Variations in Morbidity after Radical Prostatectomy

TLDR

Recent studies of cancer surgery show outcome variations among hospitals and surgeons, and in prostatectomy, postoperative complications are lower when performed in high‑volume centers and by high‑volume surgeons. The study aimed to examine variations in morbidity after radical prostatectomy for prostate cancer. Using SEER‑Medicare data on 11,522 radical prostatectomies from 1992‑1996, the authors inferred postoperative, late urinary, and long‑term incontinence complication rates from claims and examined their association with hospital and surgeon volume. The results revealed that postoperative morbidity and late urinary complications were significantly lower in very‑high‑volume hospitals and surgeons compared to low‑volume ones, while long‑term continence outcomes were less consistent, and substantial surgeon‑to‑surgeon variation was observed.

Abstract

Recent studies of surgery for cancer have demonstrated variations in outcomes among hospitals and among surgeons. We sought to examine variations in morbidity after radical prostatectomy for prostate cancer.We used the Surveillance, Epidemiology, and End Results-Medicare linked data base to evaluate health-related outcomes after radical prostatectomy. The rates of postoperative complications, late urinary complications (strictures or fistulas 31 to 365 days after the procedure), and long-term incontinence (more than 1 year after the procedure) were inferred from the Medicare claims records of 11,522 patients who underwent prostatectomy between 1992 and 1996. These rates were analyzed in relation to hospital volume and surgeon volume (the number of procedures performed at individual hospitals and by individual surgeons, respectively).Neither hospital volume nor surgeon volume was significantly associated with surgery-related death. Significant trends in the relation between volume and outcome were observed with respect to postoperative complications and late urinary complications. Postoperative morbidity was lower in very-high-volume hospitals than in low-volume hospitals (27 percent vs. 32 percent, P=0.03) and was also lower when the prostatectomy was performed by very-high-volume surgeons than when it was performed by low-volume surgeons (26 percent vs. 32 percent, P<0.001). The rates of late urinary complications followed a similar pattern. Results for long-term preservation of continence were less clear-cut. In a detailed analysis of the 159 surgeons who had a high or very high volume of procedures, wide surgeon-to-surgeon variations in these clinical outcomes were observed, and they were much greater than would be predicted on the basis of chance or observed variations in the case mix.In men undergoing prostatectomy, the rates of postoperative and late urinary complications are significantly reduced if the procedure is performed in a high-volume hospital and by a surgeon who performs a high number of such procedures.