Venous thromboembolism after radical prostatectomy: The effect of surgical caseload - Abstract

Several risk factors increase VTE after RP: advanced age, comorbidities such as cardiopulmonary disease, rheumatologic diseases, prior history of VTE, more advanced prostate cancer, and simultaneous pelvic lymph node dissection.

To date, the effect of annual surgical caseload (ASC), an established determinant of various RP outcomes, has not been tested. A previous study showed in adjusted analyses that patients operated for colorectal cancer by very high ASC surgeons were 60% less likely to suffer a VTE than those operated by low ASC surgeons. Moreover, some authors hypothesized that laparoscopy may contribute to a higher risk of VTE, due to peritoneal insufflation, reverse Trendelenburg position and prolonged operative time. The VTE rates reported in the current population-based study closely reflect those reported in institutional series. Moreover, we validated the practice-makes-perfect concept, since ASC was linked to VTE. We could not detect statistically significantly differences between minimally invasive radical prostatectomy (MIRP) patients and others. Our results indicate that lower rates of VTE should be expected in patients treated by high ASC surgeons. Our findings suggest that VTE-specific processes of care need to be improved, with the intent of reaching the level recorded in patients treated by high ASC surgeons. Finally, MIRP seems to be no risk factor for VTE.

OBJECTIVE: To examine the effect of annual surgical caseload (ASC) on the likelihood of venous thromboembolism (VTE) after radical prostatectomy (RP).

PATIENTS AND METHODS: Between 1999 and 2008, 36 699 RPs were performed in the state of Florida. Logistic regression models predicting the likelihood of VTE were fitted. Covariates included year of surgery, age, race, baseline Charlson Comorbidity Index (CCI), lymph node dissection, ASC and surgical approach.

RESULTS: The overall VTE rate was 0.3%. It was higher in patients operated within the low (0.4%) and intermediate (0.3%) ASC tertile than in those operated within the high-ASC tertile (0.1%, P < 0.001). Mortality rate was 6.0% in patients with VTE vs 0.1% in others (P < 0.001). Median length of stay and median total hospital charges were 9 vs 3 days (P < 0.001) and $51 571 vs $24 943 (P < 0.001) in patients with VTE vs others, respectively. In multivariable analyses predicting VTE, patients operated on by low-ASC surgeons were at higher risk of VTE than those operated on by high-ASC surgeons (odds ratio [OR]= 3.78, P < 0.001). Additionally, black patients were more likely to experience a VTE (OR = 1.80, P= 0.023). Patients with CCI ≥ 1 were also more likely to experience a VTE than others (OR = 1.65, P= 0.016). Conversely, patients who had undergone minimally invasive radical prostatectomy were not more likely to experience a VTE than those who had undergone open RP (OR = 1.97, P= 0.086).

CONCLUSIONS: RP by high-ASC surgeons exerts a protective effect on the likelihood of VTE.  Additionally, VTE is associated with higher mortality, prolonged length of stay and increased hospital charges.

Written by:
Schmitges J, Trinh QD, Sun M, Abdollah F, Bianchi M, Budäus L, Salomon G, Schlomm T, Perrotte P, Shariat SF, Montorsi F, Menon M, Graefen M, Karakiewicz PI. Are you the author?
Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf Department of Urology, University Hospital Hamburg-Eppendorf; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center Department of Urology, University of Montreal Health Center, Montreal, QC, Canada; Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI; Weill Medical College of Cornell University, New York, NY, USA; Department of Urology, Vita Salute San Raffaele University, Milan, Italy.

Reference: BJU Int. 2012 Feb 7. Epub ahead of print.
doi: 10.1111/j.1464-410X.2012.10941.x

PubMed Abstract
PMID: 22313499