Klein Eric A, Bianco Fernando J, Serio Angel M, Eastham James A, Kattan Michael W, Pontes J Edson, Vickers Andrew J, Scardino Peter T
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.
J Urol. 2008 Jun;179(6):2212-6; discussion 2216-7. doi: 10.1016/j.juro.2008.01.107. Epub 2008 Apr 18.
We have previously reported that there is a learning curve for open radical prostatectomy. In the current study we determined whether the effects of the learning curve are modified by patient risk, as defined by preoperative tumor characteristics.
The study included 7,683 eligible patients with prostate cancer treated with open radical prostatectomy by 1 of 72 surgeons. Surgeon experience was coded as the total prior number of radical prostatectomies done by the surgeon before a patient surgery. Multivariate survival time regression models were used to evaluate the association between surgeon experience and biochemical recurrence separately in each preoperative risk group.
We saw no evidence that patient risk affected the learning curve. There was a statistically significant association between biochemical recurrence and surgeon experience on all analyses. The absolute risk difference in a patient receiving treatment from a surgeon with 10 vs 250 prior radical prostatectomies was 6.6% (95% CI 3.4-10.3), 12.0% (95% CI 6.9-18.2) and 9.7% (95% CI 1.2-18.2) in patients at low, medium and high preoperative risk. Recurrence-free probability in patients with low risk disease approached 100% for the most experienced surgeons.
Cancer control after radical prostatectomy improves with increasing surgeon experience irrespective of patient risk. Excellent rates of cancer control in patients with low risk disease treated by the most experienced surgeons suggest that the primary reason that recurrence develops in such patients is inadequate surgical technique. The results have significant implications for clinical care.
我们之前报道过开放性根治性前列腺切除术存在学习曲线。在本研究中，我们确定术前肿瘤特征所定义的患者风险是否会改变学习曲线的影响。
该研究纳入了7683例符合条件的前列腺癌患者，由72名外科医生中的1名进行开放性根治性前列腺切除术。外科医生的经验编码为该外科医生在患者手术前完成的根治性前列腺切除术的总例数。多变量生存时间回归模型用于分别评估每个术前风险组中外科医生经验与生化复发之间的关联。
我们没有发现患者风险影响学习曲线的证据。在所有分析中，生化复发与外科医生经验之间存在统计学上的显著关联。术前低、中、高风险患者中，接受过10例与250例既往根治性前列腺切除术的外科医生治疗的患者，其绝对风险差异分别为6.6%（95%CI 3.4 - 10.3）、12.0%（95%CI 6.9 - 18.2）和9.7%（95%CI 1.2 - 18.2）。对于经验最丰富的外科医生，低风险疾病患者的无复发生存概率接近100%。
无论患者风险如何，随着外科医生经验的增加，根治性前列腺切除术后的癌症控制情况会得到改善。经验最丰富的外科医生治疗的低风险疾病患者的癌症控制率极高，这表明此类患者复发的主要原因是手术技术不足。这些结果对临床护理具有重要意义。
