Comparative effectiveness of prostate cancer surgical treatments: a population based analysis of postoperative outcomes

Abstract

Purpose: Enthusiasm for laparoscopic surgical approaches to prostate cancer treatment has grown despite limited evidence of improved outcomes compared with open radical prostatectomy. We compared laparoscopic prostatectomy with or without robotic assistance vs open radical prostatectomy in terms of postoperative outcomes and subsequent cancer directed therapy.

Materials and methods: Using a population based cancer registry linked with Medicare claims we identified men 66 years old or older with localized prostate cancer who underwent radical prostatectomy from 2003 to 2005. Outcome measures were general medical/surgical complications and mortality within 90 days after surgery, genitourinary/bowel complications within 365 days, radiation therapy and/or androgen deprivation therapy within 365 days and length of hospital stay.

Results: Of the 5,923 men 18% underwent laparoscopic radical prostatectomy. Adjusting for patient and tumor characteristics, there were no differences in the rate of general medical/surgical complications (OR 0.93 95% CI 0.77-1.14) or genitourinary/bowel complications (OR 0.96 95% CI 0.76-1.22), or in postoperative radiation and/or androgen deprivation (OR 0.80 95% CI 0.60-1.08). Laparoscopic prostatectomy was associated with a 35% shorter hospital stay (p <0.0001) and a lower bladder neck/urethral obstruction rate (OR 0.74, 95% CI 0.58-0.94). In laparoscopic cases surgeon volume was inversely associated with hospital stay and the odds of any genitourinary/bowel complication.

Conclusions: Laparoscopic prostatectomy and open radical prostatectomy have similar rates of postoperative morbidity and additional treatment. Men considering prostate cancer surgery should understand the expected benefits and risks of each technique to facilitate decision making and set realistic expectations.

Figure 1

Cumulative Distribution of Annual Procedure-Specific Surgeon Volume in Laparoscopic Radical Prostatectomy (With or Without Robotic Assistance) Patients For each patient, we estimated procedure-specific annual Medicare surgeon volume as the number of procedures of the same type (ORP or LRP) performed by the patient's surgeon in the 365 days prior to that patient's procedure, including the patient's surgery.

Figure 2 (A - D)

Relationship of Annual Procedure-Specific Surgeon Volume in SEER-Medicare with Postoperative Outcomes For LRP (with or without robotic assistance) patients, plots are derived from multivariable linear regression models adjusted for patient and tumor characteristics and corrected for within-surgeon correlation. A, predicted length of stay (LOS, days); B, predicted risk of general medical or surgical complication within 90 days of surgery; C, predicted risk of any genitourinary or bowel complication within 365 days of surgery; D, predicted risk of bladder neck or urethral obstruction within 365 days of surgery. Blue dots represent individual predicted outcomes. The linear relationship between each outcome (solid line) and 95% confidence intervals around the mean predicted values (dashed lines) are shown.

Figure 2 (A - D)

Relationship of Annual Procedure-Specific Surgeon Volume in SEER-Medicare with Postoperative Outcomes For LRP (with or without robotic assistance) patients, plots are derived from multivariable linear regression models adjusted for patient and tumor characteristics and corrected for within-surgeon correlation. A, predicted length of stay (LOS, days); B, predicted risk of general medical or surgical complication within 90 days of surgery; C, predicted risk of any genitourinary or bowel complication within 365 days of surgery; D, predicted risk of bladder neck or urethral obstruction within 365 days of surgery. Blue dots represent individual predicted outcomes. The linear relationship between each outcome (solid line) and 95% confidence intervals around the mean predicted values (dashed lines) are shown.

Figure 2 (A - D)

Relationship of Annual Procedure-Specific Surgeon Volume in SEER-Medicare with Postoperative Outcomes For LRP (with or without robotic assistance) patients, plots are derived from multivariable linear regression models adjusted for patient and tumor characteristics and corrected for within-surgeon correlation. A, predicted length of stay (LOS, days); B, predicted risk of general medical or surgical complication within 90 days of surgery; C, predicted risk of any genitourinary or bowel complication within 365 days of surgery; D, predicted risk of bladder neck or urethral obstruction within 365 days of surgery. Blue dots represent individual predicted outcomes. The linear relationship between each outcome (solid line) and 95% confidence intervals around the mean predicted values (dashed lines) are shown.

Figure 2 (A - D)

Relationship of Annual Procedure-Specific Surgeon Volume in SEER-Medicare with Postoperative Outcomes For LRP (with or without robotic assistance) patients, plots are derived from multivariable linear regression models adjusted for patient and tumor characteristics and corrected for within-surgeon correlation. A, predicted length of stay (LOS, days); B, predicted risk of general medical or surgical complication within 90 days of surgery; C, predicted risk of any genitourinary or bowel complication within 365 days of surgery; D, predicted risk of bladder neck or urethral obstruction within 365 days of surgery. Blue dots represent individual predicted outcomes. The linear relationship between each outcome (solid line) and 95% confidence intervals around the mean predicted values (dashed lines) are shown.