BERLIN, GERMANY (UroToday.com) - EAU 2007 - Dr. David Neal, Massachusetts, USA chaired a debate on "Surgical Volume and Quality of Results" at the plenary session of the EAU on Friday March 23, 2007. A panel comprised of Drs. P. Scardino, New York, USA G. Vallancien, Paris, France and H. Van Poppel, Leuven, Belgium discussed the topic.

Dr. Neal stated that in the UK, hospitals had to be covering a minimum of one million people to perform radical prostatectomies (RP), cystectomies or complex nephrectomies. He set the stage for the ensuing discussion.

Dr. Vallancien supported the notion that volume is important. Globally, 70% of publications on the topic of volume outcomes suggest a relationship. In France, a death rate of 0.13% was reported for RP. Over the last 5 years, the number of RPs has doubled in France. Over half of hospitals in France perform less than 50 RPs per year. The death rate of these low volume hospitals was 0.14% as compared of 0.04% at higher volume centers. This suggests 2-5 fold increased deaths in centers doing less than 100 cases, which translated to about 76 deaths. The causes were analyzed and were mostly were medical. The responsibility lay with the surgeon, staff and hospital as adequate response to medical complications as well as high quality surgery necessitates that all 3 are competent. The French NCI is recommending that only hospitals performing at least 30 RPs are allowed to perform them. Dr Neal commented that other outcomes in addition to death are also important.

Dr. Van Poppel was tasked with arguing that volume is not responsible for outcomes. AUA data shows that urologists who perform 8 RPs per year is in the top tenth percentile. Low volume surgeons can get good outcomes in high volume centers, he said. A variety of studies suggest that a minimal number of RPs is required for good outcomes, and this number varies and in one study was as low as 12 RPs/year. But why do low volume urologists continue doing RPs? There is certainly a financial motivation and feeling of need to provide the care. He collected data for the EORTC GU group from 27 urologists at 23 centers on their outcomes from their last 10 RPs. The data suggests vast differences in outcomes. There was no surgeon that had optimal outcomes for all the parameters measured. The group of urologists doing only 1-4 RP/year had 4units or more blood transfusions, but similar duration of surgery and margin status outcomes. At some centers, the detectable PSA 3 month's post-op was detectable in over 50%. Yet, the highest volume surgeons did not have the best PSA and continence outcomes, as those doing 25-50 cases/year did better. He felt a standard should be set with regard to duration (less than 3 hours), blood transfusion rate (less than 3 units), PSA outcomes (>80% undetectable) and continence (>80%).

Dr. Scardino stated that volume is important, but not in and of itself. What is more important is the way the surgeon performs the operation. He asked to what degree the outcomes are related to surgeon factors, tumor factors and patient factors. Their data assessed 1, 000 surgeons and a total of 10,737 cases. The surgeons were separated by volume (1-10, 11-19, 20-32, and 33-121). The 30-day mortality rates were not different (0.4-0.74). After accounting for patient and tumor variables, surgical volume did relate to better urinary incontinence, fewer strictures and lower complication rates. Even among high volume surgeons, there was a wide spectrum of outcomes that did not follow a normal statistical distribution. For these high volume surgeons, those who did poorly with respect to one outcome measure also did worse in the other two categories. In 4,629 patients having an RP by 44 surgeons, the positive margin rate was better among high volume surgeons. However, among this group some clearly did better than others. This suggests that technique in addition to volume is important. Finally, they followed surgeons over the course of their career and adjusted for case-mix. It included 9,662 patients having an RP at 1 of 4 institutions. The 5-year progression-free probabilities reflected a learning cure for the first 250-500 cases. This was true even after adjusting for positive surgical margins. The probability of recurrence decreased from 21% in the first 10 cases to 12% after 250 prior cases. For every 11 men treated by an inexperienced surgeon, one will relapse compared to those treated by an experienced surgeon. The message is that even busy surgeons have consistent technical aspects that continually impact their outcome, even after many cases. The lifelong experience in addition to technique matters most.

EAU 2007 Conference Coverage on UroToday.com

Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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