The procedure is widely used and remains one of the most technically challenging operations for urologists, with the intraoperative risk of bleeding and the postoperative risks of incontinence, surgical and medical complications, and impotence. The technique has evolved with the aim of improving cancer control, continence, and potency. Failure to perform a radical resection of the tumour can result in positive surgical margins, which can determine a prostate-specific antigen (PSA) persistence after surgery or PSA relapse during follow-up. Intraoperative and postoperative complications may have considerable financial implications and cancer control failure can necessitate costly adjuvant treatments such as hormonal manipulation or radiotherapy.

The number of RPs performed is still increasing and the procedure is performed by many urologists in small, medium, and large hospitals. The complication rate of the procedure varies considerably among centres [2]. The quality of the surgeon and the surgery itself should be optimal and possibly standardised. Questions have been raised about whether RP and other difficult procedures should only be performed at high-volume centres to improve outcomes and decrease costs.

Several recent studies have shown substantial variation in outcomes after cancer surgery in general. These studies showed that surgical volumes can be considered a surrogate for surgical experience. Surgical experience has been associated with improved outcomes after different types of cancer surgery including esophagectomy, pancreatectomy, primary colon and breast cancer surgery, craniotomy for cerebrovascular aneurysms, and pelvic exenteration [3,4]. However, this was not shown to be the case for less complex procedures [5].

One of the first reports on the effect of the surgeon and hospital volume on quality of care in hospitals was published in 1987 by Hughes et al. [6], who demonstrated that hospital volume was a predictor of patient outcome in terms of in-hospital mortality and extended length of hospital stay.

To date, few studies have addressed the relationship of RP hospital volume and costs [7]. Recently two studies showed that centralising RP to specialised centres with high-volume surgeons could be one way of improving economic outcomes and the use of health resources. However, in these studies the reasons that high-surgical volume reduced costs were not clarified [7,8]. Many explanations could be advanced. High surgical volume may result in a shorter hospital stay, reduced complication and reoperation rates, reduced blood loss during surgery with less need for transfusions, or reduced operating time.

Another important parameter is the selection of centres and patients. In fact, a nerve-sparing procedure is more likely to be requested by young healthy patients who are more interested in preserving potency. These patients usually seek or are referred to centres of excellence that are usually high-volume academic centres. This is also true of newer RP techniques such as laparoscopy or robotic surgery. Because of the high costs, these new procedures should be centralised in selected teaching centres where the surgeons are trained to perform them on a daily basis.

However, these parameters and characteristics were not considered in the trials published so far and this was probably due to the difficulty in finding data on the quality of RP. Quality of surgery is certainly an important issue that should be considered together with costs. In 2001, van Poppel and the European Organization for Research and Treatment of Cancer Genito-Urinary Group (EORTC GU Group) reported the results of a feasibility study on quality control of RP. The aim of the study was to assess whether the quality of surgery was an important prognostic factor for patients undergoing RP. This study also investigated whether the surgical quality could be assessed by any means. Questionnaires were collected from 23 different institutes and looked at 232 RPs performed for T1–T2 prostate cancer. Blood loss, duration of surgery, margin status, postoperative PSA, and urinary incontinence were analysed and correlated with the annual number of RPs performed at the institution. The mean values obtained for each parameter were very different in the various centres. The outcome in terms of tumour control and incontinence could not be related to a higher or lower number of RPs performed. The conclusions were that quality control of RP is feasible on the basis of an analysis of a few parameters, such as surgical margins, postoperative PSA, and incontinence, which might indicate urologists whose surgical skills were better or worse than a proposed average [9].

Eastham et al. also studied the variation between individual surgeons in the rate of positive surgical margins in RP specimens. The results showed a surprising degree of variability ranging from 10% to 48%, even among surgeons practising at major urban centers. A large variation in morbidity after RP was also reported, even for high-volume surgeons [4]. The reasons for the differences in outcomes between surgeons must be analysed. Interestingly, the age of the urologist performing the surgery is a variable. Tsai has reported that age affects the type and length of postoperative care for patients with prostate cancer—the older the surgeon the better. Moreover, in high-volume hospitals, which are usually university teaching hospitals, surgery is often performed by residents or young fellows and this may explain these results and some of the cost differences between low- and high-volume centres [10].

These findings suggest that the quality of surgery for prostate cancer can still be improved. Continuing education programs, educational videos of surgery, filming of surgical procedures followed by comments on the various operative steps by residents, coworkers, or colleagues, and sharing experience with centres of excellence may contribute to a more uniform approach and to a decrease in the variability in surgical quality and outcomes.

The combination of the two important parameters that have been discussed up to now (the quality of surgery with a resulting good cancer control, high continence and potency rates, and the reduction in costs with reductions in complication rate, blood loss, operating time, and hospital stay) should be the goal of our work.

It is interesting to consider what patients expect from an operation like RP and what the hospital administration is looking for. They are probably looking for different outcomes. Patients generally want to be cured of the disease (cancer control), to be continent, and to be potent and consequently they will choose the more experienced surgeon and procedure without much interest in costs. The hospital administration, on the other hand, is more likely to concentrate on costs, which are related to other parameters such as blood loss, complications, surgical time, and hospital stay. This could be particularly true for high-volume hospitals where >200 RPs are performed each year. As urologists, we should aim to increase surgical quality and reduce costs to satisfy both the patients’ expectations and the needs of the hospital administration.

Future studies should consider the relationship between high-volume RP centres, costs, and the quality of surgery in terms of urinary cancer control and lower rates of incontinence and impotence.

References

1. Lu-Yao GL, Yao SL. Population based study of long-term survival in patients with clinically localized prostate cancer. Lancet. 1997;349:906–910.
2. Gheiler EL, Lovisolo JAJ, Tiguert R, et al.. Results of a clinical care pathway for radical prostatectomy patients in an open hospital-multiphysician system. Eur Urol. 1999;34:210–216.
3. Eastham JA, Kattan MK, Riedel E, Begg CB, et al.. Variations among individual surgeons in the rate of positive surgical margins in radical prostatectomy specimens. J Urol. 2003;170:2292–2295.
4. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA. 1998;280:1747–1751.
5. Hu JC, Gold KF, Pashos CL, Metha SS, Litwin MS. Role of surgeon volume in radical prostatectomy outcomes. J Clin Oncol. 2003;21:401–405.
6. Hughes RG, Hunt SS, Luft HS. Effects of surgeon volume and hospital volume on quality of care in hospitals. Med Care. 1987;25:489–493.
7. Ellison LM, Heaney JA, Birkmeyer JD. The effect of hospital volume on mortality and resource use after radical prostatectomy. J Urol. 2000;163:867–869.
8. Ramirez A, Benayoun S, Briganti A, et al.. High radical prostatectomy surgical volume is related to lower radical prostatectomy total hospital charges. Eur Urol. 2006;50:58–63.
9. Van Poppel H, Collette L, Kirkali Z, Brausi M, et al.. Quality control of radical prostatectomy: a feasibility study. Eur J Cancer. 2001;37:884–891.
10. Tsai DY, Virgo KS, Colberg JW, et al.. The age of the urologists affects the postoperative care of the prostate carcinoma patients. Cancer. 1999;86:1314–1317.

Maurizio Brausi,
AUSL Modena, Via G. Molinari 1, 41012 Carpi, Modena, Italy

published online 27 March 2006.

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