Laparoscopic radical prostatectomy: Cure is more likely with experienced surgeons

Sep 01, 2009

Laparoscopic radical prostatectomy has a definite learning curve, but it is slower than the learning curve for open surgery and is worsened in surgeons with prior open training.

After previously publishing a report on the learning curve for open retropubic radical prostatectomy (J Natl Cancer Inst 2007; 99:1171-7), Andrew J. Vickers, PhD, and colleagues undertook a similar analysis of laparoscopic radical prostatectomy. Replicating the findings from the open surgery study, the data for the laparoscopic procedures showed that the chance of patients achieving cure increased gradually with increasing surgeon experience, reported Dr. Vickers, associate attending research methodologist at Memorial Sloan-Kettering Cancer Center, New York, working with Bertrand Guillonneau, MD, and colleagues.

After adjusting for stage, grade, and PSA, there was a highly statistically significant association between surgeon experience and 5-year risk of cancer recurrence. Comparing the recurrence rates for patients treated by inexperienced surgeons who had performed 10 prior cases versus those operated on by the most experienced surgeons (750 cases performed), there was an 8% absolute risk difference (17% vs. 9%) after controlling for case mix.

"We believe our findings have important implications for the organization of cancer care," said Dr. Vickers. "As the surgeon has an enormous impact on the patient's chance of being cured, we would suggest more patients should be treated at high-volume centers where there are surgeons with a high degree of surgical experience."

In addition, in a finding that Dr. Vickers said was "surprising and concerning," surgeons with prior open experience had poorer results than those whose first radical prostatectomy was done as a laparoscopic procedure. The absolute difference in 5-year risk of recurrence between these two groups was 12.3%.

"We think the finding that laparoscopic skills do not translate well from open radical prostatectomy may be generalized to other surgical applications," he said. "However, we recommend that other centers investigate whether moving from open to laparoscopic surgery is a risk factor for poorer patient outcomes."

The study included data from 29 surgeons operating on 4,702 patients at seven institutions across five countries between January 1998 and June 2007. For all but one surgeon, data were available for their complete laparoscopic prostatectomy case experience. Just over half of the surgeons (55%) had experience performing open prostatectomy before switching to the laparoscopic approach. There was no association between surgeon experience and patient characteristics, suggesting that case mix or patient selection is unlikely to explain the results.

"A very nice thing about this cohort is that the patients were all treated relatively recently, after the stage shift in diagnosed prostate cancer," Dr. Vickers said.

The study also explored whether first-generation surgeons might have poorer results than second-generation students, as the former group learn from their mistakes and teach their "students" to avoid them. However, risk of recurrence after laparoscopic prostatecomy was similar between first and second-generation surgeons.

Findings from the study appeared in The Lancet Oncology (2009; 10:475-80).