Learning curve and stage migration of a radical retropubic prostatectomy series over a 10-y period

Abstract

Objective: To show the impact of learning curve and patient selection on complication rate and biochemical recurrence-free survival of a UK radical prostatectomy series for localised prostate cancer and to model the influence of common preoperative variables on biochemical recurrence after controlling for learning curve. Patients and Methods: From 1989 to 1999, 280 of 350 patients who underwent anatomical radical retropubic prostatectomy (RRP) at our institution had complete records and follow-up of at least 1 y. After exclusions of preoperative staging, factors reflecting the learning curve, early complications and prostate-specific antigen (PSA) outcome were recorded on 217 patients. Procedures before 1995 were compared with procedures after 1995. Results: Comparison of the two groups showed a significant decrease in operating time (mean 152 vs 130 min), blood loss (mean 1500 vs 1000 ml), transfusion rate (83 vs 42%) and hospital stay (mean 7 vs 6 days). Median preoperative PSA changed significantly from 13.2 to 11.5 ng/ml. Only 17% were diagnosed by rectal examination compared to 27% in the early years. The number of clinical T1 tumours increased from 33 to 47%. This did lead to an increase of organ-confined tumours on pathological staging by 25%. Biochemical recurrence-free survival improved significantly after 1995. After controlling for the learning curve PSA and clinical stage were significant predictors of PSA recurrence. Conclusion: Time trends of case selection, stage migration and a steep learning curve are shown over a 10-y period. Factors associated with the learning curve as well as case selection have a significant impact on outcome. There may be other as yet not specified factors over time, which have a significant impact on PSA recurrence-free survival. Patients with a PSA of 20 ng/ml and above have a poor outcome and do not appear to be suitable candidates for RRP.

PSA recurrence following radical prostatectomy is comparable for all age groups in the UK

“…We know that outcome after RP in the UK is less optimistic compared to the often quoted large American series of RP. 4,10,11 This multicentre study assesses whether the age of English men undergoing RP is related to outcome (PSA recurrence-free survival). Such information would allow clinicians to counsel and select suitable candidates for RP irrespective of age.…”

The effect of learning curve on the outcome of caesarean section

“…Direct supervision and practical experience are essential. Previous research has indicated that both the operative outcomes and complication rate may be directly related to experience of the surgeon 1,2 . In any training scheme, it is important to ensure that trainees are competent in performing a procedure before they are allowed to do it independently.…”

“…Previous research has indicated that both the operative outcomes and complication rate may be directly related to experience of the surgeon. 1,2 In any training scheme, it is important to ensure that trainees are competent in performing a procedure before they are allowed to do it independently. However, there is little quantitative information on the approximate number of particular operation a trainee should perform before they can be considered adequately skilled to perform the operation independently.…”

The changes in prostate cancer and its management in the North West of England over a 10-year period

“…It showed that there has been a significant stage migration towards lower clinical and pathological stages, resulting in large improvements in 5-year PSA recurrence-free survival after RP between 1998 and 2002. 7,8 Although there are many options available for those diagnosed with localised PCa, there is limited evidence to suggest outcomes are better with any single modality. A recent systematic review by Wilt et al concluded that there is not enough high-quality evidence to compare effectiveness and harms of treatments for clinically localised PCa.…”