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Surgeon heterogeneity significantly affects functional and oncological outcomes after radical prostatectomy in the Swedish LAPPRO trial

Nyberg, Martin LU ; Sjoberg, Daniel D. ; Carlsson, Sigrid V. ; Wilderäng, Ulrica ; Carlsson, Stefan ; Stranne, Johan ; Wiklund, Peter LU ; Steineck, Gunnar ; Haglind, Eva and Hugosson, Jonas , et al. (2021) In BJU International 127(3). p.361-368
Abstract

Objectives: To evaluate how surgeon heterogeneity – the variation in outcomes between individual surgeons – influences functional and oncological outcomes after robot-assisted laparoscopic prostatectomy (RALP) and retropubic radical prostatectomy (RRP), and to assess whether surgeon heterogeneity affects the comparison between RALP and RRP. Patients and Methods: Laparoscopic Prostatectomy Robot Open (LAPPRO) is a prospective, controlled, non-randomized trial performed at 14 Swedish centres with 68 operating surgeons. A total of 4003 men with localized prostate cancer were enrolled between 2008 and 2011. The endpoints were urinary incontinence, erectile dysfunction (ED) and recurrence at 24 months after surgery. Logistic regression... (More)

Objectives: To evaluate how surgeon heterogeneity – the variation in outcomes between individual surgeons – influences functional and oncological outcomes after robot-assisted laparoscopic prostatectomy (RALP) and retropubic radical prostatectomy (RRP), and to assess whether surgeon heterogeneity affects the comparison between RALP and RRP. Patients and Methods: Laparoscopic Prostatectomy Robot Open (LAPPRO) is a prospective, controlled, non-randomized trial performed at 14 Swedish centres with 68 operating surgeons. A total of 4003 men with localized prostate cancer were enrolled between 2008 and 2011. The endpoints were urinary incontinence, erectile dysfunction (ED) and recurrence at 24 months after surgery. Logistic regression models were built to evaluate surgeon heterogeneity and, secondarily, surgeon-specific factors were added to the models to investigate their influence on heterogeneity and the comparison between RALP and RRP. Results: Among surgeons who performed at least 20 surgeries during the study period (n=25), we observed statistically significant heterogeneity for incontinence (P = 0.001), ED (P < 0.001) and rate of recurrent disease (P < 0.001). The significant heterogeneity remained when analysing only experienced surgeons with a stated experience of at least 250 radical prostatectomies (n=12). Among all participating surgeons (n=68), differences in surgeon volume explained 42% of the observed heterogeneity for incontinence (P = 0.003), 11% for ED (P = 0.03) and 19% for recurrence (P = 0.01). Taking surgeon volume into account when comparing RALP and RRP had a significant impact on the results. The effect was greatest for functional outcomes, and the additional adjustments for the surgeons' previous experience changed whether the difference between techniques was statistically significant or not. The surgeons’ annual volume had the greatest effect on the recurrence rate. Conclusions: There was a large degree of heterogeneity among surgeons regarding both functional and oncological outcomes and this had a significant impact on the results when comparing RALP and RRP. Some of the observed heterogeneity was explained by differences in surgeon volume. Efforts to decrease heterogeneity are warranted and variation among surgeons must be accounted for when conducting comparative analyses between surgical techniques.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
biochemical recurrence, erectile dysfunction, prostate cancer, radical prostatectomy, surgeon heterogeneity, urinary incontinence
in
BJU International
volume
127
issue
3
pages
361 - 368
publisher
Wiley-Blackwell
external identifiers
  • scopus:85091691272
  • pmid:32916021
ISSN
1464-4096
DOI
10.1111/bju.15238
language
English
LU publication?
yes
id
0bc373d2-da69-4a33-a1b5-cfaed0048196
date added to LUP
2020-11-20 14:55:31
date last changed
2021-10-06 01:41:27
@article{0bc373d2-da69-4a33-a1b5-cfaed0048196,
  abstract     = {<p>Objectives: To evaluate how surgeon heterogeneity – the variation in outcomes between individual surgeons – influences functional and oncological outcomes after robot-assisted laparoscopic prostatectomy (RALP) and retropubic radical prostatectomy (RRP), and to assess whether surgeon heterogeneity affects the comparison between RALP and RRP. Patients and Methods: Laparoscopic Prostatectomy Robot Open (LAPPRO) is a prospective, controlled, non-randomized trial performed at 14 Swedish centres with 68 operating surgeons. A total of 4003 men with localized prostate cancer were enrolled between 2008 and 2011. The endpoints were urinary incontinence, erectile dysfunction (ED) and recurrence at 24 months after surgery. Logistic regression models were built to evaluate surgeon heterogeneity and, secondarily, surgeon-specific factors were added to the models to investigate their influence on heterogeneity and the comparison between RALP and RRP. Results: Among surgeons who performed at least 20 surgeries during the study period (n=25), we observed statistically significant heterogeneity for incontinence (P = 0.001), ED (P &lt; 0.001) and rate of recurrent disease (P &lt; 0.001). The significant heterogeneity remained when analysing only experienced surgeons with a stated experience of at least 250 radical prostatectomies (n=12). Among all participating surgeons (n=68), differences in surgeon volume explained 42% of the observed heterogeneity for incontinence (P = 0.003), 11% for ED (P = 0.03) and 19% for recurrence (P = 0.01). Taking surgeon volume into account when comparing RALP and RRP had a significant impact on the results. The effect was greatest for functional outcomes, and the additional adjustments for the surgeons' previous experience changed whether the difference between techniques was statistically significant or not. The surgeons’ annual volume had the greatest effect on the recurrence rate. Conclusions: There was a large degree of heterogeneity among surgeons regarding both functional and oncological outcomes and this had a significant impact on the results when comparing RALP and RRP. Some of the observed heterogeneity was explained by differences in surgeon volume. Efforts to decrease heterogeneity are warranted and variation among surgeons must be accounted for when conducting comparative analyses between surgical techniques.</p>},
  author       = {Nyberg, Martin and Sjoberg, Daniel D. and Carlsson, Sigrid V. and Wilderäng, Ulrica and Carlsson, Stefan and Stranne, Johan and Wiklund, Peter and Steineck, Gunnar and Haglind, Eva and Hugosson, Jonas and Bjartell, Anders},
  issn         = {1464-4096},
  language     = {eng},
  number       = {3},
  pages        = {361--368},
  publisher    = {Wiley-Blackwell},
  series       = {BJU International},
  title        = {Surgeon heterogeneity significantly affects functional and oncological outcomes after radical prostatectomy in the Swedish LAPPRO trial},
  url          = {http://dx.doi.org/10.1111/bju.15238},
  doi          = {10.1111/bju.15238},
  volume       = {127},
  year         = {2021},
}