Cancer control and functional outcomes after radical prostatectomy as markers of surgical quality: analysis of heterogeneity between surgeons at a single cancer center

Abstract

Background: Previous studies have shown that complications and biochemical recurrence rates after radical prostatectomy (RP) vary between different surgeons to a greater extent than might be expected by chance. Data on urinary and erectile outcomes, however, are lacking.

Objective: In this study, we examined whether between-surgeon variation, known as heterogeneity, exists for urinary and erectile outcomes after RP.

Design, setting, and participants: Our study consisted of 1910 RP patients who were treated by 1 of 11 surgeons between January 1999 and July 2007.

Intervention: All patients underwent RP at Memorial Sloan-Kettering Cancer Center.

Measurements: Patients were evaluated for functional outcome 1 yr after surgery. Multivariable random effects models were used to evaluate the heterogeneity in erectile or urinary outcome between surgeons, after adjustment for case mix (age, prostate-specific antigen, pathologic stage and grade, comorbidities) and year of surgery.

Results and limitations: We found significant heterogeneity in functional outcomes after RP (p<0.001 for both urinary and erectile function). Four surgeons had adjusted rates of full continence <75%, whereas three had rates >85%. For erectile function, two surgeons in our series had adjusted rates <20%; another two had rates >45%. We found some evidence suggesting that surgeons' erectile and urinary outcomes were correlated. Contrary to the hypothesis that surgeons "trade off" functional outcomes and cancer control, better rates of functional preservation were associated with lower biochemical recurrence rates.

Conclusions: A patient's likelihood of recovering erectile and urinary function may differ depending on which of two surgeons performs his RP. Functional preservation does not appear to come at the expense of cancer control; rather, both are related to surgical quality.

Fig. 1

Forest plot for probability of erectile function (erectile rigidity score of 1 or 2) at 1 yr. The proportions are for a patient with the mean level of all covariates. The vertical line represents the mean adjusted proportion of patients with erectile function at 1 yr for all surgeons.

Fig. 2

Forest plot for probability of full continence (urinary control score of 1 [no pads]) at 1 yr. The proportions are for a patient with the mean level of all covariates. The vertical line represents the mean adjusted proportion of patients who were continent at 1 yr for all surgeons.

Fig. 3

Scatter plot of adjusted urinary and erectile outcomes. Each circle represents a single surgeon, and the size of the circle is proportion to the number of patients treated by that surgeon.

Fig. 4

Scatter plot of adjusted biochemical recurrence (BCR) rates versus recovery of both urinary and erectile function at 12 mo. Each circle represents a single surgeon, and the size of the circle is in proportion to the number of patients treated by that surgeon.