical retropubic prostatectomy: a review of outcomes and side-effects. Acta Oncol 2011; 50 Suppl 1:92-7. [PMID: 21604947 DOI: 10.3109/0284186x.2010.535848] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Radical prostatectomy (RP) is worldwide probably the most common procedure to treat localized prostate cancer (PC). Due to a more widespread use of Prostate-Specific Antigen (PSA) testing, patients operated today are often younger and have organ confined disease justifying a more preservative surgery. At the same time, surgical technique has improved resulting in lower risk of permanent side-effects. This paper aims to give an overview of results from modern surgery regarding cancer control and side-effects. A brief overview of the history is given. MATERIAL AND METHODS A literature research identified recently published papers focusing on outcome and side-effects after RP. RESULTS One large randomized study (SPCG-4) compared RP and watchful waiting (WW). The study showed that RP was superior to WW in preventing local progression (RR = 0.36), distant metastasis (RR = 0.65) and death from PC (RR = 0.65). Observational studies also show a better outcome for men treated with RP compared to WW. Peri-operative mortality after RP is low in most material around 0.1%. The risk of stricture of the vesico-urethral anastomosis has decreased with improved technique from historically 10-20% to a low incidence of around 2-9% today. Also the risk of incontinence has declined with improved technique. However, while the rates of severe incontinence is usually very low, as many as 30% still report light incontinence after long-term follow-up. Erectile dysfunction (ED) is still a frequent side-effect after RP. This risk is dependent on age, pre-operative sexual function, surgical technique and other risk factors for ED such as smoking, diabetes, etc. In selected subgroups the risk of ED is low. Inguinal hernia is a more recently described complication after open retropubic RP with a postoperative incidence of 15-20% within three years of surgery. CONCLUSION RP is an effective method to achieve cancer control in selected patients. With modern technique it is a safe procedure with a low risk of permanent side-effects except for ED.
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Affiliation(s)
- Jonas Hugosson
- Institute of Clinical Sciences, Department of Urology, Sahlgrenska Academy at University of Gothenburg, Bruna Stråket 11 B, Göteborg, Sweden.
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10
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Newman DH. Screening for breast and prostate cancers: moving toward transparency. J Natl Cancer Inst 2010; 102:1008-11. [PMID: 20498425 DOI: 10.1093/jnci/djq190] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Despite mortality reductions found in early trials, recent population-based data suggest that breast and prostate cancer screening have not yielded expected benefits. Whereas evidence-based appraisals generally mistrust disease-specific mortality as a primary outcome measure, cancer screening trials have consistently used this endpoint, largely because of the impracticality of studies with enough statistical power to detect all-cause mortality reductions, which would require millions of subjects. The acceptance of disease-specific mortality as a practical surrogate for all-cause mortality may explain the discrepancy between expected and actual impact. Screening may reduce deaths from the target cancer but may increase deaths from other causes, most likely because of overdiagnosis, an increasingly recognized risk of cancer screening. Recognition of the discrepancy between the expected and the actual impact of screening and recognition of overdiagnosis as a source of harm may be critical for understanding and projecting the potential impact of cancer screening programs.
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Affiliation(s)
- David H Newman
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York City, NY 10029, USA.
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Bhojani N, Capitanio U, Suardi N, Jeldres C, Isbarn H, Shariat SF, Graefen M, Arjane P, Duclos A, Lattouf JB, Saad F, Valiquette L, Montorsi F, Perrotte P, Karakiewicz PI. The Rate of Secondary Malignancies After Radical Prostatectomy Versus External Beam Radiation Therapy for Localized Prostate Cancer: A Population-Based Study on 17,845 Patients. Int J Radiat Oncol Biol Phys 2010; 76:342-8. [DOI: 10.1016/j.ijrobp.2009.02.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 02/06/2009] [Accepted: 02/07/2009] [Indexed: 11/29/2022]
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Affiliation(s)
- Fritz H Schröder
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, USA
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13
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Mayer EK, Purkayastha S, Athanasiou T, Darzi A, Vale JA. Assessing the quality of the volume-outcome relationship in uro-oncology. BJU Int 2008; 103:341-9. [PMID: 18990134 DOI: 10.1111/j.1464-410x.2008.08021.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess systematically the quality of evidence for the volume-outcome relationship in uro-oncology, and thus facilitate the formulating of health policy within this speciality, as 'Implementation of Improving Outcome Guidance' has led to centralization of uro-oncology based on published studies that have supported a 'higher volume-better outcome' relationship, but improved awareness of methodological drawbacks in health service research has questioned the strength of this proposed volume-outcome relationship. METHODS We systematically searched previous relevant reports and extracted all articles from 1980 onwards assessing the volume-outcome relationship for cystectomy, prostatectomy and nephrectomy at the institution and/or surgeon level. Studies were assessed for their methodological quality using a previously validated rating system. Where possible, meta-analytical methods were used to calculate overall differences in outcome measures between low and high volume healthcare providers. RESULTS In all, 22 studies were included in the final analysis; 19 of these were published in the last 5 years. Only four studies appropriately explored the effect of both the institution and surgeon volume on outcome measures. Mortality and length of stay were the most frequently measured outcomes. The median total quality scores within each of the operation types were 8.5, 9 and 8 for cystectomy, prostatectomy and nephrectomy, respectively (possible maximum score 18). Random-effects modelling showed a higher risk of mortality in low-volume institutions than in higher-volume institutions for both cystectomy and nephrectomy (odds ratio 1.88, 95% confidence interval 1.54-2.29, and 1.28, 1.10-1.49, respectively). CONCLUSION The methodological quality of volume-outcome research as applied to cystectomy, prostatectomy and nephrectomy is only modest at best. Accepting several limitations, pooled analysis confirms a higher-volume, lower-mortality relationship for cystectomy and nephrectomy. Future research should focus on the development of a quality framework with a validated scoring system for the bench-marking of data to improve validity and facilitate rational policy-making within the speciality of uro-oncology.
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Affiliation(s)
- Erik K Mayer
- Department of Urology, St Mary's Hospital Campus, Imperial College Healthcare NHS Trust, London, UK.
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14
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Oh KS, Sandler HM. CounterPoint: second malignancies after radiotherapy for prostate cancer: keeping perspective. Urology 2008; 72:971-3. [PMID: 18817957 DOI: 10.1016/j.urology.2008.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Revised: 07/07/2008] [Accepted: 07/10/2008] [Indexed: 11/26/2022]
Affiliation(s)
- Kevin S Oh
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, Michigan 48109-0010, USA
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Wilt TJ, Shamliyan TA, Taylor BC, MacDonald R, Kane RL. Association between hospital and surgeon radical prostatectomy volume and patient outcomes: a systematic review. J Urol 2008; 180:820-8; discussion 828-9. [PMID: 18635233 DOI: 10.1016/j.juro.2008.05.010] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2007] [Indexed: 11/28/2022]
Abstract
PURPOSE We examined the association between hospital and surgeon volume, and patient outcomes after radical prostatectomy. MATERIALS AND METHODS Databases were searched from 1980 to November 2007 to identify controlled studies published in English. Information on study design, hospital and surgeon annual radical prostatectomy volume, hospital status and patient outcome rates were abstracted using a standardized protocol. Data were pooled with random effects models. RESULTS A total of 17 original investigations reported patient outcomes in categories of hospital and/or surgeon annual number of radical prostatectomies, and met inclusion criteria. Hospitals with volumes above the mean (43 radical prostatectomies per year) had lower surgery related mortality (rate of difference 0.62, 95% CI 0.47-0.81) and morbidity (rate difference -9.7%, 95% CI -15.8, -3.6). Teaching hospitals had an 18% (95% CI -26, -9) lower rate of surgery related complications. Surgeon volume was not significantly associated with surgery related mortality or positive surgical margins. However, the rate of late urinary complications was 2.4% lower (95% CI -5, -0.1) and the rate of long-term incontinence was 1.2% lower (95% CI -2.5, -0.1) for each 10 additional radical prostatectomies performed by the surgeon annually. Length of stay was lower, corresponding to surgeon volume. CONCLUSIONS Higher provider volumes are associated with better outcomes after radical prostatectomy. Greater understanding of factors leading to this volume-outcome relationship, and the potential benefits and harms of increased regionalization is needed.
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Affiliation(s)
- Timothy J Wilt
- Minnesota Evidence-based Practice Center, Minneapolis, Minnesota, USA.
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16
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Impact of Hospital and Surgeon Volume on Mortality and Complications After Prostatectomy. J Urol 2008; 180:155-62; discussion 162-3. [DOI: 10.1016/j.juro.2008.03.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Indexed: 11/20/2022]
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17
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Jeldres C, Suardi N, Capitanio U, Montorsi F, Shariat SF, Perrotte P, Peloquin F, Pharand D, Graefen M, Karakiewicz PI. High surgical volume is associated with a lower rate of secondary therapy after radical prostatectomy for localized prostate cancer. BJU Int 2008; 102:463-7. [PMID: 18476966 DOI: 10.1111/j.1464-410x.2008.07705.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the relationship between surgical volume (SV), defined as the number of radical prostatectomies (RPs) within a calendar year, and the time to secondary therapy (ST) after RP, as this might represent an important determinant of cancer control. PATIENTS AND METHODS The study included 7937 men treated with RP by 130 urologists between 1989 and 2000. Radiotherapy or any form of hormonal manipulation represented ST. Univariable and multivariable Cox regression analyses was used to evaluate the time to ST after RP. RESULTS SV was an independent (P = 0.02) predictor of ST-free survival after RP, and the multivariable rate of ST sharply decreased with increasing SV. CONCLUSIONS The use of ST is inversely proportional to SV of up to 24 RPs per year. A higher annual SV might be indicative of less restrictive use of RP in high-risk patients who eventually require combined treatments.
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Affiliation(s)
- Claudio Jeldres
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
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Walz J, Montorsi F, Jeldres C, Suardi N, Shariat SF, Perrotte P, Arjane P, Graefen M, Pharand D, Karakiewicz PI. The effect of surgical volume, age and comorbidities on 30-day mortality after radical prostatectomy: a population-based analysis of 9208 consecutive cases. BJU Int 2008; 101:826-32. [DOI: 10.1111/j.1464-410x.2007.07373.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Walz J, Gallina A, Saad F, Montorsi F, Perrotte P, Shariat SF, Jeldres C, Graefen M, Bénard F, McCormack M, Valiquette L, Karakiewicz PI. A Nomogram Predicting 10-Year Life Expectancy in Candidates for Radical Prostatectomy or Radiotherapy for Prostate Cancer. J Clin Oncol 2007; 25:3576-81. [PMID: 17704404 DOI: 10.1200/jco.2006.10.3820] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Candidates for definitive therapy for localized prostate cancer (PCa) should have life expectancy (LE) in excess of 10 years. However, LE estimation is difficult. To circumvent this problem, we developed a nomogram predicting 10-year LE for patients treated with either radical prostatectomy (RP) or external-beam radiation therapy (EBRT) and compared it with an existing tool. Patients and Methods Between 1989 and 2000, 9,131 men were treated with either RP (n = 5,955) or EBRT (n = 3,176), without any secondary therapy and all deaths were considered unrelated to PCa. Age and Charlson comorbidity index (CCI) predicted 10-year LE in Cox regression models. We used 200 bootstrap resamples to internally validate the nomogram. Results Median age was 66 years, median CCI was 1, median follow-up was 5.9 years and median actuarial survival was 13.8 years. Advanced age (P < .001), elevated CCI score (P < .001) and treatment type (EBRT v RP, P < .001) were independent predictors of poor 10 year LE. The nomogram predicting 10 year LE after either RP or EBRT was 84.3% accurate in split sample validation and was 2.9% (P = .007) more accurate than the existing tool. A cutoff of 70% or less was 84% accurate in identifying men who did not survive beyond 10 years. Conclusion Our nomogram can accurately identify those individuals who do not have sufficient LE to warrant definitive PCa treatment and can help optimizing therapy decision-making.
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Affiliation(s)
- Jochen Walz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montréal, Québec, Canada
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Karakiewicz PI, Briganti A, Chun FKH, Valiquette L. Outcomes Research: A Methodologic Review. Eur Urol 2006; 50:218-24. [PMID: 16762484 DOI: 10.1016/j.eururo.2006.05.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Accepted: 05/03/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We explored the history and conceptual trends of outcomes research. METHODS We described different aspects of this field, after dividing it into conceptually distinct strata. RESULTS Outcomes research can be divided into macro, meso and micro levels. Each level is further subdivided. Macro-level research targets cost and health care utilization, as well as racial, ethnic and geopolitical population health determinants. Meso-level studies address effectiveness, variability, disease impact, clinical modeling and program evaluation studies. Finally, micro-level studies address all aspects of direct patient-clinician decision-making. CONCLUSIONS An explosion of outcomes research has occurred in the past decades. Wide access to information technology, data sharing and collaborative efforts between researchers represent some of the ingredients that did and will continue to fuel that growth.
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Nuttall M, van der Meulen J, Phillips N, Sharpin C, Gillatt D, McIntosh G, Emberton M. A systematic review and critique of the literature relating hospital or surgeon volume to health outcomes for 3 urological cancer procedures. J Urol 2006; 172:2145-52. [PMID: 15538220 DOI: 10.1097/01.ju.0000140257.05714.45] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE We performed a systematic review and critique of the literature of the relationship between hospital or surgeon volume and health outcomes in patients undergoing radical surgery for cancer of the bladder, kidney or prostate. MATERIALS AND METHODS Four electronic databases were searched to identify studies that describe the relationship between hospital or surgeon volume and health outcomes. RESULTS All included studies were performed in North America. A total of 12 studies were found that related hospital volume to outcomes. For radical prostatectomy and cystectomy all 8 included studies showed improvement in at least 1 outcome measure with increasing volume and never deterioration. For nephrectomy the 4 included studies produced conflicting results. Four studies were found that related surgeon volume to outcomes. All radical prostatectomy and cystectomy studies showed that some outcomes were better with higher surgeon volume and never deterioration. We did not find any studies of the effect of surgeon volume on outcomes after nephrectomy. The 3 studies of the combined effect of hospital and surgeon volume on outcomes after radical prostatectomy or cystectomy suggest that high volume hospitals have better outcomes, in part because of the effect of surgeon volume and vice versa. CONCLUSIONS Outcomes after radical prostatectomy and cystectomy are on average likely to be better if these procedures are performed by and at high volume providers. For radical nephrectomy the evidence is unclear. The impact of volume based policies (increasing volume to improve outcomes) depends on the extent to which "practice makes perfect" explains the observed results. Further studies should explicitly address selective referral and confounding as alternative explanations. Longitudinal studies should be performed to evaluate the impact of volume based policies.
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Affiliation(s)
- Martin Nuttall
- Clinical Effectiveness Unit, University College London (ME), London, United Kingdom.
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Alibhai SMH, Leach M, Tomlinson G, Krahn MD, Fleshner N, Holowaty E, Naglie G. 30-day mortality and major complications after radical prostatectomy: influence of age and comorbidity. J Natl Cancer Inst 2005; 97:1525-32. [PMID: 16234566 DOI: 10.1093/jnci/dji313] [Citation(s) in RCA: 153] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Radical prostatectomy is associated with excellent long-term disease control for localized prostate cancer. Prior studies have suggested an increased risk of short-term complications among older men who underwent radical prostatectomy, but these studies did not adjust for comorbidity. METHODS We examined mortality and complications occurring within 30 days following radical prostatectomy among all 11,010 men who underwent this surgery in Ontario, Canada, between 1990 and 1999 using multivariable logistic regression modeling. We adjusted for comorbidity using two common comorbidity indices. Statistical tests were two-sided. RESULTS Overall, 53 men (0.5%) died, and 2195 [corrected] (19.9%[corrected]) had one or more complications within 30 days of radical prostatectomy. In models adjusted for comorbidity and year of surgery, age was associated with an increased risk of 30-day mortality (odds ratio = 2.04 per decade of age, 95% confidence interval [CI] = 1.23 to 3.39). However, the absolute 30-day mortality risk was low, even in older men, at 0.66% (95% CI = 0.2 to 1.1%) for men aged 70-79 years. In adjusted models, age was associated with an increased risk of cardiac (Ptrend < .001), respiratory (Ptrend = .01), and miscellaneous medical (Ptrend = .058) complications. Similarly, increasing comorbidity was associated with a higher risk of all categories of complications. CONCLUSIONS Increasing comorbidity is a stronger predictor than age of almost all categories of early complications after radical prostatectomy. The risk of postoperative mortality after radical prostatectomy is relatively low for otherwise healthy older men up to age 79.
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Affiliation(s)
- Shabbir M H Alibhai
- Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Canada.
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Abstract
For a variety of medical conditions and procedures, a higher volume-better outcome relationship has been hypothesized for over 25 years. An extensive, consistent body of literature supports a relationship between hospital volume and short-term outcomes for cancers treated with technologically complex surgical procedures. For cancer primarily treated by low-risk surgery, there are few studies. Recent studies found a modest (about 2%) difference in survival benefit between high-volume and low-volume providers associated with colon cancer surgery. Few evaluations in the last 15 years have addressed nonsurgical cancers, eg, lymphomas and testicular cancer. No reports have addressed recurrent or metastatic cancer. Care is better at high-volume providers for a select minority of cancers. Whether provider volume matters in the majority of cancers at the time of presentation has not been evaluated.
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Affiliation(s)
- B E Hillner
- Massey Cancer Center, Department of Internal Medicine, Medical College of Virginia at Virginia Commonwealth University, Box 980170, Richmond, VA 23298-0170, USA.
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Hillner BE, Smith TJ, Desch CE. Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care. J Clin Oncol 2000; 18:2327-40. [PMID: 10829054 DOI: 10.1200/jco.2000.18.11.2327] [Citation(s) in RCA: 479] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To conduct a comprehensive review of the health services literature to search for evidence that hospital or physician volume or specialty affects the outcome of cancer care. METHODS We reviewed the 1988 to 1999 MEDLINE literature that considered the hypothesis that higher volume or specialization equals better outcome in processes or outcomes of cancer treatments. RESULTS An extensive, consistent literature that supported a volume-outcome relationship was found for cancers treated with technologically complex surgical procedures, eg, most intra-abdominal and lung cancers. These studies predominantly measured in-hospital or 30-day mortality and used the hospital as the unit of analysis. For cancer primarily treated with low-risk surgery, there were fewer studies. An association with hospital and surgeon volume in colon cancer varied with the volume threshold. For breast cancer, British studies found that physician specialty and volume were associated with improved long-term outcomes, and the single American report showed an association between hospital volume of initial surgery and better 5-year survival. Studies of nonsurgical cancers, principally lymphomas and testicular cancer, were few but consistently showed better long-term outcomes associated with larger hospital volume or specialty focus. Studies in recurrent or metastatic cancer were absent. Across studies, the absolute benefit from care at high-volume centers exceeds the benefit from break-through treatments. CONCLUSION Although these reports are all retrospective, rely on registries with dated data, rarely have predefined hypotheses, and may have publication and self-interest biases, most support a positive volume-outcome relationship in initial cancer treatment. Given the public fear of cancer, its well-defined first identification, and the tumor-node-metastasis taxonomy, actual cancer care should and can be prospectively measured, assessed, and benchmarked. The literature suggests that, for all forms of cancer, efforts to concentrate its initial care would be appropriate.
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Affiliation(s)
- B E Hillner
- Massey Cancer Center and Department of Internal Medicine, Medical College of Virginia at Virginia Commonwealth University, Richmond, VA 23298-0170, USA.
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