Increasing Surgeon Experience Research Articles

Endovascular Repair of Abdominal Aortic Aneurysm

In the now 20 years since it was initially described, endovascular repair of abdominal aortic aneurysm (EVAR) has matured to the point where some 70% to 80% of potentially eligible patients are treated with this modality.1 Furthermore, the majority of patients managed with conventional open operation are those in whom anatomic considerations disallow EVAR. In the current issue of Circulation , Schanzer et al2 detail anatomic characteristics of a large patient cohort treated with EVAR, indicating that the primary study end point of abdominal aortic aneurysm (AAA) sac enlargement may be alarmingly high (40% at 3 years); such sac enlargement is considered a surrogate in their report for threat of late AAA rupture, representing, of course, EVAR treatment failure. Although the implications of this study referable to appropriate patient (anatomic) selection for, and close follow-up after EVAR are both evident and emphasized elsewhere,3 the authors' concerns relative to late performance of EVAR are, at this point in the evolution of this technology, refuted by a substantial body of literature. To wit, in consideration of the clinically relevant outcomes of late AAA rupture and/or freedom from AAA-related mortality, EVAR has perhaps exceeded the expectations of even its more aggressive proponents. A surfeit of literature encompassing single-center cohort studies, registries/trials, and even randomized trials of EVAR versus open repair for AAA has verified the clinical effectiveness of EVAR. In the 7000 EVAR-treated patients represented in these studies1,4,–,7 reflecting the above-noted different study designs, freedom from AAA-related mortality averages a minimum of 95% even out to 5 years with actuarial methods. A large longitudinal study of EVAR in Medicare beneficiaries (with a time interval identical to that in the Schantzer study) found late AAA rupture after EVAR …

The Surgical Learning Curve for Artificial Urinary Sphincter Procedures Compared to Typical Surgeon Experience

BackgroundThe artificial urinary sphincter (AUS) is a well-established treatment for male stress urinary incontinence. ObjectiveWe aimed to characterize the surgical learning curve for reoperation rates after AUS implantation. Design, setting, and participantsThe study cohort consisted of 65 602 adult males who received an AUS between 1988 and 2008, constituting close to 90% of all operations conducted during that time. Data on reoperations were obtained from the manufacturer, which requires documentation for warranty coverage. MeasurementsSurgeon experience was calculated as the number of original AUS implants performed prior to the index patient's surgery. Multivariable logistic regression models were used to examine the association between experience and reoperative rates, adjusted for case mix. Results and limitationsThere was a slow but steady decrease in reoperative rates with increasing surgeon experience (p=0.020), showing no plateau through 200 procedures. The risk of reoperation for a surgeon with five prior cases was 24.0%, which decreased to 18.1% for a surgeon with 100 prior implants (absolute risk difference [ARD]: 5.9%; 95% confidence interval [CI], 1.3–10.1%) and to 13.2% for a surgeon with 200 prior implants (ARD: 10.7%; 95% CI, 2.6–16.6%). Two-thirds of contemporary patients (having AUS procedure between years 2000 and 2008) saw a surgeon who had done ≤25 prior AUS implants; only 9% saw a surgeon with ≥100 prior procedures. ConclusionsThe learning curve for AUS surgery appears to be very long and without an obvious plateau. This is in contrast to typical surgeon experience, suggesting a considerable burden of avoidable reoperations. Efforts to flatten the learning are urgently needed.

Single-port hysterectomy with pelvic lymph node dissection in the porcine model: feasibility and validation of a novel robotic lightweight endoscope positioner

The purpose of this study was to evaluate the feasibility and validity of a modified single-port robotic lightweight endoscope in the performance of single-port hysterectomy with pelvic lymph node dissection in the porcine model. Task completion times were recorded for each component of the procedure: port placement, docking of the surgical robot, operative time for the procedures. For each task, linear regression modeling was performed using SPSS to determine whether a correlation existed between task completion time and increasing surgeon experience. All robotic-assisted LESS procedures were performed successfully without the addition of laparoscopic ports or open conversion. Regression analysis demonstrated a strong correlation between the number of procedures and task completion time for robot docking and pelvic lymph node dissection, correlation coefficients 0.74 and 0.77, p = 0.001, respectively. This study demonstrated the feasibility and effectiveness of a new, compact single-port robotic voice-activated endoscope at improving laparoscope guidance during the performance of single-port hysterectomy with pelvic lymph node dissection in the porcine model. Further work is needed to better define the ideal operative procedure for single-site surgery in oncology and integration of new single-port robotic platforms into clinical practice.

Does doctors' experience matter in LASIK surgeries?

In this article, we use a longitudinal census of laser in situ keratomileusis (LASIK) eye surgeries collected directly from patient charts to examine the learning-by-doing hypothesis in medicine. LASIK surgery has precise measures of presurgical condition and postsurgical outcomes. Unlike other types of surgery, the impact of unobservable underlying patient conditions on outcomes is minimal. Individual learning by doing is identified through observations of surgical outcomes over time, based on the cumulative number of surgeries performed. Collective learning is identified separately, through changes in a group adjustment rule determined jointly by all the surgeons in a structured internal review process. Our unique data set overcomes some of the measurement problems in patient outcomes encountered in other studies and improves the possibility of identifying and separating the impact of learning by doing from other effects. We cannot conclude that the outcome of LASIK surgery improves as an individual surgeon's experience increases, but we find strong evidence that experience accumulated by surgeons as a group in a clinic significantly improves outcomes.

422 FEMORAL TO PUDENDAL NERVE TRANSFER REINNERVATES URETHRAL AND ANAL SPHINCTERS IN A CANINE MODEL

calculated as the number of original AUS implants performed prior to the index patient’s surgery. Multivariable logistic regression models were used to examine the association between experience and reoperative rates adjusted for case-mix. RESULTS: Most surgeons included in our analyses performed fewer than 5 AUS implants (n 4757; 59%); 23% (n 1813) had a lifetime history 10 or more prior cases and 2% (n 134) performed 50 or more AUS implants. The analysis of any reoperation within 5 years included 40,347 male patients treated with an AUS between 1988 and 2003. Nearly 1 in 4 (n 9098; 23%) underwent reoeperative surgery. There was a slow decrease in reoperative rates with increasing surgeon experience (p 0.020). The risk of reoperation for a surgeon with 5 prior cases was 24%, which decreased to 18% for a surgeon with 100 prior implants (absolute risk difference 5.9%; 95%CI 1.3%, 10.1%) and to 13% for a surgeon with 200 prior implants (absolute risk difference 10.7%; 95%CI 2.6%, 16.6%). Two-thirds of contemporary patients saw surgeons who had done 25 or fewer AUS implants; only 9% saw a surgeon with 100 or more prior procedures. The figure gives predicted 5 year probability of reoperative surgery plotted against surgeon experience. The overlaying density plot shows the distribution of patients by surgeon experience in 2000–2008. CONCLUSIONS: There is a clear and obvious disparity between the learning curve for AUS surgery and typical surgeon experience, suggesting a considerable burden of avoidable reoperations. Attempts to speed up the learning curve, perhaps though advanced or apprenticed training, are urgently needed.

Reverse Total Shoulder Replacement in Patients with Severe Glenoid Bone Loss

A commonly cited contraindication to reverse total shoulder arthroplasty is deficient glenoid bone stock. Deficient glenoid bone stock can lead to inadequate glenoid baseplate fixation and, eventually, glenoid component loosening and prosthesis failure . However, with improved prosthetic designs and increased surgeon experience, indications for use of reverse total shoulder arthroplasty continue to expand to include shoulders that would have previously seemed doomed to failure if treated with a reverse prosthesis. In this article, 3 cases are presented, 1 of cuff tear arthropathy and 2 of chronic anterior dislocations, in whom primary reverse total shoulder arthroplasty was performed despite the presence of severe glenoid bone deficiency. Corticocancellous bone grafting was used at the time of the reverse arthroplasty to augment the deficient glenoid and allow for simultaneous and adequate glenoid component fixation. All 3 cases showed excellent results in short-term follow-up, providing surgeons with an option for how to treat these difficult shoulders.

Early Complications of Volar Plating of Distal Radius Fractures and Their Relationship to Surgeon Experience

Fractures of the distal radius are among the most common fractures in adults. Recently, there has been a trend towards open reduction and internal fixation of these fractures through a volar approach. The purpose of this study was to assess the early complications of volar locking plate fixation of distal radius fractures with an emphasis on defining the relationship between surgeon experience and incidence of complications. Following IRB approval, we conducted a retrospective chart review of the initial 96 distal radius fractures (92 patients) treated by open reduction and internal fixation of distal radius fracture using a volar locked plate. Our outcome measurements were incidence of postoperative complications and radiographic loss of reduction. Twenty-two complications occurred in 21 patients. Of these, five complications (5%) required surgical treatment or hospitalization. Seventeen complications (18%) required no surgical intervention or hospitalization. Transient nerve dysfunction was the most common complication, accounting for 12 of 22 complications. The first 30 patients experienced significantly more complications than those treated later in the series (p = 0.03). There was a trend towards increased incidence of complications in cases where more than 10days elapsed between injury and surgery or where supplementary Kirschner wire fixation was used. There was no correlation between patient age, sex, severity of fracture, or presence of ulnar styloid fracture and the development of complications or loss of reduction. The incidence of complications decreased significantly with increased surgeon experience, suggesting that many of these early complications are avoidable.

1860 CLASSIFICATION AND TRENDS OF PERI-OPERATIVE COMPLICATIONS IN 1250 CASES OF EXTRAPERITONEAL ROBOT ASSISTED RADICAL PROSTATECTOMY (ERARP)

You have accessJournal of UrologyProstate Cancer: Localized VIII1 Apr 20101860 CLASSIFICATION AND TRENDS OF PERI-OPERATIVE COMPLICATIONS IN 1250 CASES OF EXTRAPERITONEAL ROBOT ASSISTED RADICAL PROSTATECTOMY (ERARP) Ahmed Ghazi, Mathew Lux, Changyong Feng, Maura Drnevich, Hitendra Patel, and Jean Joseph Ahmed GhaziAhmed Ghazi More articles by this author , Mathew LuxMathew Lux More articles by this author , Changyong FengChangyong Feng More articles by this author , Maura DrnevichMaura Drnevich More articles by this author , Hitendra PatelHitendra Patel More articles by this author , and Jean JosephJean Joseph More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1800AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Extraperitoneal robot assisted radical prostatectomy (ERARP)is a growing surgical procedure for localized carcinoma of the prostate. Since its introduction, the procedure has undergone significant modifications with the continued goal of improving patient outcomes. The crucial step in the establishment of any new surgical technique is to maintain or improve the quality of surgical care, which should reflect in low complication rates, as well as good oncological and functional results. Various studies have also shown that perioperative complications, conversion rate, and morbidity decreased with increasing experience. In this study, we categorized our perioperative complications using the recently revised Clavien classification system and assesed the trends related to our increasing experience. METHODS Perioperative complications of 1250 patients who underwent ERARP for prostate cancer were reviewed. The complications were categorized according to the Clavien classification system. Patients were classified into 3 groups of consecutive patients (0-400, 400-800 and 800-1250). The incidences of perioperative complications were analyzed, to study the impact of the learning curve. RESULTS A total of 214 complications were found, with 2(0.9%) intraoperative, 168(69.7%) early postoperative & 44(20.5%) late postoperative complications table 1. According to the Clavien classification system 68(31.8%) grade I, 70(32.7%) grade II, 74(34.6%) grade III, 13(6%) grade IV & 0 grade V complications were recorded. There were significant differences in the rates of urinary retention, bladder neck contracture, anastomosis leak & lymphocele among the 3 groups, with a p-value of 0.002,0.001,0.02 & 0.02 respectively. The grade of complications decreased with an increase in surgeon's experience. The commonest Clavien grade during the first, second & third group of patients was grade III, II & I respectively. Table 1. Complications Treatment No (%) Clavien grade INTRAOPERATIVE COMPLICATIONS Rectal injury Double layer suture 1(0.45%) IIIb Ureter injury Intraoperative repair with DJ application 1(0.45%) IIIb EARLY POSTOPERATIVE (<1mth) Urinary retention Catheterization for 7 days 21(9.8%) I Anastomosis leak Prolong catheter for 7 days 23(10.7%) I DVT Conservative 9(4.2%) II Clot retention Flushing of catheter and conservative 5(2.3%) I Hematoma Conservative / open evacuation 10(4.7%) I /IIIb Gross hematuria conservative 7(3.3%) I Urinoma/ pelvic abcess Conservative / Percutaneous drainage 9(4.2%) I /IIIa Lymhocele Percutaneous drainage +/- sclerotherapy 21(9.8%) IIIa Urinary tract infection conservative 44(20.5%) II Epididymitis & orchitis conservative 17(7.5%) II Obturator nerve injury conservative 2(0.9%) LATE POSTOPERATIVE (>1mth) Urethral stricture dilatation /Visual internal ureterotomy 2(0.9%) IIIa /IIIb Bladder neck contracture Dilatation / TUR bladder neck 23(10.7%) IIIa /IIIb Myocardial infarction conservative 3(1.4%) IVa Arrhythmia conservative 2(0.9%) IVa Stroke conservative 3(1.4%) IVa Pulmonary embolism conservative 4(1.9%) IVa Inguinal hernia Surgical repair 7(3.3%) IIIb CONCLUSIONS Our experience proves that extraperitoneal approach for RARP is a well established & safe technique for the management of prostate cancer with an acceptable range of peri-operative complications. The severity of complications as classified using the Clavien system decreased with increased surgeon experience. Rochester, NY© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e722 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Ghazi More articles by this author Mathew Lux More articles by this author Changyong Feng More articles by this author Maura Drnevich More articles by this author Hitendra Patel More articles by this author Jean Joseph More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A Detailed Analysis of the Reduction Mammaplasty Learning Curve: A Statistical Process Model for Approaching Surgical Performance Improvement

The increased focus on quality and efficiency improvement within academic surgery has met with variable success among plastic surgeons. Traditional surgical performance metrics, such as morbidity and mortality, are insufficient to improve the majority of today's plastic surgical procedures. In-process analyses that allow rapid feedback to the surgeon based on surrogate markers may provide a powerful method for quality improvement. The authors reviewed performance data from all bilateral reduction mammaplasties performed at their institution by eight surgeons between 1995 and 2007. Multiple linear regression analyses were conducted to determine the relative impact of key factors on operative time. Explanatory learning curve models were generated, and complication data were analyzed to elucidate clinical outcomes and trends. A total of 1068 procedures were analyzed. The mean operative time for bilateral reduction mammaplasty was 134 +/- 34 minutes, with a mean operative experience of 11 +/- 4.7 years and total resection volume of 1680 +/- 930 g. Multiple linear regression analyses showed that operative time (R = 0.57) was most closely related to surgeon experience and resection volume. The complication rate diminished in a logarithmic fashion with increasing surgeon experience and in a linear fashion with declining operative time. The results of this study suggest a three-phase learning curve in which complication rates, variance in operative time, and operative time all decrease with surgeon experience. In-process statistical analyses may represent the beginning of a new paradigm in academic surgical quality and efficiency improvement in low-risk surgical procedures.

Editorial Comment

The authors evaluate the impact of bilateral nerve-sparing technique on pathologic and functional outcomes of a large cohort of men who underwent robotic radical prostatectomy by 3 experienced surgeons. Some limitations of this study, as discussed by the authors, are the retrospective nature of the analysis, and the fact that the “extrafascial dissection” was initiated in 2006; therefore, by their own criteria, 10.4% of the patients in the IF group would have had EF dissection if they had undergone surgery after 2006. Also, the series is sequential, so the most recent patients have the benefit of increased surgeon experience and probably a slightly lower risk of disease because of stage migration in the PSA era, and the questionnaire data are absent in 25% of the cohort. The most significant limitation, however, is that multivariate analysis to examine the independent effect of nerve-sparing technique on positive margins and sexual function is not performed. Results that appear positive in univariate analysis may be affected by subtle prostate cancer risk, age, or era of treatment differences. 1 Nelles J.L. Freedland S.J. Presti Jr, J.C. et al. Impact of nerve sparing on surgical margins and biochemical recurrence: results from the SEARCH database. Prostate Cancer Prostatic Dis. 2009; 12: 172-176 Crossref PubMed Scopus (22) Google Scholar We congratulate the authors for the prospective data collection, validated quality of life data, and the comprehensive reporting of their pathologic information. Extrafascial Versus Interfascial Nerve-sparing Technique for Robotic-assisted Laparoscopic Prostatectomy: Comparison of Functional Outcomes and Positive Surgical Margins CharacteristicsUrologyVol. 74Issue 3PreviewTo evaluate the pathologic and functional outcomes of patients with bilateral interfascial (IF) or extrafascial nerve-sparing (EF-NSP) techniques. It is believed that the IF-NSP technique used during robotic-assisted radical prostatectomy (RARP) spares more nerve fibers, while EF dissection may lower the risk for positive surgical margins (PSM). Full-Text PDF Editorial CommentUrologyVol. 74Issue 3PreviewIn this issue of Urology, Shikanov et al report the results of nerve-sparing radical prostatectomy in a large, prospective cohort.1 Three experienced surgeons used a partial extrafascial approach for moderately aggressive cancer and an interfascial approach for less aggressive cancer. Full-Text PDF ReplyUrologyVol. 74Issue 3PreviewWe appreciate the thoughtful and valid editorial comments. However, some issues have to be considered and reiterated. Full-Text PDF Editorial CommentUrologyVol. 74Issue 3PreviewThe introduction of robotic procedures for prostate cancer surgery is an unquestionably exciting development for the field of urology, much as that for any scientific discovery or innovative biotechnology brought to this field. However, for this application to be considered a major advancement, it must undergo proper and responsible evaluation of its merits. The touted advantages of robotic radical prostatectomy include reduced surgical blood loss and improved visualization during surgery, and claims have also been put forward that the surgery affords equivalent, if not heightened, outcomes of oncologic control and functional recovery of erectile function and urinary continence, when compared to the conventional open surgical approaches. Full-Text PDF

Anastomotic Complications Associated with Stapled Versus Hand-Sewn Anastomosis

To compare anastomotic complications of stapled versus hand-sewn cervical esophago-gastric anastomosis. All patients undergoing esophageal resection are entered into a prospectively maintained database. The database was queried to identify patients who had near total esophagectomy with cervical esophago-gastric anastomosis. The effect of anastomotic technique and surgeon experience on anastomotic complications, leak, and stricture were analyzed. Eighty-one patients underwent open or minimally invasive esophagectomy and gastric pull-up with or without thoracic mobilization. Eighteen patients had hand-sewn anastomosis and 63 had a partially stapled anastomosis. There was no significant difference between leak rate (22% (4/18) versus 7% (5/63) P = 0.09) and anastomotic stricture rate (38% (7/18) versus 26% (17/63), P = 0.34) between the two groups. Dividing the experience chronologically into three groups of 27 reveals a trend towards decreased leak rate with experience. The leak rate was only 3.7 % (1/27) in the most recent group compared with 14.8% (4/27) in the first group (P = 0.17). In our experience, there was no significant difference in anastomotic complications between hand-sewn and stapled anastomosis. However, there is a decreasing trend in anastomotic complications with increasing surgeon experience.

Effect of Surgeon Training, Specialization, and Experience on Outcomes for Cancer Surgery: A Systematic Review of the Literature

Outcomes after cancer resections have been shown to be better for high-volume surgeons compared with low-volume surgeons; however, reasons for this relationship have been difficult to identify. The objective of this study was to assess studies examining the effect of surgeon training and experience on outcomes in surgical oncology. A systematic review of the literature was performed to assess articles examining the impact of surgeon training, certification, and experience on outcomes. Studies were included if they examined cancer resections and performed multivariable analyses adjusting for relevant confounding variables. An extensive literature search identified 29 studies: 27 examined surgeon training/specialization, 1 assessed surgeon certification, and 4 evaluated surgeon experience. Of the 27 studies examining training/specialization, 25 found that specialized surgeons had better outcomes than nonspecialized surgeons. One study found that American Board of Surgery (ABS)-certified surgeons had better outcomes than noncertified surgeons. Of the two studies examining time since ABS certification, both found that increasing time was associated with better outcomes. Of the four studies that examined experience, three studies found that increasing surgeon experience was associated with improved outcomes. Although numerous studies have examined the impact of surgeon factors on outcomes, only a few cancers have been examined, and outcome measures are inconsistent. Most studies do not appear robust enough to support major policy decisions. There is a need for better data sources and consistent analyses which assess the impact of surgeon factors on a broad range of cancers and help to uncover the underlying reasons for the volume-outcome association.

The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study

We previously reported the learning curve for open radical prostatectomy, reporting large decreases in recurrence rates with increasing surgeon experience. Here we aim to characterise the learning curve for laparoscopic radical prostatectomy. We did a retrospective cohort study of 4702 patients with prostate cancer treated laparoscopically by one of 29 surgeons from seven institutions in Europe and North America between January, 1998, and June, 2007. Multivariable models were used to assess the association between surgeon experience at the time of each patient's operation and prostate-cancer recurrence, with adjustment for established predictors. After adjusting for case mix, greater surgeon experience was associated with a lower risk of recurrence (p=0.0053). The 5-year risk of recurrence decreased from 17% to 16% to 9% for a patient treated by a surgeon with 10, 250, and 750 prior laparoscopic procedures, respectively (risk difference between 10 and 750 procedures 8.0%, 95% CI 4.4-12.0). The learning curve for laparoscopic radical prostatectomy was slower than the previously reported learning curve for open surgery (p<0.001). Surgeons with previous experience of open radical prostatectomy had significantly poorer results than those whose first operation was laparoscopic (risk difference 12.3%, 95% CI 8.8-15.7). Increasing surgical experience is associated with substantial reductions in cancer recurrence after laparoscopic radical prostatectomy, but improvements in outcome seem to accrue more slowly than for open surgery. Laparoscopic radical prostatectomy seems to involve skills that do not translate well from open radical prostatectomy. National Cancer Institute, the Allbritton Fund, and the David J Koch Foundation.

Complications of epilepsy surgery in the first 8 years after neurosurgical training

Background Surgery is the most effective means of eliminating or reducing seizures in cases of medically refractory epilepsy. As elective surgery, however, there is little tolerance for complications. We have reviewed the early operative experience of a single epilepsy surgeon to identify the presence or absence of a surgical learning curve. Methods All phase II (diagnostic) and phase III (therapeutic) procedures for epilepsy surgery during the surgeon's first 8 years of practice were retrospectively reviewed. Complications were analyzed and subdivided into major or minor. Trends in complication rates were evaluated. Results During the first 8 years, there were 96 phase II and 94 phase III cases. Complications occurred in 26 (14%) of 190 cases, including 16 major (8%) and 10 minor (5%) complications. There was a decline in both the number and severity of complications associated with temporal lobectomy over time. Complications involving subdural grids shifted, over time, from those attributed to surgical technique or experience to those felt to be unavoidable risks of the procedure itself. Over time there was a decline in the proportion of major vs minor complications, but the overall complication rate remained stable. Conclusions There appears to be a surgical learning curve for epilepsy surgery involving complications associated with removal of medial temporal lobe structures, which lessen as the surgeon's experience increases.

Advances in robotic prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) has emerged as an important treatment option for localized prostate cancer. As such, methods to improve instrumentation, technique, outcomes, and cost require continued investigation. For example, a recently introduced four-armed robotic system has limited the need for bedside assistants, while an enhanced understanding of pelvic anatomy as visualized robotically has led to valuable modifications in operative technique. Increased surgeon experience has decreased perioperative morbidity, and has resulted in short-term pathologic and functional outcomes that compare favorably with open radical prostatectomy. Meanwhile, quality-of-life studies using validated instruments are helping to define the time course of patient recovery. Nevertheless, costs associated with robotic surgery remain daunting. As the follow-up of patients treated with RALP matures, future studies, ideally with a prospective, randomized design, will be needed to establish the long-term oncologic efficacy of the procedure and to evaluate the overall advantages of RALP compared with open surgery.

Surgeon Experience is Strongly Associated With Biochemical Recurrence After Radical Prostatectomy for All Preoperative Risk Categories

We have previously reported that there is a learning curve for open radical prostatectomy. In the current study we determined whether the effects of the learning curve are modified by patient risk, as defined by preoperative tumor characteristics. The study included 7,683 eligible patients with prostate cancer treated with open radical prostatectomy by 1 of 72 surgeons. Surgeon experience was coded as the total prior number of radical prostatectomies done by the surgeon before a patient surgery. Multivariate survival time regression models were used to evaluate the association between surgeon experience and biochemical recurrence separately in each preoperative risk group. We saw no evidence that patient risk affected the learning curve. There was a statistically significant association between biochemical recurrence and surgeon experience on all analyses. The absolute risk difference in a patient receiving treatment from a surgeon with 10 vs 250 prior radical prostatectomies was 6.6% (95% CI 3.4-10.3), 12.0% (95% CI 6.9-18.2) and 9.7% (95% CI 1.2-18.2) in patients at low, medium and high preoperative risk. Recurrence-free probability in patients with low risk disease approached 100% for the most experienced surgeons. Cancer control after radical prostatectomy improves with increasing surgeon experience irrespective of patient risk. Excellent rates of cancer control in patients with low risk disease treated by the most experienced surgeons suggest that the primary reason that recurrence develops in such patients is inadequate surgical technique. The results have significant implications for clinical care.

Laparoscopic Lymph Node Dissection in Clinically Node-Negative Patients Undergoing Laparoscopic Nephrectomy for Renal Carcinoma

Accurate staging of renal cell carcinoma (RCC) is important when risk-stratifying patients for clinical trials and identifying patients most likely to benefit from adjuvant therapy. We investigated the feasibility and potential role of laparoscopic lymph node dissection (LND) in patients undergoing radical nephrectomy with clinically node-negative RCC. We retrospectively compared 50 consecutive patients undergoing laparoscopic nephrectomy without LND (Nx group) with 50 consecutive patients undergoing combined laparoscopic nephrectomy and retroperitoneal LND (LND group). The two groups had similar clinical and pathological characteristics; the only difference was a higher proportion of non-clear cell histology in the LND group. In the Nx group, no patient was identified as having node-positive RCC; 5 of 50 patients (10%) in the LND group had nodal disease (P = 0.0155). Among a subgroup of patients with clinically localized RCC, 3 of 46 (6.5%) patients had node-positive disease identified by LND. All patients with positive nodes had primary tumors that were at least 7 cm in diameter, pT3 or pT4, and high grade. With increased surgeon experience, extent of the LND was incrementally increased. The mean number of nodes recovered was 7.8; however, a mean of 12.1 nodes were recovered using an extended LND. The mean numbers of nodes recovered from the paraaortic, interaortocaval, paracaval, and retrocaval regions were 9.8, 4.2, 2.4, and 5.0, respectively. The overall risk of intraoperative and postoperative complications was similar between groups. Laparoscopic LND in patients undergoing nephrectomy for RCC is safe and feasible, and may improve staging accuracy.

Seasonal variation in surgical outcomes as measured by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)

Conclusion: There are seasonal variations in surgical outcomes with respect to postoperative morbidity and mortality. Summary: The complete experience of a surgical procedure is complex and involves interactions between both systems and individuals. It is assumed that increased surgeon experience can help produce favorable outcomes. In July and August, there are relatively new trainees in most academic medical centers. At this time of the year, the trainees are less familiar with their roles and responsibilities. It is postulated there may be more adverse outcomes in surgical procedures performed early in the academic year vs later. The authors propose that the National Surgical Quality Improvement Program (NSQIP) is a database that is sufficiently large to allow a multicenter, risk-adjustment analysis of surgical morbidity and mortality on a month-to-month basis. In this study, the authors use 30-day morbidity and mortality rates derived from NSQIP-participating hospitals and compared two periods of care: an early group from July 1 to August 30 and a late group from April 15 to June 15. The postoperative morbidity rate was 18% higher in the early (n = 9941) vs late (n = 10, 310) groups (odds ratio, 1.18; 95% confidence interval [CI], 1.07-1.29, P = .0005; c-index, 0.794). Mortality was 41% higher in the early group compared with the late group (odds ratio, 1.41; 95% CI, 1.11-1.80; P = .005; c-index 0.938). Comment: The study really cannot reliably implicate inexperience of resident trainees as contributing to the so-called July effect. No hospitals without training programs were included as controls. In addition, other studies have suggested a “July effect” does not exist (Surgery 2001;130:346-53 and J Gen Intern Med 2003;18:639-45). The authors also noted an uptake in morbidity and mortality in December. At this point, resident inexperience is not likely important. Also, many attending surgeons take a vacation in July and August; therefore, slightly more urgent cases may be performed in those months than at other times of the year. It may be that less attending supervision in peak vacation months or more urgent surgery in the summer months and December are contributing more to seasonal variation in surgical morbidity and mortality than the inexperience of resident physicians.

The Surgical Learning Curve for Prostate Cancer Control After Radical Prostatectomy

The learning curve for surgery--i.e., improvement in surgical outcomes with increasing surgeon experience--remains primarily a theoretical concept; actual curves based on surgical outcome data are rarely presented. We analyzed the surgical learning curve for prostate cancer recurrence after radical prostatectomy. The study cohort included 7765 prostate cancer patients who were treated with radical prostatectomy by one of 72 surgeons at four major US academic medical centers between 1987 and 2003. For each patient, surgeon experience was coded as the total number of radical prostatectomies performed by the surgeon before the patient's operation. Multivariable survival-time regression models were used to evaluate the association between surgeon experience and prostate cancer recurrence, defined as a serum prostate-specific antigen (PSA) of more than 0.4 ng/mL followed by a subsequent higher PSA level (i.e., biochemical recurrence), with adjustment for established clinical and tumor characteristics. All P values are two-sided. The learning curve for prostate cancer recurrence after radical prostatectomy was steep and did not start to plateau until a surgeon had completed approximately 250 prior operations. The predicted probabilities of recurrence at 5 years were 17.9% (95% confidence interval [CI] = 12.1% to 25.6%) for patients treated by surgeons with 10 prior operations and 10.7% (95% CI = 7.1% to 15.9%) for patients treated by surgeons with 250 prior operations (difference = 7.2%, 95% CI = 4.6% to 10.1%; P<.001). This finding was robust to sensitivity analysis; in particular, the results were unaffected if we restricted the sample to patients treated after 1995, when stage migration related to the advent of PSA screening appeared largely complete. As a surgeon's experience increases, cancer control after radical prostatectomy improves, presumably because of improved surgical technique. Further research is needed to examine the specific techniques used by experienced surgeons that are associated with improved outcomes.

Transnasal Endoscopic Surgery of the Pituitary: Modifications and Results Over 10 Years

A 10-year retrospective review of three endoscopic approaches used by the authors for pituitary gland surgery is presented. We review our results and complications and outline the advantages and disadvantages of each. The variations in nasal anatomy that factor in the endoscopic approach are tabulated and discussed. A chart review and examination of computed tomography and magnetic resonance imaging scans of patients who have had endoscopic pituitary surgery by the authors was performed. We gathered specific details of the operative approach, nasal-sinus anatomy, tumor location, required ancillary nasal procedures, and postoperative complications. Ninety patients had endoscopic pituitary surgery. Operative reports and review of radiographic studies were possible for 75 patients. The surgical approach progressed over 10 years from endoscopic transseptal (42) to bilateral transostial (13) to unilateral transostial (20). Adequate exposure for the degree of resection was achieved in all patients. Complications included hemorrhage requiring return to the operating room (1), transient visual field loss (2), and transient diabetes insipidus (7). Four patients subsequently had craniotomy to resect suprasellar tumor extension. The average follow-up was 6 years. One patient required revision endoscopic resection 3 years later for tumor recurrence. Anatomic findings included nasal septal deflections in 36 (48%) of the patients, abnormalities of the turbinates in 42 (56%), and variances of the sphenoid sinus septum in 59 (79%) of the patients. In the unilateral transostial approach, the operative side was often determined by anatomic factors. The authors have exclusively used endoscopic surgery of pituitary gland tumors for over 10 years. Modifications to the approach have occurred as a result of increased surgeon experience and improved technology. The unilateral transostial approach is safe, effective, and recommended.