Southport and Ormskirk Hospital NHS Trust and Royal Liverpool, UK.
BJU Int. 2012 Feb;109(3):346-54. doi: 10.1111/j.1464-410X.2011.10334.x. Epub 2011 Jul 19.
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.
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.
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.
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.
详细分析英国泌尿外科学会（BAUS）肿瘤学复杂手术数据库，报告英国根治性前列腺切除术（RP）的结果，特别关注手术医生的手术量。
从 2004 年 1 月至 2009 年 9 月，从 BAUS 复杂手术数据库中提取所有 RP 条目。分析患者年龄、前列腺特异性抗原（PSA）水平、临床肿瘤分期和活检 Gleason 评分，以及手术变量，包括手术入路、淋巴结清扫状态、出血量、住院时间和单个医生的手术量。术后变量评估包括手术标本 Gleason 评分和病理肿瘤分期、前列腺重量和阳性切缘（PSM）的存在以及生化复发的证据。
该数据库共收录了 8032 例 RP 病例，其中 4206 例可获得随访数据。患者平均年龄为 61.8 岁，平均 PSA 为 8.3ng/mL。5429 例患者接受了开放式 RP 手术，2219 例患者接受了腹腔镜 RP 手术。整个系列的 PSM 率为 38%。对病理分期的 PSM 进行分析，发现 pT2 PSM 率为 24%。对可能影响 PSM 的变量进行多变量分析，发现术前临床 TNM 分期、医生手术量、RP 标本 Gleason 评分和病理 TNM 分期是重要参数（P<0.01）。当分析前列腺重量和 PSM 状态时，发现前列腺重量较小与 PSM 状态有显著关联。有趣的是，8-10 级 Gleason 高分活检癌中有 45%在 RP 分析中降级为 Gleason 评分 7 或更低。对医生年度手术量的分析表明，54%的医生每年平均手术量不足 10 例，6%的医生每年平均手术量超过 30 例。当将个别手术结果变量与医生的手术量进行比较时，结果表明手术量超过 20 例后，手术效果明显改善，并且有持续改善的趋势，达到每年 40 例的最高手术量。
高手术量医生的围手术期和术后并发症较少，手术和无病生存率较好。在英国，将当前的《提高结果指南》从每位医生每年 5 例 RP 手术提高至不少于 20 例（理想情况下提高至每年 35 例或更多例），可能会提高整体结果。
