Identifying under-performing surgeons

The learning curve in the training of percutaneous nephrolithotomy

OBJECTIVES

To investigate the learning curve in the training of percutaneous nephrolithotomy (PCNL).

METHODS

A total of 104 PCNL cases were included in this evaluation to define the learning curve of a surgeon with no previous experience at performing solo PCNL. Two parameters of expertise were reviewed, namely the operation and fluoroscopic screening times. The operation time was calculated as the beginning of access with the needle until the nephrostomy tube was placed and secured. PCNL procedures were analyzed in seven sets of 15 cases regarding the operation and fluoroscopy times, stone size, stone clearance rate, blood transfusion rate, and estimated blood loss.

RESULTS

The mean operation time was 2.4 h for the first 15 patients. It decreased to a mean of 1.5 h for cases 46 through 60. No further decrease in the operation time was observed after case 60. The fluoroscopic screening time was a peak of 17.5 min in the first 15 cases, whereas it dropped to a mean of 8.9 min for cases 46 through 60. The decline in the mean fluoroscopy screening time continued in cases 61 to 104, but the decline was not significant. There was no significant difference in stone size, stone clearance rate, blood transfusion rate, and estimated blood loss among each set of cases.

CONCLUSIONS

This study suggests that the surgical competence in PCNL can be reached after 60 cases. PCNL and fluoroscopy times drop to a steady-state level after performing 60 procedures.

A systematic review and critique of the literature relating hospital or surgeon volume to health outcomes for 3 urological cancer procedures

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.

Defining the Learning Curve for Percutaneous Nephrolithotomy

PURPOSE

To define the learning curve for percutaneous nephrolithotomy (PCNL) using three potential surrogate markers of surgical expertise.

MATERIALS AND METHODS

The learning curve of an endourologist with no previous experience at performing solo PCNL was studied. Three putative parameters of expertise were reviewed, namely, operating time, fluoroscopic screening time, and radiation dose. Operations were analyzed in cohorts of 15 to determine when a plateau was reached for all three variables. Comparison was then made with the results of a surgeon who had performed more than 1600 PCNLs. Stone type and stone clearance rate were also noted.

RESULTS

The mean operating time of the novice surgeon fell to a plateau of 92 minutes after 60 cases, but screening time and radiation dose did not plateau until case 115, when values of 231 seconds and 406 cGy/cm2 were recorded, respectively. The senior surgeon had a mean operating time of 98 minutes and screening parameters equivalent to those of the novice surgeon after 115 cases. The complexity of the stones tackled grew with increasing experience, although stone-free rates remained constant.

CONCLUSIONS

This study of the learning curve of a single surgeon suggests that competence at performing PCNL is reached after 60 cases and excellence after 115. Radiation parameters are a valuable tool in the assessment of operative competence.

Changes in patient characteristics and outcomes for radical cystectomy in England

OBJECTIVES

To describe temporal changes in patient characteristics and outcomes for radical cystectomy (RC) in England between 1995 and 2002, using routinely collected administrative data.

PATIENTS AND METHODS

Data were extracted from the Hospital Episode Statistics database of the Department of Health in England, describing all patients recorded as having undergone RC between 1995/1996 and 2001/2002; 8228 patients were included.

RESULTS

Of the patients who had undergone RC, two-thirds were > or = 65 years old and 75.6% were men. From 1995/1996 to 2001/2002 the annual number of RCs increased from 1013 to 1254, the proportion of patients admitted as an emergency decreased from 6.5% to 4.9%, the mean length of hospital stay decreased from 20.7 days to 18.7 days, and in-hospital mortality rates fell from 5.3% to 3.6%. The length of hospital stay and in-hospital mortality rates were higher in older patients, in female patients, and in those admitted as an emergency.

CONCLUSIONS

There was no sign of centralization of RCs over the study period, as the 25% increase in annual hospital volume was accompanied by a similar increase in the annual number of RCs. Length of hospital stay and in-hospital mortality rates have decreased.

Surgical management of bladder cancer in 2003

Recent advances in molecular and cell biology have led to a greater understanding of the basic biology of bladder cancer. However, despite these advances, surgery remains a key component of modern bladder cancer treatment. Endoscopy is the mainstay of the diagnosis and treatment of superficial bladder cancer. Adjuvant intravesical therapy is recommended for patients with high-risk superficial bladder cancer (Ta/T1 high grade). Select patients with invasive bladder cancer (T2/T3) are candidates for bladder-sparing approaches, incorporating transurethral resection of bladder tumor (TURBT), radiation and chemotherapy. The results and complications of endoscopic therapy are discussed. The role of partial cystectomy, radical cystoprostatectomy, prostate-sparing cystectomy, laparoscopic radical cystectomy, lymphadenectomy and urethrectomy in invasive bladder cancer are discussed. The tumor control outcomes and complications of radical cystoprostatectomy (still the gold standard) for organ-confined and node-positive bladder cancer are reported. Surgery remains an integral part of the management of patients with bladder cancer. Improved understanding of the biology of bladder cancer, combined with better surgical techniques and safety, continues to improve the survival and quality of life of patients with bladder cancer.