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Post-prostatectomy urinary outcomes vary widely by patient and surgeon

JAMA Surgery
Reuters Health - 27/01/2021 - Patient-reported urinary outcomes three months after radical prostatectomy vary by patient and by surgeon, and a new study suggests that outcomes may be better with top-performing surgeons.

Researchers examined data from the Michigan Urological Surgery Improvement Collaborative on 4,582 men who underwent radical prostatectomy for localized prostate cancer between April 2014 and July 2018. The primary endpoint was patient-reported urinary function scores (0-100 range) with a score of 74 points or higher indicating good function.

Overall, mean patient-reported urinary function scores were 88.5 at baseline, 53.6 at three months, 68.0 at six months, and 73.7 at 12 months.

At three months, the proportion of a surgeon's patients who reported good urinary function scores varied from 0% to 54.5%, based on surgeon-specific outcomes for 48 different surgeons.

Top-performing surgeons were defined as those above the 75th percentile based on the proportion of their patients reporting good urinary function at three months.

"There is no doubt patient characteristics play a role in outcomes, however, top performing surgeons achieved better outcomes even after we accounted for the patient characteristics that are associated with differences in outcomes," said lead study author Dr. Gregory Auffenberg, an assistant professor of urology at Northwestern University Feinberg School of Medicine in Chicago.

"Whether that is due to skill or experience or something else we cannot entirely conclude, but we demonstrate that something at the surgeon level also is associated with differences in outcomes," Dr. Auffenberg said by email.

Patients had worse outcomes with advancing age, higher BMI, higher Gleason scores, and more advanced T stage.

For example, men were less likely to report good urinary function at three months with a BMI of 30-34 (adjusted odds ratio 0.66) or a BMI of 35 or more (aOR 0.68) than with a BMI below 25.

And, men with a biopsy Gleason score of 8-10 were less likely to report good urinary function at three months than men with a Gleason score of 6 (aOR 0.80).

Compared to men with a clinical T stage of T1c or less, men with staging of T2a or above were also less likely to report good urinary function (aOR 0.70).

Men were more likely to report good urinary outcomes at three months when they received bilateral nerve-sparing surgery (aOR 1.48). In addition, each 10-point increase in baseline urinary function scores was associated with good urinary function at three months (aOR 1.12).

One limitation of the study is that surgeon-level analyses included all surgeons with at least 10 patients reporting good baseline urinary function, leaving some surgeons to be evaluated based on a very small sample of patients. It's also possible that some patient factors that were not measured - such as utilization of pelvic floor rehabilitation - might have influenced urinary outcomes.

"Patient characteristics have a huge impact on outcomes," said Dr. Quoc-Dien Trinh, director of Ambulatory Clinical Operations in the Division of Urological Surgery at Brigham and Women's Hospital in Boston, and coauthor of a commentary accompanying the study.

"But the gap in outcomes between top- and low-performers cannot be solely attributed to patient characteristics," Dr. Trinh said by email. "I think it's important for referring physicians and patients to understand that the difference in outcomes between best and worst surgeon can be quite significant, and this is a good example."

SOURCE: https://bit.ly/3poPqDn and https://bit.ly/3a6sK4o JAMA Surgery, online January 20, 2021.

By Lisa Rapaport (Editing by Christine Soares)

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