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Hospital Volume and Outcomes of Robot-Assisted Radical Prostatectomy
TAKE-HOME MESSAGE
- As robotic-assisted radical prostatectomy continues to be performed outside high-volume academic centers, there is ongoing debate as to which factors are important for optimal outcomes. In this retrospective evaluation of the National Cancer Data Base, the authors evaluated perioperative and oncologic outcomes based on hospital volume. Hospitals were subdivided into quintiles. Compared with very low–volume hospitals (3–45 cases), higher-volume hospitals had substantially lower rates of conversion, prolonged length of stay, 30-day readmissions, and positive surgical margins.
- Although these data suggest that, at a high level, patients at higher-volume hospitals are more likely to have better perioperative oncologic outcomes, there are many factors contributing to effective prostate cancer care. Urologists and their hospitals should continue to monitor outcomes and appropriately counsel patients to ensure that they are meeting reasonable outcome measures for their patients.
– Michael H. Johnson, MD
abstract
This abstract is available on the publisher's site.
Access this abstract nowPURPOSE
Robot-assisted radical prostatectomy has become the predominant surgical modality to manage localized prostate cancer in the U.S. However, there are few studies focusing on the associations between hospital volume and outcomes of robot-assisted radical prostatectomy.
MATERIALS AND METHODS
We identified robot-assisted radical prostatectomies for clinically localized (cT1-2N0M0) prostate cancer diagnosed between 2010 and 2014 in the National Cancer Database. We categorized annual average hospital robot-assisted radical prostatectomy volume into very low, low, medium, high and very high by most closely sorting the final included patients into 5 equal-sized groups (quintiles). Outcomes included 30-day mortality, 90-day mortality, conversion (to open), prolonged length of stay (more than 2 days), 30-day (unplanned) readmission, positive surgical margin and lymph node dissection rates.
RESULTS
A total of 114,957 patients were included in the study, and hospital volume was categorized into very low (3 to 45 cases per year), low (46 to 72), medium (73 to 113), high (114 to 218) and very high (219 or more). Overall 30-day mortality (0.12%), 90-day mortality (0.16%) and conversion rates (0.65%) were low. Multivariable logistic regressions showed that compared with the very low volume group, higher hospital volume was associated with lower odds of conversion to open surgery (OR 0.23, p <0.001 for very high), prolonged length of stay (OR 0.25, p <0.001 for very high), 30-day readmission (OR 0.53, p <0.001 for very high) and positive surgical margins (OR 0.61, p <0.001 for very high). Higher hospital volume was also associated with higher odds of lymph node dissection in the intermediate/high risk cohort (OR 3.23, p <0.001 for very high).
CONCLUSIONS
Patients undergoing robot-assisted radical prostatectomy at higher volume hospitals are likely to have improved perioperative and superior oncologic outcomes compared to lower volume hospitals.
Additional Info
Disclosure statements are available on the authors' profiles:
Associations Between Hospital Volume and Outcomes of Robot-Assisted Radical Prostatectomy
J Urol 2020 May 01;203(5)926-932, L Xia, CD Sperling, BL Taylor, R Talwar, RR Chelluri, JD Raman, DJ Lee, DI Lee, TJ GuzzoFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
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This study utilizes the National Cancer Data Base in evaluating the associations between hospital volume and postoperative outcomes in patients undergoing robotic-assisted radical prostatectomy (RARP) for clinically localized disease (CT1-2N0M0). It is known that decentralization of this procedure has occurred with increasing availability of robotic platforms across health systems, with improved perioperative outcomes demonstrated as volumes increase to approximately 100 RALP cases per year.1 The authors conclude that patients undergoing RARP at higher-volume centers may experience better perioperative and oncologic outcomes, with important limitations noted. A lack of consensus indeed remains on the specific factors predicting these differences in postoperative outcomes between low- and high-volume centers. Increasing surgeon experience has been associated with decreased risk of positive surgical margins after RALP, as surgeon and team experience on the learning curve is a critical factor.2 Appropriate preoperative selection for lymph node dissection, experience level of the operative team, involvement of trainees, perioperative optimization of post-RALP recovery pathways, and strict adherence to fundamental surgical principles are important factors that may vary across institutions. To account for the numerous variables, undoubtedly strong leadership, communication, and meticulous technique of the primary surgeon is essential to provide the highest-quality operation for these patients. Further studies may clarify the specific factors impacting the quality of RALP and should also consider the long-term impacts on functional and oncologic outcomes.
References