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Successful prostate surgery: It's quality of surgery not quantity that matters most

By Emma Mason

Eurekalert, September 22, 2003

A surgeon's personal skill in performing radical prostate surgery and not necessarily the number of operations performed is the key to a patient's future quality of life and the potential for cure. Surgeons must be honest with patients about their own success rates and prospective patients should not be afraid to ask tough questions, a leading urologist said today (Monday 22 September).

Professor Hendrik Van Poppel told ECCO 12 – The European Cancer Conference – that his research showed that contrary to what might be expected, expertise is not necessarily linked to the number of radical prostectomies a surgeon performs.

Professor Van Poppel, chairman at the Department of Urology at Gasthuisberg Katholieke Universiteit in Leuven, Belgium, said that the quality of surgery was evaluated of 27 surgeons in 23 centres that were part of the European Organisation and Research and Treatment of Cancer (EORTC) Genito-Urinary Group.

He said that it was perfectly possible to use a checklist to look retrospectively for the quality of a particular surgeon. A few parameters could determine quality.

The parameters used were length of surgery, blood loss, postoperative continence, the pathological status of the resection margins and the rate of undetectable PSA (prostate specific antigen) after surgery. The survey related the results from over 230 radical prostectomies to the annual number of these operations performed, classified in five categories ranging from more than 50 a year to less than five a year.

"What we found was that these parameters varied considerably and cannot be absolutely related to caseload. Indeed, we saw that some centres with a high caseload did not have better oncological or urological results. It really does depend on the skill of individual surgeons."

Although many patients in eastern Europe and the former USSR are still not diagnosed until the cancer had spread, in western Europe 80% are diagnosed at a point where the disease is still potentially curable.

Those who are under 70 when they are diagnosed are usually suitable for curative treatment, either through surgery or radiotherapy. Professor Van Poppel said that in his institute 50 patients a year have external beam radiotherapy, 25 have brachytherapy (where the radiation source is placed at the heart of the tumour) while 260 patients a year have radical prostectomies. Surgical outcome was therefore extremely important.

He said that the variability of skill between surgeons could be translated not only into complications such as incontinence in the immediate and longer post-operative period, but also into statistically significant differences in PSA progression. [High PSA levels are an indicator for the presence of prostate cancer].

"It is clear that the surgeon who performs radical prostatectomy matters. There can be a relevant difference in the complications and in cure. A surgeon must inform his patients about his own results relating to potency, continence and cure and not just quote those of high standard centres that have reported their experience.

"It is equally important that a patient questions his surgeon and that he asks the right questions – for example: how much incontinence his surgeon's own patients have after surgery, how many operations does his surgeon perform and how many patients with the same stage of the disease as his own are cured?"

Professor Van Poppel said that the research had been the first attempt to evaluate the quality of surgery in radical prostatectomy. "With a correct simple retrospective analysis of 10 consecutive cases done by one urological surgeon, one is able to distinguish whether the quality is good, fair or poor for each of the parameters assessed."