Impact Of Hospital Volume Research Articles

The impact of hospital volume, residency, and fellowship training on perioperative outcomes after radical prostatectomy

ObjectivesAlthough high-volume hospitals have been associated with improved outcomes for radical prostatectomy (RP), the association of residency or fellowship teaching institutions or both and this volume-outcome relationship remains poorly described. We examine the effect of teaching status and hospital volume on perioperative RP outcomes. Methods and materialsWithin the Nationwide Inpatient Sample, we focused on RPs performed between 2003 and 2007. We tested the rates of prolonged length of stay beyond the median of 3 days, in-hospital mortality, and intraoperative and postoperative complications, stratified according to teaching status. Multivariable logistic regression analyses further adjusted for confounding factors. ResultsOverall, 47,100 eligible RPs were identified. Of these, 19,193 cases were performed at non-teaching institutions, 24,006 at residency teaching institutions, and 3,901 at fellowship teaching institutions. Relative to patients treated at non-teaching institutions, patients treated at fellowship teaching institutions were healthier and more likely to hold private insurance. In multivariable analyses, patients treated at residency (OR = 0.92, P = 0.015) and fellowship (OR = 0.82, P = 0.011) teaching institutions were less likely to experience a postoperative complication than patients treated at non-teaching institutions. Patients treated at residency (OR = 0.73, P<0.001) and fellowship (OR = 0.91, P = 0.045) teaching institutions were less likely to experience a prolonged length of stay. ConclusionsMore favorable postoperative complication profile and shorter length of stay should be expected at residency and fellowship teaching institutions following RP. Moreover, postoperative complication rates were lower at fellowship teaching than at residency teaching institutions, despite adjustment for potential confounders.

Temporal trends and volume-outcome associations after traumatic brain injury: a 12-year study in Taiwan

The purpose of this study was to evaluate temporal trends in traumatic brain injury (TBI); the impact of hospital volume and surgeon volume on length of stay (LOS), hospitalization cost, and in-hospital mortality rate; and to explore predictors of these outcomes in a nationwide population in Taiwan. This population-based patient cohort study retrospectively analyzed 16,956 patients who had received surgical treatment for TBI between 1998 and 2009. Bootstrap estimation was used to derive 95% confidence intervals for differences in effect sizes. Hierarchical linear regression models were used to predict outcomes. Patients treated in very-high-volume hospitals were more responsive than those treated in low-volume hospitals in terms of LOS (-0.11; 95% CI -0.20 to -0.03) and hospitalization cost (-0.28; 95% CI -0.49 to -0.06). Patients treated by high-volume surgeons were also more responsive than those treated by low-volume surgeons in terms of LOS (-0.19; 95% CI -0.37 to -0.01) and hospitalization cost (-0.43; 95% CI -0.81 to -0.05). The mean LOS was 24.3 days and the average LOS for very-high-volume hospitals and surgeons was 61% and 64% shorter, respectively, than that for low-volume hospitals and surgeons. The mean hospitalization cost was US $7,292.10, and the average hospitalization cost for very-high-volume hospitals and surgeons was 19% and 22% lower, respectively, than that for low-volume hospitals and surgeons. Advanced age, male sex, high Charlson Comorbidity Index score, treatment in a low-volume hospital, and treatment by a low-volume surgeon were significantly associated with adverse outcomes (p < 0.001). The data suggest that annual surgical volume is the key factor in surgical outcomes in patients with TBI. The results improve the understanding of medical resource allocation for this surgical procedure, and can help to formulate public health policies for optimizing hospital resource utilization for related diseases.

Impact of Hospital Volume on Outcomes of Care in France

Cette étude contribue à la littérature sur le lien entre le volume d’activité et les résultats de soins en exploitant pour la première fois les données hospitalières françaises à l’échelle nationale. Elle teste l’existence et l’ampleur de la corrélation volume-résultats afin de répondre à une question majeure pour l’organisation des soins hospitaliers : est-ce que les résultats de soins sont meilleurs dans les établissements lorsque l’activité consacrée à ces soins est plus élevée ? Les résultats montrent que le volume d’activité constituerait un bon critère de régulation pour améliorer les résultats dans certains domaines mais qu’il y aurait peu de bénéfice à concentrer l’activité hospitalière au-delà d’un certain point.

Hospital Volume is a Determinant of Postoperative Complications, Blood Transfusion and Length of Stay After Radical or Partial Nephrectomy

We examined the impact of hospital volume on short-term outcomes after nephrectomy for nonmetastatic renal cell carcinoma. Using the Nationwide Inpatient Sample we identified 48,172 patients with nonmetastatic renal cell carcinoma treated with nephrectomy (1998 to 2007). Postoperative complications, blood transfusions, prolonged length of stay and in-hospital mortality were examined. Stratification was performed according to teaching status, nephrectomy type (partial vs radical nephrectomy) and surgical approach (open vs laparoscopic). Multivariable logistic regression models were fitted. Patients treated at high volume centers were younger and healthier at nephrectomy. High hospital volume predicted lower blood transfusion rates (8.5% vs 9.7% vs 11.8%), postoperative complications (14.4% vs 16.6% vs 17.2%) and shorter length of stay (43.1% vs 49.8% vs 54.0%, all p <0.001). In multivariable analyses stratified according to teaching status, nephrectomy type and surgical approach, high hospital volume was an independent predictor of lower rates of postoperative complications (OR 0.73-0.88), blood transfusions (OR 0.71-0.78) and prolonged length of stay (OR 0.76-0.89, all p <0.001). Exceptions were postoperative complications at nonteaching centers (OR 0.94, p >0.05) and blood transfusions in nephrectomies performed laparoscopically (OR 0.68, p >0.05). On average, high hospital volume results in more favorable outcomes during hospitalization after nephrectomy.

Survival after treatment for carcinoma invading bladder muscle: a Dutch population‐based study on the impact of hospital volume

Study Type - Prognosis (cohort). Level of Evidence 2a. What's known on the subject? and What does the study add? The subject of mortality and survival rates after radical cystectomies in high-volume hospitals in comparison to low-volume hospitals has been extensively studied. Postoperative mortality is known to be significantly lower with high-volume providers, but for survival rates there was only a trend forwards this finding. For this reason, we performed this Dutch population-based study on survival rates, to see if we had enough power to support this trend with significant findings. To our knowledge, this is the first study of good quality showing a significant beneficial effect for survival in high-volume hospitals. • To examine the volume-outcome relationship for carcinoma invading bladder muscle (MIBC) with respect to differences in survival rates among all hospitals in the Netherlands as a guide for regionalization initiatives. • This population-based retrospective study included all patients (n= 13 033) newly diagnosed with MIBC during the period 1999-2008 in the Netherlands, selected from the Netherlands Cancer Registry. • Data were collected on demographics, morphology, stage at diagnosis and after surgery, primary treatment, vital status and date of follow-up or death. • The relative survival rate (RSR) per treatment was analysed for age, stage and hospital surgical volume. • Overall 5 and 10-year RSR for all treatments of MIBC was 32% and 25%, respectively. • Although 71.7% of the patients featured stages II and III, radical cystectomy was only performed in only 42% and 44% of these patients, respectively. • Relative survival for MIBC remained unchanged in the two consecutive time periods (1999-2003 and 2004-2008). • In all, 34% of patients diagnosed in low-volume hospitals (<10 cystectomies/year) underwent cystectomy vs 42% of those diagnosed in high-volume hospitals (P= 0.000). • In a multivariate analysis long-term survival (>30 days after surgery) was significantly lower in patients after cystectomy for stage II/III in low-volume hospitals (hazard ratio [HR] 1.17, P= 0.036). A high lymph node count (>20) was associated with a lower risk of death (HR 0.52, P= 0.000). • The 10-year RSR for patients with MIBC in the Netherlands was modest (25%) and has remained unchanged in the last decade. • The chance of undergoing cystectomy is significantly higher in high-volume hospitals. Long-term survival after cystectomy is higher in high-volume hospitals. • Regionalization of bladder cancer treatments could improve overall outcomes.

Invited Commentary

Invited Commentary

Impact of Hospital Volume on Chest Tube Duration, Length of Stay, and Mortality After Lobectomy

Numerous studies have suggested an inverse relationship between hospital volume and short-term mortality after various major operations. However, the volume-outcome relationship after lung cancer surgery remains controversial. We investigated the effects of hospital volume on various outcomes after lobectomy for lung cancer, including chest tube duration, postoperative length of stay, and in-hospital mortality. From a total of 5.85 million inpatients in the Japanese Diagnosis Procedure Combination database, we identified 19,831 patients who underwent lobectomy for lung cancer between July and December in 2007 and 2008. Patients were divided into low (≤24 per year), medium-low (25 to 43), medium-high (44 to 67), or high (≥68) hospital-volume groups. Multivariate regression analyses were conducted to analyze the concurrent effects of various factors on postoperative outcomes. Overall in-hospital mortality was 0.69%, and was significantly lower in the high-volume group compared with the low-volume group (0.48% versus 0.94%; odds ratio 0.60; p=0.047). Chest tube removal occurred earlier in the high-volume group than in the low-volume group (mean 4.0 days versus 5.1; p<0.001). Postoperative length of stay was shorter in the high-volume group than in the low-volume group (mean 11.5 days versus 15.9, p<0.001). Higher hospital volume was associated with significantly shorter chest tube duration and postoperative length of stay, and lower in-hospital mortality after lobectomy for lung cancer. However, the differences in outcomes between high-volume and low-volume hospitals may be too small to support regionalization of lung cancer operations to high-volume centers.

The Impact of Hospital Volume on the Development of Infectious Complications After Elective Abdominal Aortic Surgery in the Medicare Population

A relationship exists between higher hospital volume and lower mortality, yet the impact of hospital volume on infectious complications after elective abdominal aortic aneurysm (AAA) repair is unknown. The Medicare database (2005-2007) was utilized. Top 10% for volume were categorized as high-volume (HV) and compared to low-volume (LV) centers for infectious complications and utilization. A total of 42 155 endovascular aneurysm repair (EVAR) and 17 210 open AAA were identified. Mortality in HV was significantly lower than in LV after EVAR and open AAA. After EVAR, HV had lower than LV rates of overall infection (3.10% vs 3.51%; P = .021), PNA (0.94% vs 1.27%, P = .002), and sepsis (0.31% vs 0.45%; P = .03). Length of stay (LOS) and total hospital charges were significantly lower at HV compared to LV after both EVAR and open AAA. For Medicare beneficiaries, undergoing elective AAA repair at hospitals performing higher volume significantly reduced postoperative infectious complications and hospital resource utilization. Further analysis identifying systematic reasons for disparities may offer cost savings and improve outcomes.

Hospital Variation in 30-Day Mortality After Colorectal Cancer Surgery in Denmark

This study examines variation between hospitals in 30-day mortality after surgery for colorectal cancer (CRC) in Denmark and explores whether hospital volume and patient characteristics contribute to any variation between hospitals. Little is known about the variation between hospitals in 30-day mortality after CRC surgery, and the impact of treatment and patient characteristics that might contribute to such variation. Hospital variation was quantified using a multilevel approach on data derived from a nationwide database of all adenocarcinomas of colon and rectum diagnosed in Denmark in 2001 to 2004. These data were linked to several central registers providing information on patient's socioeconomic status, comorbidity, and use of medication. In total 11,287 patients, who underwent surgery at any of the 43 surgical departments were included. Hospitals varied from 3.5% to 44.1% in 30-day mortality after emergency colon cancer surgery, and the multilevel analysis showed that emergency patients were 5 times [odd ratio (OR) = 4.6)] as likely to die within 30 days in hospitals with the worst performance compared to those with the best performance. The American Society of Anesthesiologists (ASA) score increased the variation between hospitals (OR = 5.8), whereas the other potential explanatory variables had no effect on the variation. For patients who had elective surgery for colon and rectal cancer the variation in 30-day mortality between hospitals was small and nonsignificant. Hospital variation in 30-day mortality after CRC surgery are due to differences in hospitals' ability to take care of emergency patients, especially those with high ASA scores.

Impact of Hospital Volume on In-Hospital Mortality of Infants Undergoing Repair of Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) remains a significant cause of neonatal morbidity and mortality. Previous studies have suggested that hospital volume is an independent predictor of in-hospital mortality. We sought to validate this effect using a large national database incorporating 37 free-standing children's hospitals in the United States. Infants who underwent repair of CDH from 2000 to 2008 at Pediatric Health Information Systems-member hospitals were evaluated. Hospitals were categorized by tertiles into low-volume (≤6 cases/yr), medium-volume (6-10 cases/yr), and high-volume (>10 cases/yr). Using generalized linear mixed models with random effects, we computed the risk-adjusted odds ratio of mortality by yearly hospital volume of CDH repair, after adjustment for salient patient and hospital characteristics. There were 2203 infants who underwent repair with an overall survival of 82%. Average yearly hospital volume of CDH repair varied from 1.4 to 17.5 cases per year. Smaller birthweight (adjusted odds ratio [aOR]: 0.56 per kg, P < 0.001), year of birth (P < 0.001), chromosomal abnormalities (aOR: 3.83, P < 0.01), longer time to repair (aOR: 1.12 per week, P < 0.05), the thoracic approach for repair (P < 0.02), and requirement for extracorporeal membrane oxygenation (aOR: 10.31, P < 0.0001), or inhaled nitric oxide (aOR: 5.25, P < 0.0001) were each independently associated with mortality. Compared with low-volume hospitals, medium-volume (aOR: 0.56, P < 0.05) and high-volume (aOR: 0.44, P < 0.01) hospitals had a significantly lower mortality. The rate of extracorporeal membrane oxygenation use at each facility was not independently associated with mortality. This large study suggests that hospitals which perform high volumes of CDH repair achieve lower in-hospital mortality. These data support the paradigm of regionalized centers of excellence for the management of infants with this morbid condition.

Impact of hospital volume on clinical outcomes of endoscopic biliary drainage for acute cholangitis based on the Japanese administrative database associated with the diagnosis procedure combination system

We aimed to determine the relationship between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis, using the Japanese administrative database associated with the diagnosis procedure combination (DPC) system. A total of 8698 patients with endoscopic biliary drainage were referred to 654 hospitals. We corrected patients' data from the database to compare risk-adjusted length of stay (LOS) and drainage-related complications in relation to the hospital volume. Hospital volume was categorized into three groups based on number of cases during the study period: low-volume hospitals (LVHs; <16 cases), medium-volume hospitals (MVHs; 16-32 cases), and high-volume hospitals (HVHs; >32 cases). Significant variation in mean LOS was observed between hospital volume categories (26.8±22.6days in LVHs vs. 23.3±21.5days in MVHs vs. 19.7±17.2days in HVHs, P<0.001). There was a significant difference with regard to complications of endoscopic biliary drainage (5.6% in LVHs vs. 4.3% in MVHs vs. 3.2% in HVHs, P<0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with a decrease in risk-adjusted LOS. The standardized coefficient of MVHs was -0.155, whereas that of HVHs was -0.802. Multiple logistic regression analysis showed that hospital volume decreased the relative risk of drainage-related complications. The odds ratio (OR) of MVHs was 0.764 [95% confidence interval (CI), 0.604-0.965], whereas the OR of HVHs was 0.561 (95% CI, 0.434-0.725). There was a significant association between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis.

Impact of Hospital Volume on Postoperative Complications and In-hospital Mortality After Renal Surgery: Data From the Japanese Diagnosis Procedure Combination Database

Previous studies on the relationship between nephrectomy volume and outcomes focused mainly on operative mortality. Little is known about the association between operative volume and postoperative complications. This study analyzed the influence of hospital volume on postoperative complications and in-hospital mortality after nephrectomy or nephroureterectomy. Using the Diagnosis Procedure Combination database in Japan, 7988 patients undergoing nephrectomy or nephroureterectomy between July and December in 2006 and 2007 were identified. The cases were divided into low (≤26/y), medium (27-64), or high (≥65) hospital volume groups. Logistic regression analyses were performed to model the concurrent effects of hospital volume and other factors on postoperative complications and in-hospital mortality. In-hospital mortality was 0.84%. The overall postoperative complication rate was 7.4%. Factors associated with mortality or morbidity were age, hypertension, chronic lung diseases, cardiac diseases, chronic renal failure, and duration of anesthesia. Video-assisted surgery showed a significantly lower rate of mortality (odds ratio [OR], 0.28; P <.01) and postoperative complications (OR, 0.47; P <.01) than open surgery. The difference of mortality between high and low-volume groups was not significant (0.5% vs 1.0%) (OR, 0.48; P = .089). Although higher hospital volume was associated with fewer postoperative complications (OR, 0.72; P = .014), the difference was slight (7.1% vs 7.8%). Less comorbidity and invasive surgery and shorter anesthesia were associated with lower mortality and morbidity after renal surgery. Despite volume disparities, the magnitude of difference was only 0.7% in complications and 0.5% in mortality.

Disparities in vascular surgery: Is it biology or environment?

Disparities in health care are well documented for several racial, ethnic, and gender groups. In peripheral arterial disease, differences in prevalence, treatment selection, treatment outcomes, and resulting quality of life have negative effects on some minority groups and women. It may be easy to document disparities, but it is harder to understand their underlying causes. Are there biologic differences between members of racial and ethnic groups that influence disease presentation and outcomes? Or is the socioeconomic environment that surrounds them the true driver of observed differences? This article reviews the evidence for racial and gender disparities in vascular surgery and presents some potential mechanisms that may explain the disparities.

Surgery residency training programmes have greater impact on outcomes after pancreaticoduodenectomy than hospital volume or surgeon frequency

BackgroundHospital volume of pancreaticoduodenectomy (PD) and surgeon frequency of PD have been shown to impact outcomes. The impact of surgery residency training programmes after PD is unknown. This study was undertaken to determine the impact of surgery training programmes on outcomes after PD, as well as their importance relative to hospital volume and surgeon frequency of PD. MethodsThe State of Florida Agency for Healthcare Administration Database was queried for patients undergoing PD during 2002–2007. Measures of outcome were compared for patients undergoing PD at centres with vs. without surgery residency training programmes. ResultsA total of 2345 PDs were identified, of which 1478 (63%) were undertaken at training centres and 867 (37%) were performed at non-training centres. Patients undergoing PD at training centres had shorter lengths of stay, lower hospital charges and lower in-hospital mortality. Relative to surgeon frequency of PD, training centres had a greater favourable impact on hospital length of stay, hospital charges and in-hospital mortality (P < 0.001 for each, ancova). Relative to hospital volume of PDs undertaken, training centres had a greater impact on hospital charges (P < 0.001, ancova). ConclusionsSurgery residency training programmes have a favourable effect on outcomes following PD and their impact on outcome is greater than the impact of hospital volume or surgeon frequency of PD.

The Impact of Hospital Volume on Surgical Outcome in Patients with Rectal Cancer

This study was designed to investigate, in a population-based setting, the surgical outcome in patients with rectal cancer according to the hospital volume. Since 1995 all patients with rectal cancer have been registered in the Swedish Rectal Cancer Registry. Hospitals were classified, according to number treated per year, as low-volume, intermediate-volume, or high-volume hospitals (<11, 11-25, or >25 procedures per year). Postoperative mortality, reoperation rate within 30 days, local recurrence rate, and overall five-year survival were studied. For postoperative morbidity and mortality the whole cohort from 1995 to 2003 (n = 10,425) was used. For cancer-related outcome only, those with five-year follow-ups, from 1995 to 1998, were used (n = 4,355). In this registry setting the postoperative mortality rate was 3.6% in low-volume hospitals, and 2.2% in intermediate-volume and high-volume hospitals (P = 0.002). The reoperation rate was 10%, with no differences according to volume. The overall local recurrence rates were 9.4%, 9.3%, and 7.5%, respectively (P = 0.06). Significant difference was found among the nonirradiated patients (P = 0.004), but not among the irradiated patients (P = 0.45). No differences were found according to volume in the absolute five-year survival. Postoperative mortality and local recurrence in nonirradiated patients were lower in high-volume hospitals. No difference was seen between volumes in reoperation rates, overall local recurrence, or absolute five-year survival.

W1030 The Impact of Hospital Volume On Rate of Cholecystectomy Following Hospitalization for Acute Biliary Pancreatitis

W1030 The Impact of Hospital Volume On Rate of Cholecystectomy Following Hospitalization for Acute Biliary Pancreatitis

Surgical volume and outcomes of off-pump coronary artery bypass graft surgery: Does it matter?

Coronary artery bypass grafting performed off-pump has emerged in recent years as a less morbid alternative to on-pump bypass grafting. However, the impact of hospital volume on the outcomes of off-pump relative to on-pump bypass grafting has not been evaluated. We conducted a retrospective study of patients undergoing off-pump (n = 26,011) and on-pump (n = 99,344) coronary artery bypass grafting during 2000 through 2004 in 124 California hospitals, using the California Patient Discharge Database. Generalized linear mixed models were used to compare in-hospital mortality and postoperative complications in patients undergoing on-pump versus off-pump bypass grafting, accounting sequentially for differences in patient characteristics and hospital-level effects. The relative mortality and complication rates for patients undergoing on-pump versus off-pump coronary bypass were evaluated across hospital volume quartiles. Mean length of stay was lower for patients who underwent off-pump compared with on-pump bypass grafting (8.7 vs 9.6 days; P < .001), as were unadjusted mortality and complication rates (2.2% vs 3.3%; 10.1% vs 11.6%, respectively; P < .001). For hospitals in the highest percent off-pump bypass quartile, adjusted mortality and complication rates for patients having off-pump bypass were significantly lower than for the on-pump group (odds ratio [OR] = 0.50; 95% confidence intervals [CI], 0.41-0.61; OR = 0.73; 95% CI, 0.66-0.81, respectively; P < .001); by contrast, for hospitals in the lowest percent off-pump bypass quartile, mortality and complications were similar in off-pump and on-pump groups (OR = 1.10; 95% CI, 0.75-1.63; OR = 0.92; 95% CI, 0.72-1.16, respectively; P > .05). Outcomes were significantly better for off-pump compared with on-pump coronary artery bypass grafting. Although the benefit of off-pump bypass grafting increased as the relative use of the procedure at a hospital increased, off-pump bypass grafting can be safely implemented across numerous hospitals.

Impact of Hospital Volume on Surgical Outcome for Head and Neck Cancer

The objective of this study was to define the prognostic significance of surgical center case volume on outcome for head and neck cancer (HNC). Florida cancer registry and inpatient hospital data were queried for HNC diagnosed from 1998 to 2002. Of the 11,160 operative cases of HNC identified, 35.3% were treated at low-volume centers (LVCs), 32.7% in intermediate-volume centers (IVC), and 32.1% at high-volume centers (HVC). A larger proportion of high-grade tumors (27.9%) and lesions over 30 mm (39.7%) were resected at HVC (p < 0.001). Median survival was 61 months for HVC, 52 months for IVC, and 47 months for LVC (p < 0.001). Univariate analysis demonstrated significantly improved survival at HVC for low-, medium-, and high-grade tumors, small tumors (<30 mm), and for cancers of the parotid, larynx, and pharynx. On multivariate analysis, corrected for patient comorbidities, treatment at a HVC was a significant independent predictor of improved survival (HR = 1.25, p = 0.001). We conclude that HNC patients treated at HVC have significantly better long-term survival and cure rates. Where possible, patients with large (>30 mm), high-grade or parotid, larynx, and pharynx tumors should be evaluated and offered care at a high-volume center.

The Impact of Hospital Volume on the Number of Nodes Retrieved and Outcome in Colorectal Cancer

We sought to examine the impact of hospital surgical volume on the number of nodes harvested and survival in colorectal cancer (CRC). Between January 1994 and December 2004, a total of 8567 patients with T1, 2, 3, and 4 primary tumors and N0, N1, or N2 disease were studied. Hospitals were stratified into very low volume (VLV) (<33 cases/year), low volume (LV) (33-56 cases/year), and medium volume (MV) (57-84 cases/year). Surgery for CRC was performed most commonly at VLV hospitals: 3488 (40.7%) VLV centers versus 2359 (27.5%) LV centers versus 2720 (31.7%) MV centers. The mean number of nodes retrieved for VLV centers was 8.6, for LV centers 9.4, and MV centers 10.2 (P < 0.0002). Actuarial 5-year survival for VLV centers was 71.4 per cent, for LV centers 75.6 per cent, and for MV 77.0 per cent (P < 0.00001). By Cox proportional hazards analysis, hospital volumes (P < 0.0011) and the number of lymph nodes harvested (P < 0.0034) remain significant predictors of disease specific survival. The number of nodes retrieved is impacted by hospital volumes. Hospital volumes impact survival in CRC. These findings cannot be attributed solely to improved staging due to increased node retrieval in VLV, LV, and MV hospitals.

Holmium Laser Enucleation Versus Transurethral Resection of the Prostate: Results From a 2-Center Prospective Randomized Trial in Patients With Obstructive Benign Prostatic Hyperplasia

To our knowledge we report the first multicenter, prospective, randomized study comparing holmium laser enucleation (HoLEP) and transurethral prostate resection (TURP) for obstructive benign prostatic hyperplasia. From January to October 2002, 100 consecutive patients with symptomatic obstructive benign prostatic hyperplasia were randomized at 2 centers to surgical treatment with HoLEP (52 in group 1) or TURP (48 in group 2). Patients in the 2 groups were preoperatively assessed by scoring subjective symptoms questionnaires. Preoperative and perioperative parameters were also evaluated, the latter at 1, 6 and 12 months of followup. At baseline all patients had obstruction (Schäfer grade greater than 2). At the 1, 6 and 12-month followups no statistically significant differences were observed between the 2 groups in terms of urodynamic findings and subjective symptom scoring. In the HoLEP group mean total time in the operating room +/- SD was significantly longer than for TURP (74 +/- 19.5 vs 57 +/- 15 minutes, p <0.05), while catheterization time (31 +/- 13 vs 57.78 +/- 17.5 minutes, p <0.001 and hospital stay (59 +/- 19.9 vs 85.8 +/- 18.9 hours, p <0.001) were significantly shorter in the HoLEP group. Transient stress and urge incontinence were more common in the HoLEP group, although at the 12-month followup results were comparable. The overall complication rate was comparable in the 2 groups. Erectile function was also maintained in the followup period from baseline in each group, as expected. HoLEP and TURP were equally effective for relieving obstruction and lower urinary tract symptoms. HoLEP was associated with shorter catheterization time and hospital stay. At 1 year of followup complications were similar in the 2 groups.