Impact of surgeon and hospital volume on outcomes of radical prostatectomy

Abstract

An emerging body of literature has established a relationship between case volume and outcomes after radical prostatectomy (RP). Such findings come in the context of an already well-established association between both surgeon and hospital case volume in the field of cardiovascular surgery and for several high-risk cancer operations. The purpose of this review is to identify and summarize the seminal studies to date that investigate the impact of RP volume on patient outcomes. We performed a literature search of the English language studies available through PubMed that pertain to this topic. Thirteen original studies and a meta-analysis were found, which focus on the impact of hospital RP volume on surgical outcomes (including length of stay, perioperative complication rate, perioperative mortality, readmission rate, and several long term measures of treatment effect). Eight studies were identified that interrogated the relationship between individual surgeon case volume and outcomes. Across multiple outcome metrics, there is a pervasive association between higher hospital RP case volume and improved outcomes. Increasing individual surgeon volume may also portend better outcomes, not only perioperatively, but even with respect to long-term cancer control and urinary function. While most data arise from retrospective cohort studies, these studies, for the most part, are of sound design, show an impressive magnitude of effect, and demonstrate an impact on outcome that is proportional to surgical volume. Further research should focus on finding a means by which to translate these observations into improvements in the quality of prostate cancer care. To address differences in outcome between low volume and high volume surgeons, some have proposed and implemented subspecialization within practice groups, while others have looked toward subspecialty certification for urologic oncologists. With regard to differences in hospital volume, regionalization of care has been proposed as a solution, but is fraught with pitfalls. It may be more pragmatic and, ultimately more beneficial to patients, however, to identify processes of care that are already in place at high volume hospitals and implement them at lower volume centers. Similarly, we advocate careful studies to identify successful surgical techniques of high volume surgeons and efforts to disseminate these techniques.