UK radical prostatectomy outcomes and surgeon case volume: based on an analysis of the British Association of Urological Surgeons Complex Operations Database.

OBJECTIVE: To undertake a detailed analysis of the British Association of Urological Surgeons (BAUS) Section of Oncology Complex Operations Database to report UK outcomes of radical prostatectomy (RP) with particular reference to the case volume of the operating surgeon. MATERIALS AND METHODS: All RP entries on the BAUS complex operations database were extracted from its commencement in January 2004 to September 2009. Patient age, prostate-specific antigen (PSA) levels, clinical tumour stage and biopsy Gleason score were analyzed together with operative variables, including the surgical approach, lymphadenectomy status, blood loss, hospital length of stay and individual surgeon case volume. The postoperative variables assessed included surgical specimen Gleason score and pathological tumour stage, prostate weight and the presence of positive surgical margins (PSM), as well as evidence of biochemical recurrence. RESULTS: A total of 8032 RP cases were entered on the database and Follow-up data was available on 4206 cases. Mean patient age was 61.8 years and the mean presenting PSA was 8.3 ng/mL. Open RP procedures were performed on 5429 patients and laparoscopic RP on 2219. The positive surgical margin (PSM) rate for the entire series was 38%. Analysis of PSM by pathological stage revealed a pT2 PSM rate of 24%. Multivariate analysis of variables which might affect PSM revealed pre-operative clinical TNM stage, surgeon case volume, RP specimen Gleason score and pathological TNM stage were significant parameters (P < 0.01). When prostate weight and PSM status were analysed, these was a significant association between smaller prostate weight and PSM status. Interestingly, 45% of high grade Gleason 8-10 needle biopsy cancers were downgraded to Gleason scores 7 or less on RP analysis. Analysis of annual surgeon caseload revealed that 54% of surgeons performed an average of less than 10 procedures per annum and 6% of surgeons performed an average of 30 or more procedures per annum. When individual outcome variables where examined against surgeon case activity it was demonstrated that outcomes are clearly improved beyond 20 cases and there is a trend to continued improvement up to the series maximum of 40 cases per annum. CONCLUSIONS: High volume surgeons have less peri-operative and postoperative complications and better surgical and disease-free outcomes than low volume surgeons. In the UK, raising the current minimum Improving Outcomes Guidance threshold from five RP cases per surgeon per annum to no less than 20 (and ideally to 35 or more cases per annum) could potentially improve overall outcomes.

Reducing laparoscopic radical prostatectomy false-positive margin rates using cyanoacrylate tissue glue.

BACKGROUND: Trauma to the prostate surface from laparoscopic instruments may have a role in creating false-positive margins during laparoscopic radical prostatectomy (LRP). OBJECTIVE: To determine the feasibility of using cyanoacrylate glue to repair iatrogenic lacerations and to evaluate the glue's effect on the positive surgical margin rates of LRP specimens. DESIGN, SETTING, AND PARTICIPANTS: We used porcine kidneys as a surrogate experimental tissue to help determine the quality, robustness, and adequacy of glued repairs in experimentally created lacerations. A matched control group of unrepaired kidney specimens and kidney specimens repaired with glue were subjected to full histopathologic processing. Exposure of a nephron to surface marker ink was considered to be a "positive margin." The efficacy and impact of glue repairs on LRP specimens that had sustained iatrogenic intraoperative surface trauma were also assessed. MEASUREMENTS: We evaluated the success of glue repair in preventing subcapsular renal parenchymal staining. We also compared the rate of positive margins in LRP specimens with and without routine glue repair of the surface of the prostate. RESULTS AND LIMITATIONS: The glue remained effective throughout the entire laboratory process and did not interfere with histopathologic assessment. As hypothesised, cyanoacrylate glue repair of the renal lacerations prevented staining of subcapsular tissues with marker dye and therefore prevented what might otherwise be considered false-positive staining. The rate of positive margins of the 40 LRP specimens without glue repair was 35%, compared with a rate of 10% for 40 glue-repaired specimens. The limitations of the study are that follow-up was short and that the prostatectomy specimens were compared with consecutive controls rather than with matched randomised controls. CONCLUSIONS: Cyanoacrylate glue is a novel, inexpensive, and very effective prostate repair agent that does not interfere with histologic processing. It is possible to accurately repair iatrogenic prostate lacerations with cyanoacrylate glue and, in doing so, to considerably reduce the rate of spurious false-positive surgical margins.