Surgeon experience is strongly associated with biochemical recurrence after radical prostatectomy for all preoperative risk categories

Abstract

Purpose: 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.

Materials and methods: 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.

Results: 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.

Conclusions: 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.

Figure 1

The learning curve for cancer control after radical prostatectomy, stratified by pre-operative risk group. Predicted probability of freedom of biochemical recurrence (BCR) at 5 years with increasing surgeon experience. Probabilities are for a patient with typical cancer severity in the risk group (mean PSA, pathological stage and grade) within each group. Light grey lines: low risk; Medium grey lines: intermediate risk; Black lines: high risk. Dotted lines are 95% C.I.