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The New England Journal of Medicine Apr 2002Recent studies of surgery for cancer have demonstrated variations in outcomes among hospitals and among surgeons. We sought to examine variations in morbidity after...
BACKGROUND
Recent studies of surgery for cancer have demonstrated variations in outcomes among hospitals and among surgeons. We sought to examine variations in morbidity after radical prostatectomy for prostate cancer.
METHODS
We used the Surveillance, Epidemiology, and End Results-Medicare linked data base to evaluate health-related outcomes after radical prostatectomy. The rates of postoperative complications, late urinary complications (strictures or fistulas 31 to 365 days after the procedure), and long-term incontinence (more than 1 year after the procedure) were inferred from the Medicare claims records of 11,522 patients who underwent prostatectomy between 1992 and 1996. These rates were analyzed in relation to hospital volume and surgeon volume (the number of procedures performed at individual hospitals and by individual surgeons, respectively).
RESULTS
Neither hospital volume nor surgeon volume was significantly associated with surgery-related death. Significant trends in the relation between volume and outcome were observed with respect to postoperative complications and late urinary complications. Postoperative morbidity was lower in very-high-volume hospitals than in low-volume hospitals (27 percent vs. 32 percent, P=0.03) and was also lower when the prostatectomy was performed by very-high-volume surgeons than when it was performed by low-volume surgeons (26 percent vs. 32 percent, P<0.001). The rates of late urinary complications followed a similar pattern. Results for long-term preservation of continence were less clear-cut. In a detailed analysis of the 159 surgeons who had a high or very high volume of procedures, wide surgeon-to-surgeon variations in these clinical outcomes were observed, and they were much greater than would be predicted on the basis of chance or observed variations in the case mix.
CONCLUSIONS
In men undergoing prostatectomy, the rates of postoperative and late urinary complications are significantly reduced if the procedure is performed in a high-volume hospital and by a surgeon who performs a high number of such procedures.
Topics: Aged; General Surgery; Hospitals; Humans; Male; Medicare; Outcome Assessment, Health Care; Postoperative Complications; Prostatectomy; Prostatic Neoplasms; SEER Program; United States; Urinary Incontinence; Urologic Diseases; Workforce
PubMed: 11948274
DOI: 10.1056/NEJMsa011788 -
European Surgical Research. Europaische... 2022The disruption to surgical training and medical education caused by the global COVID-19 pandemic highlighted the need for realistic, reliable, and engaging educational...
OBJECTIVES
The disruption to surgical training and medical education caused by the global COVID-19 pandemic highlighted the need for realistic, reliable, and engaging educational opportunities available outside of the operating theatre and accessible for trainees of all levels. This article presents the design and development of a virtual reality curriculum which simulates the surgical mentorship experience outside of the operating theatre, with a focus on surgical anatomy and surgical decision-making.
METHOD
This was a multi-institutional study between London's King's College and Imperial College. The index procedure selected for the module was robotic radical prostatectomy. For each stage of the surgical procedure, subject-matter experts (N = 3) at King's College London, identified (1) the critical surgical-decision making points, (2) critical anatomical landmarks, and (3) tips and techniques for overcoming intraoperative challenges. Content validity was determined by an independent panel of subject-matter experts (N = 8) at Imperial College, London, using Fleiss' kappa statistic. The experts' teaching points were combined with operative footage and illustrative animations, and projected onto a virtual reality headset. The module was piloted to surgical science students (N = 15). Quantitative analysis compared participants' confidence regarding their anatomical knowledge before and after taking the module. Qualitative data were gathered from students regarding their views on using the virtual reality model.
RESULTS
Multi-rater agreement between experts was above the 70.0% threshold for all steps of the procedure. Seventy-three percentage of pilot study participants "agreed" or "strongly agreed" that they achieved a better understanding of surgical anatomy and the rationale behind each procedural step. This was reflected in an increase in the median knowledge score after trialing the curriculum (p < 0.001). 100% of subject-matter experts and 93.3% of participants "agreed" or "strongly agreed" that virtual mentorship would be useful for future surgical training.
CONCLUSIONS
This study demonstrated that virtual surgical mentorship could be a feasible and cost-effective alternative to traditional training methods with the potential to improve technical skills, such as operative proficiency and nontechnical skills such as decision-making and situational judgement.
Topics: Augmented Reality; COVID-19; Clinical Competence; Computer Simulation; Curriculum; Humans; Male; Pandemics; Pilot Projects; Prostatectomy; Robotics; SARS-CoV-2
PubMed: 34724676
DOI: 10.1159/000520386 -
Journal of Andrology 2009Penile rehabilitation has been an area of intense study and debate over the last decade. Interest in this topic was stimulated by the observation that erectile... (Review)
Review
Penile rehabilitation has been an area of intense study and debate over the last decade. Interest in this topic was stimulated by the observation that erectile dysfunction remained a significant problem after radical prostatectomy despite meticulous nerve-sparing technique. Smooth muscle alterations and fibrotic changes in the penis were identified as the underlying causes of penile atrophy, veno-occlusive dysfunction, and Peyronie's-like changes that were observed after surgery. Initial observations that intracavernous injection therapies used on a regular basis postoperatively resulted in improvements in the return of spontaneous erectile function led to the development of penile rehabilitation protocols. Chronic dosing of oral type V phosphodiesterase inhibitors is now commonly used by urologists after radical prostatectomy despite a lack of convincing evidence from randomized, placebo-controlled clinical trials. Use of local therapies to heal the penis may have applications beyond the postprostatectomy patient. This article reviews the current evidence behind penile rehabilitation therapy.
Topics: Alprostadil; Animals; Clinical Trials as Topic; Humans; Male; Penile Erection; Penis; Phosphodiesterase 5 Inhibitors; Phosphodiesterase Inhibitors; Piperazines; Prostatectomy; Purines; Sildenafil Citrate; Sulfones
PubMed: 19023141
DOI: 10.2164/jandrol.108.005835 -
British Medical Journal Mar 1949
Topics: Humans; Male; Prostatectomy; Transurethral Resection of Prostate
PubMed: 18113806
DOI: 10.1136/bmj.1.4600.386 -
Urologic Oncology Jul 2017Evidence suggests that redirecting surgeries to high-volume providers may be associated with better outcomes and significant societal savings. Whether such referrals are...
BACKGROUND
Evidence suggests that redirecting surgeries to high-volume providers may be associated with better outcomes and significant societal savings. Whether such referrals are feasible remains unanswered.
METHODS
Medicare Provider Utilization and Payment Data, SEER 18, and US Incidence data were used to determine the geographic distribution and radical prostatectomy volume for providers. Access was defined as availability of a high-volume provider within driving distance of 100 miles. The opportunity cost was defined as the value of benefits achievable by performing the surgery by a high-volume provider that was forgone by not making a referral. The savings per referral were derived from a published Markov model for radical prostatectomy.
RESULTS
A total of 14% of providers performed>27% of the radical prostatectomies with>30 cases per year and were designated high-volume providers. Providers with below-median volume (≤16 prostatectomies per year) performed>32% of radical prostatectomies. At least 47% of these were within a 100-mile driving distance (median = 22 miles), and therefore had access to a high-volume provider (>30 prostatectomies per year). This translated into a discounted savings of more than $24 million per year, representing the opportunity cost of not making a referral. The average volume for high- and low-volume providers was 55 and 13, respectively, resulting in an annual experience gap of 43 and a cumulative gap of 125 surgeries over 3 years. In 2014, the number of surgeons performing radical prostatectomy decreased by 5% while the number of high- and low-volume providers decreased by 25% and 11% showing a faster decline in the number of high-volume providers compared with low-volume surgeons.
CONCLUSIONS
About half of prostatectomies performed by surgeons with below-median annual volume were within a 100-mile driving distance (median of 22 miles) of a high-volume surgeon. Such a referral may result in minimal additional costs and substantially improved outcomes.
Topics: Humans; Male; Prostatectomy; Prostatic Neoplasms; Surgeons
PubMed: 28284890
DOI: 10.1016/j.urolonc.2017.01.021 -
Journal of Surgical Oncology Sep 2017Surgery for prostate cancer is associated with adverse effects. We studied long-term risk of adverse effects after retropubic (RRP) and robot-assisted radical...
BACKGROUND AND OBJECTIVES
Surgery for prostate cancer is associated with adverse effects. We studied long-term risk of adverse effects after retropubic (RRP) and robot-assisted radical prostatectomy (RARP).
METHODS
In the National Prostate Cancer Register of Sweden, men who had undergone radical prostatectomy (RP) between 2004 and 2014 were identified. Diagnoses and procedures indicating adverse postoperative effects were retrieved from the National Patient Register. Relative risk (RR) of adverse effects after RARP versus RRP was calculated in multivariable analyses adjusting for year of surgery, hospital surgical volume, T stage, Gleason grade, PSA level at diagnosis, patient age, comorbidity, and educational level.
RESULTS
A total of 11 212 men underwent RRP and 8500 RARP. Risk of anastomotic stricture was lower after RARP than RRP, RR for diagnoses 0.51 (95%CI = 0.42-0.63) and RR for procedures 0.46 (95%CI = 0.38-0.55). Risk of inguinal hernia was similar after RARP and RRP but risk of incisional hernia was higher after RARP, RR for diagnoses 1.48 (95%CI = 1.01-2.16), and RR for procedures 1.52 (95%CI = 1.02-2.26).
CONCLUSIONS
The postoperative risk profile for RARP and RRP was quite similar. However, risk of anastomotic stricture was lower and risk of incisional hernia higher after RARP.
Topics: Aged; Anastomosis, Surgical; Constriction, Pathologic; Humans; Incisional Hernia; Male; Prostatectomy; Prostatic Neoplasms; Registries; Robotic Surgical Procedures; Sweden
PubMed: 28591934
DOI: 10.1002/jso.24687 -
The Canadian Journal of Urology Aug 2020Holmium laser enucleation of the prostate (HoLEP) has become an increasingly common surgical management option for treatment of symptomatic benign prostatic hyperplasia... (Review)
Review
INTRODUCTION
Holmium laser enucleation of the prostate (HoLEP) has become an increasingly common surgical management option for treatment of symptomatic benign prostatic hyperplasia (BPH). Transurethral resection of the prostate (TURP) has long been considered the gold standard, contemporary literature and newer guidelines indicate that HoLEP has become the new size-independent endoscopic gold standard for surgical BPH treatment.
MATERIALS AND METHODS
We provide a review and update on current HoLEP surgical techniques, outcomes, safety, and durability according to the growing body of literature.
RESULTS
The current body of literature and guidelines indicate HoLEP as a safe and effective surgical treatment for symptomatic BPH regardless of prostate size. Durable long term subjective and objective outcomes have been demonstrated in previous studies, extending beyond 10 years.
CONCLUSIONS
HoLEP continues to demonstrate durable long term efficacy for treating patients suffering from lower urinary tract symptoms (LUTS) due to BPH. The American Urological Association (AUA) guidelines recommend its use as a size-independent endoscopic treatment option. HoLEP has proven itself to be the new gold standard in surgical treatment for LUTS secondary to BPH with the ability to endoscopically treat prostates independent of size, with durable long term outcomes.
Topics: Humans; Lasers, Solid-State; Male; Organ Size; Prostatectomy; Prostatic Hyperplasia; Treatment Outcome
PubMed: 32876002
DOI: No ID Found -
Cleveland Clinic Journal of Medicine Jan 2007Men who become persistently incontinent after undergoing prostatectomy have a variety of options for regaining control, ranging from behavioral changes to surgery. To... (Review)
Review
Men who become persistently incontinent after undergoing prostatectomy have a variety of options for regaining control, ranging from behavioral changes to surgery. To determine the best therapy, one should define the problem with a thorough urologic evaluation.
Topics: Cholinergic Antagonists; Humans; Male; Prostatectomy; Urinary Incontinence
PubMed: 17373348
DOI: 10.3949/ccjm.74.1.57 -
TheScientificWorldJournal Apr 2008Current treatment options for men with early localized prostate cancer are either some form of radical therapy or active surveillance. Radical therapy is usually... (Review)
Review
Current treatment options for men with early localized prostate cancer are either some form of radical therapy or active surveillance. Radical therapy is usually associated with significant adverse effects that might jeopardize a man's quality of life. Some observers believe that PSA screening has resulted in the over diagnosis and over treatment of prostate cancer. Many men are being diagnosed with an early stage, small volume, unifocal or unilateral prostate cancer but are reluctant to accept watchful waiting or active surveillance. Focal cryoablation is the less than complete ablation of the gland with ice. Based on review of the limited amount of material available in the current literature, focal cryoablation can provide acceptable cancer control while preserving sexual potency and urinary continence. Focal cryoablation may fill a void in the therapeutic options available to patients with unifocal or unilateral prostate cancer who have a strong desire to maintain their quality of life.
Topics: Cryosurgery; Humans; Male; Minimally Invasive Surgical Procedures; Prostatectomy; Prostatic Neoplasms
PubMed: 18454259
DOI: 10.1100/tsw.2008.56 -
Bulletin Du Cancer May 2005This literature review highlights the laparoscopic prostatectomy, partial and total nephrectomy, nephroureterectomy, and total cystectomy. The indications, operative... (Review)
Review
This literature review highlights the laparoscopic prostatectomy, partial and total nephrectomy, nephroureterectomy, and total cystectomy. The indications, operative technique, complications and outcomes of each are discussed.
Topics: Cystectomy; Female; Humans; Laparoscopy; Male; Nephrectomy; Prostatectomy; Ureter; Urologic Surgical Procedures
PubMed: 15932810
DOI: No ID Found