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

doi:10.1016/j.eururo.2021.04.028

European Urology

Volume 80, Issue 5, November 2021, Pages 531-545

https://doi.org/10.1016/j.eururo.2021.04.028 Get rights and content

Abstract

Context

The impact of surgeon and hospital volume on outcomes after radical prostatectomy (RP) for localised prostate cancer (PCa) remains unknown.

Objective

To perform a systematic review on the association between surgeon or hospital volume and oncological and nononcological outcomes following RP for PCa.

Evidence acquisition

Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. All comparative studies for nonmetastatic PCa patients treated with RP published between January 1990 and May 2020 were included. For inclusion, studies had to compare hospital or surgeon volume, defined as caseload per unit time. Main outcomes included oncological (including prostate-specific antigen persistence, positive surgical margin [PSM], biochemical recurrence, local and distant recurrence, and cancer-specific and overall survival) and nononcological (perioperative complications including need for blood transfusion, conversion to open procedure and within 90-d death, and continence and erectile function) outcomes. Risk of bias (RoB) and confounding assessments were undertaken. Both a narrative and a quantitative synthesis were planned if the data allowed.

Evidence synthesis

Sixty retrospective comparative studies were included. Generally, increasing surgeon and hospital volumes were associated with lower rates of mortality, PSM, adjuvant or salvage therapies, and perioperative complications. Combining group size cut-offs as used in the included studies, the median threshold for hospital volume at which outcomes start to diverge is 86 (interquartile range [IQR] 35–100) cases per year. In addition, above this threshold, the higher the caseload, the better the outcomes, especially for PSM. RoB and confounding were high for most domains.

Conclusions

Higher surgeon and hospital volumes for RP are associated with lower rates of PSMs, adjuvant or salvage therapies, and perioperative complications. This association becomes apparent from a caseload of >86 (IQR 35–100) per year and may further improve hereafter. Both high- and low-volume centres should measure their outcomes, make them publicly available, and improve their quality of care if needed.

Patient summary

We reviewed the literature to determine whether the number of prostate cancer operations (radical prostatectomy) performed in a hospital affects the outcomes of surgery. We found that, overall, hospitals with a higher number of operations per year have better outcomes in terms of cancer recurrence and complications during or after hospitalisation. However, it must be noted that surgeons working in hospitals with lower annual operations can still achieve similar or even better outcomes. Therefore, making hospital’s outcome data publicly available should be promoted internationally, so that patients can make an informed decision where they want to be treated.

Introduction

The outcomes of (oncological) surgery are closely related to the quality of the procedure and postoperative care, which is directly influenced by the proficiency of both the surgeon and the team taking care of patients. The volume of cases performed by a surgeon or an institution may be an important surrogate for these factors. There is evidence for radical cystectomy that units performing a large number of cases on a regular basis have better outcomes in terms of lower perioperative complications including mortality. It was the first procedure considered for centralisation in urological practice, and has resulted in a downward trend in complications and postoperative mortality rates [1], [2], [3].

Radical prostatectomy (RP) for prostate cancer (PCa) is associated with lower rates of immediate complications or mortality, especially when compared with radical cystectomy. However, expertise is needed, since both the negative impact of positive surgical margins (PSMs) on biochemical recurrence (BCR) [4], [5] and the positive impact of neurovascular bundle preservation [6] on postoperative potency and continence are well recognised.

Currently, the impact of caseload volume of RP on oncological and nononcological outcomes remains controversial. The aim of this study was to perform a systematic review to investigate the relationship between caseload volume of RP performed by hospital or individual surgeons for localised PCa, and oncological and nononcological outcomes in order to define minimum thresholds to optimise outcomes.

Section snippets

Evidence acquisition

The review was undertaken by the European Association of Urology (EAU) Prostate Cancer Guideline Panel. A protocol on the conduct of this systematic review has been published a priori online on PROSPERO (http://www.crd.york.ac.uk/PROSPERO; CRD42020186466).

Briefly, the systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) [7] and Cochrane [8] guidelines. Databases including MEDLINE, Embase, and Cochrane Database of

Quantity of evidence identified

The study selection process is outlined in the PRISMA flow diagram (Fig. 1). Sixty retrospective comparative studies were included [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68]. The

Conclusions

Higher hospital volume for RP, defined as annual caseload, is associated with fewer perioperative complications and lower rates of PSMs. A higher surgeon volume is associated with less need for additional therapies and lower rates of PSMs and complications. This association becomes apparent for a hospital caseload of between 35 and 100 (median 86) cases per year. Owing to the remaining uncertainty of the summarised evidence, it remains impossible to impose a minimum annual caseload that needs

References (84)

S.B. Williams et al.
Impact of centralizing care for genitourinary malignancies to high-volume providers: a systematic review
Eur Urol Oncol
(2019)
P. Rajan et al.
Oncologic outcomes after robot-assisted radical prostatectomy: a large European single-centre cohort with median 10-year follow-up
Eur Urol Focus
(2018)
O. Yossepowitch et al.
Positive surgical margins in radical prostatectomy: outlining the problem and its long-term consequences
Eur Urol
(2009)
V. Ficarra et al.
Systematic review and meta-analysis of studies reporting potency rates after robot-assisted radical prostatectomy
Eur Urol
(2012)
P. Sooriakumaran et al.
Biochemical recurrence after robot-assisted radical prostatectomy in a European single-centre cohort with a minimum follow-up time of 5 years
Eur Urol
(2012)
V. Sharma et al.
Open conversion during minimally invasive radical prostatectomy: impact on perioperative complications and predictors from national data
J Urol
(2014)
J. Schmitges et al.
Annual prostatectomy volume is related to rectal laceration rate after radical prostatectomy
Urology
(2012)
J. Schmitges et al.
Blood transfusions in radical prostatectomy: a contemporary population-based analysis
Urology
(2012)
J.D. Sammon et al.
Robot-assisted versus open radical prostatectomy: the differential effect of regionalization, procedure volume and operative approach
J Urol
(2013)
T.S. Ku et al.
Effects of hospital procedure volume and resident training on clinical outcomes and resource use in radical retropubic prostatectomy surgery in the Department of Veterans Affairs
J Urol
(2008)

A.B. Weiner et al.

Population based analysis of incidence and predictors of open conversion during minimally invasive radical prostatectomy

J Urol

(2015)

S.M. Gilbert et al.

Mortality after urologic cancer surgery: impact of non-index case volume

Urology

(2008)

B. Gershman et al.

Redefining and contextualizing the hospital volume-outcome relationship for robot-assisted radical prostatectomy: implications for centralization of care

J Urol

(2017)

L.M. Ellison et al.

The effect of hospital volume on cancer control after radical prostatectomy

J Urol

(2005)

A. Dash et al.

Patient, surgeon, and treatment characteristics associated with homologous blood transfusion requirement during radical retropubic prostatectomy: multivariate nomogram to assist patient counseling

Urology

(2004)

W.W. Choi et al.

The effect of minimally invasive and open radical prostatectomy surgeon volume

Urol Oncol Semin Orig Investig

(2012)

L. Budäus et al.

Annual surgical caseload and open radical prostatectomy outcomes: improving temporal trends

J Urol

(2010)

N.S. Barashi et al.

Incidence, risk factors, and outcomes for rectal injury during radical prostatectomy: a population-based study

Eur Urol Oncol

(2018)

S. Uppal et al.

Variation in care in concurrent chemotherapy administration during radiation for locally advanced cervical cancer

Gynecol Oncol

(2016)

E.M. Aviki et al.

Impact of hospital volume on surgical management and outcomes for early-stage cervical cancer

Gynecol Oncol

(2020)

P. Cathcart et al.

Achieving quality assurance of prostate cancer surgery during reorganisation of cancer services

Eur Urol

(2015)

M. Wirth et al.

The European Prostate Cancer Centres of Excellence: a novel proposal from the European Association of Urology Prostate Cancer Centre consensus meeting

Eur Urol

(2019)

J.F. Finks et al.

Trends in hospital volume and operative mortality for high-risk surgery

N Engl J Med

(2011)

M. Afshar et al.

Centralisation of radical cystectomies for bladder cancer in England, a decade on from the ‘Improving Outcomes Guidance’: the case for super centralisation

BJU Int

(2018)

D. Moher et al.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

PLoS Med

(2009)

Higgins JPT, Thomas J, Chandler J, et al. editors. Cochrane handbook for systematic reviews of interventions. Version...

H.-Y. Yu et al.

Hospital volume, utilization, costs and outcomes of robot-assisted laparoscopic radical prostatectomy

J Urol

(2012)

L. Xia et al.

Associations between hospital volume and outcomes of robot-assisted radical prostatectomy

J Urol

(2020)

W.S. Tan et al.

Variation in positive surgical margin status after radical prostatectomy for pT2 prostate cancer

Clin Genitourin Cancer

(2019)

T. Sugihara et al.

Is mechanical bowel preparation in laparoscopic radical prostatectomy beneficial? An analysis of a Japanese national database

BJU Int

(2013)

E.A.S. Steinsvik et al.

Does a surgeon’s annual radical prostatectomy volume predict the risk of positive surgical margins and urinary incontinence at one-year follow-up?—Findings from a prospective national study

Scand J Urol

(2013)

J. Schmitges et al.

Venous thromboembolism after radical prostatectomy: the effect of surgical caseload

BJU Int

(2012)

J. Schmitges et al.

The effect of annual surgical caseload on the rates of in-hospital pneumonia and other in-hospital outcomes after radical prostatectomy

Int Urol Nephrol

(2012)

S.B. Williams et al.

Utilization and expense of adjuvant cancer therapies following radical prostatectomy

Cancer

(2011)

A.B. Porcaro et al.

Linear extent of positive surgical margin impacts biochemical recurrence after robot-assisted radical prostatectomy in a high-volume centre

J Robot Surg

(2020)

A.B. Porcaro et al.

Risk factors of positive surgical margins after robot-assisted radical prostatectomy in high-volume centre: results in 732 cases

J Robot Surg

(2020)

M. Pohle et al.

Influences of surgical volume on perioperative and oncological outcomes following radical prostatectomy

Urol Int

(2018)

D. O’Kane et al.

Supervisor volume affects oncological outcomes of trainees performing open radical prostatectomy

ANZ J Surg

(2016)

G. Novara et al.

Recourse to radical prostatectomy and associated short-term outcomes in Italy: a country-wide study over the last decade

BJU Int

(2015)

Y. Nojiri et al.

Influence of hospital surgical volume of radical prostatectomy on quality of perioperative care

Int J Clin Oncol

(2013)

J.G. Nayak et al.

The impact of fellowship training on pathological outcomes following radical prostatectomy: a population based analysis

BMC Urol

(2014)

H. Nathan et al.

Hospital volume, complications, and cost of cancer surgery in the elderly

J Clin Oncol

(2015)

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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.
To evaluate the impact of hospital RP volumes on the incidence and risk of UI after RP (RP-UI).
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.
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.
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).
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.
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.
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
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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.
To assess current ADT use before prostate cancer surgery in Europe.
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.
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.
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.
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.
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.
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Our results did not indicate that hospital volume greater than the 75th percentile was associated with readmission. Previously, higher RP volumes have been associated with lower rates of perioperative complications including readmission [22,23]. The 75th percentile of RP procedure volume in our cohort was 27 to 36 procedures per year, which is markedly lower than previous studies which have defined high-volume thresholds at 86 and 114 RPs per year [22,23].
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 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.
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).
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View all citing articles on Scopus

^†: These authors share first authorship.

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Abstract

Context

Objective

Evidence acquisition

Evidence synthesis

Conclusions

Patient summary

Introduction

Section snippets

Evidence acquisition

Quantity of evidence identified

Conclusions

Eur Urol Oncol

Eur Urol Focus

Eur Urol

Eur Urol

Eur Urol

J Urol

Urology

Urology

J Urol

J Urol

J Urol

Urology

J Urol

J Urol

Urology

Urol Oncol Semin Orig Investig

J Urol

Eur Urol Oncol

Gynecol Oncol

Gynecol Oncol

Eur Urol

Eur Urol

Trends in hospital volume and operative mortality for high-risk surgery

N Engl J Med

Centralisation of radical cystectomies for bladder cancer in England, a decade on from the ‘Improving Outcomes Guidance’: the case for super centralisation

BJU Int

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

PLoS Med

Hospital volume, utilization, costs and outcomes of robot-assisted laparoscopic radical prostatectomy

J Urol

Associations between hospital volume and outcomes of robot-assisted radical prostatectomy

J Urol

Variation in positive surgical margin status after radical prostatectomy for pT2 prostate cancer

Clin Genitourin Cancer

Is mechanical bowel preparation in laparoscopic radical prostatectomy beneficial? An analysis of a Japanese national database

BJU Int

Does a surgeon’s annual radical prostatectomy volume predict the risk of positive surgical margins and urinary incontinence at one-year follow-up?—Findings from a prospective national study

Scand J Urol

Venous thromboembolism after radical prostatectomy: the effect of surgical caseload

BJU Int

The effect of annual surgical caseload on the rates of in-hospital pneumonia and other in-hospital outcomes after radical prostatectomy

Int Urol Nephrol

Utilization and expense of adjuvant cancer therapies following radical prostatectomy

Cancer

Linear extent of positive surgical margin impacts biochemical recurrence after robot-assisted radical prostatectomy in a high-volume centre

J Robot Surg

Risk factors of positive surgical margins after robot-assisted radical prostatectomy in high-volume centre: results in 732 cases

J Robot Surg

Influences of surgical volume on perioperative and oncological outcomes following radical prostatectomy

Urol Int

Supervisor volume affects oncological outcomes of trainees performing open radical prostatectomy

ANZ J Surg

Recourse to radical prostatectomy and associated short-term outcomes in Italy: a country-wide study over the last decade

BJU Int

Influence of hospital surgical volume of radical prostatectomy on quality of perioperative care

Int J Clin Oncol

The impact of fellowship training on pathological outcomes following radical prostatectomy: a population based analysis

BMC Urol

Hospital volume, complications, and cost of cancer surgery in the elderly

J Clin Oncol