1 Department of Urology, Tripler Army Medical Center , Honolulu, Hawaii.
J Endourol. 2014 Mar;28(3):298-305. doi: 10.1089/end.2013.0475. Epub 2013 Dec 10.
Complication rates of open radical prostatectomies (ORPs) and laparoscopic radical prostatectomies (LRPs) performed by highly experienced surgeons in centers of excellence are well known. Using a standardized, national, risk-adjusted surgical database, we compared 30-day outcomes following ORP and LRP and analyzed how trainee involvement influenced outcomes.
The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) is a risk-adjusted data collection analyzing preoperative risk factors, demographics, and 30-day postoperative outcomes. From 2005 to 2011, we identified 10,669 total prostatectomies. Of these, 2278 were ORP and 8391 were LRP. Data on trainee involvement were available on 63% of cases.
Comparison of all 10,669 prostatectomies showed a decreased incidence of overall morbidity, serious morbidity, surgical site infections, mortality, wound disruption, urinary tract infection, bleeding, and sepsis or septic shock (p<0.05) for LRP compared with ORP. Trainee involvement was associated with a higher incidence of bleeding, overall and serious morbidity (p<0.001). This difference is isolated to postgraduate year (PGY) 6-10 trainees performing ORP (p<0.001). Overall and serious morbidity was equivalent between PGY groups 1-10 versus attending without trainee performing LRP and PGY groups 1-5 versus attending without trainee performing ORP. Operative times were shorter for ORP versus LRP by an average of 38 minutes (p<0.05), and in cases involving trainees, operative times decreased with trainee experience for both procedures. The length of stay was shorter for LRP compared with ORP (3.2 vs. 1.8 days, p<0.001).
The large sample size, standardized data definitions, and quality control measures of the ACS-NSQIP database allow for in-depth analysis of subtle, but significant differences in outcomes between groups. Trainee involvement in LRP appears safe to patients. However, the increased morbidity in ORP involving trainees may be mitigated by awareness, simulation laboratories, and standardized competency assessment.
在卓越中心，经验丰富的外科医生进行开放性根治性前列腺切除术（ORP）和腹腔镜根治性前列腺切除术（LRP）的并发症发生率是众所周知的。本研究使用标准化的全国风险调整手术数据库，比较了 ORP 和 LRP 术后 30 天的结果，并分析了学员参与如何影响结果。
美国外科医师学院-国家手术质量改进计划（ACS-NSQIP）是一个风险调整数据收集，分析术前危险因素、人口统计学和 30 天术后结果。在 2005 年至 2011 年期间，我们共确定了 10669 例前列腺切除术。其中，2278 例为 ORP，8391 例为 LRP。63%的病例中有学员参与的数据。
比较所有 10669 例前列腺切除术，LRP 的总发病率、严重发病率、手术部位感染、死亡率、伤口破裂、尿路感染、出血、败血症或感染性休克均低于 ORP（p<0.05）。学员参与与出血、总发病率和严重发病率增加相关（p<0.001）。这种差异仅在 PGY 6-10 受训者进行 ORP 时存在（p<0.001）。PGY 1-10 组与无学员进行 LRP 的主治医生组和 PGY 1-5 组与无学员进行 ORP 的主治医生组之间，LRP 和 ORP 的总发病率和严重发病率相当。ORP 手术时间比 LRP 平均缩短 38 分钟（p<0.05），且在有学员参与的情况下，两种手术的手术时间随学员经验的增加而减少。LRP 的住院时间比 ORP 短（3.2 天比 1.8 天，p<0.001）。
ACS-NSQIP 数据库的样本量大、数据定义标准化和质量控制措施允许对两组之间结果的细微但显著差异进行深入分析。LRP 中学员的参与对患者是安全的。然而，涉及学员的 ORP 中发病率的增加可能通过意识、模拟实验室和标准化能力评估来减轻。
