Hopes and Dreams for Quality Improvement in Radical Prostatectomy

“We do believe that it will never be shown that an LRP performed by a qualitatively poor surgeon would be better than an RRP done by a skilled surgeon (and vice versa)…”

-Ficarra et al. Eur Urol. 2009[1]

While reviewing the point-counterpoint between Dr. Moul and Drs. Patel and Sivaraman, I dreamt of unchanged minds deeply rooted in their own experience and unable to be open to another point of view. What collection of written words on this subject could possibly modify the practice of a single individual? Dr. Patel even raises the issue of the relevance of the debate. Perhaps focusing on defining quality in radical prostatectomy might influence the occasional or aspiring practitioner. Let’s consider two relevant perspectives: that of the surgeon and that of the patient.

How does Dr. X (a surgeon who performs radical prostatectomies) ascertain whether he/she would qualify as “skilled” at performing this operation? This determination requires timely feedback about clinically important outcomes and a source for comparison. Outcomes in radical prostatectomy have proven quite challenging to measure; obligatory long surveys and distant time-points necessitate a considerable commitment of resources. I find it doubtful that the average surgeon performing radical prostatectomy makes this investment, but assume that Dr. X, unlike his competitors in the community (who sadly are more the norm in medicine today), meticulously monitors his patients. Dr. X presents outcomes honestly to patients, something that is notably difficult at the beginning of his/her career, since he/she received no feedback from his/her training experience; however, after years he/she can finally measure outcomes against published series. The results are mediocre. Dr. X begins a long series of educational activities to improve technique. After years of colossal effort, the outcomes have improved, but they remain relatively inferior. He/she rationalizes and comes up with all sorts of “explanations” for the results, some of which are reasonable-for instance, patient selection, the instruments used for assessment, and the unknown outcomes of the enormous number of unmonitored patients. Ultimately, however, the inability to make an effective comparison results in ambiguity.

A multi-institutional comparative outcomes database accomplishing much of what Dr. X desires does exist. Memorial Sloan-Kettering Cancer Center has developed the Prostate Cancer Outcomes Project, which uses advanced informatics and statistics to help surgeons judge performance.[2] It includes Internet-based, risk-adjusted, customizable, and private feedback focused on oncologic and quality-of-life outcomes. The directors of the project warily admit that outcomes may not improve as a result of implementing this feedback, but quality improvement generally starts with base assessment. Dr. X delights in the new tool and hopes it will be possible to incorporate it into his/her practice.

How does Mr. Y (a prostate cancer patient) ascertain whether or not his surgeon is “skilled” at radical prostatectomy? This determination requires accurate, available, and unbiased information about the surgeon. The contemporary model relies on the surgeon’s report: a discussion about his/her level of experience, outcomes, and perhaps a few patient references. This qualifies as available information, but questionable accuracy and the possibility of bias could throw all this information into doubt. Mr. Y has heard that the number of cases matter, but “good” clinical outcomes still vary based on practitioner.[3] An accessible database would be a tremendous asset for patients such as himself; it could be used to compare practitioners and could potentially be quite easy to use via the Internet. Mr. Y hears of the Prostate Cancer Outcomes Project, but to his surprise, he can find no public information directly comparing surgeons. Suspecting conspiratorial obfuscation, he addresses this with Dr. X.

Dr. X, as an amateur ethicist, tries to explain the professional hazards of an exposed database, mainly the incentive of nonparticipation. He is unwilling to divulge his relative rating, believing he does not truly know given the incomplete penetration of the project. Mr. Y has a tough time understanding how this privacy concern relates to his health. Dr. X more fully understands the reluctance of other surgeons performing prostatectomies to be singly compared despite multiple confounding variables. While we applaud the Prostate Cancer Outcomes Project and others like it, and hope to see their widespread application, physicians should be prepared to directly address this peculiar conundrum with patients.

Can the foregoing comments be tied into the robotic vs open radical prostatectomy debate? Yes, they can. In the absence of an unexpected death knell for one of the approaches, future comparisons should focus on the identification of aptitudes, the detailing of dedicated training with feedback, the specification of quality thresholds, the identification of substandard providers, and remediation. In other words, they should provide the means for finding the right people trained the right way doing the right procedure for every patient.

Academic surgeons need to address the following: Does the resident plan to do radical prostatectomy in practice? Does he/she have the skill to do it? Which technique does he/she have the best access to, such that he/she can learn to do it well? How can we best train all surgical residents and provide feedback? How can residents get monitored while they continue to learn? How will they identify weaknesses in technique and improve them? We might find that the answers to some of these questions vary between the robotic and open techniques. For instance, resident Z might have a better feel for open surgery. Robotic surgery may be more easily taught. Access to open surgery may be limited. Weighing these questions for the two approaches would require the teaching and training surgeon to take a powerful inward look at what is required to offer patients the best. A principled approach to radical prostatectomy requires a strong ethic and a nonprotectionist agenda.

Given that we started off dreaming, it’s perhaps appropriate that we end by dreaming. We fervently hope that all surgeons will participate in a comparative outcomes project for the purpose of quality improvement. However, today we will settle for one, we hope, skilled surgeon, open or robotic.

Financial Disclosure:Dr. Maroni has served as an investigator for Sanofi-Aventis, Vivus, and EDAP Technomed, Inc. Dr. Phillips has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

REFERENCES

1. Ficarra V, Novara G, Artibani W, et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2009;55:1037-63.

2. Vickers AJ, Sjoberg D, Basch E, et al. How do you know if you are any good? A surgeon performance feedback system for the outcomes of radical prostatectomy. Eur Urol. 2012;61:284-9.

3. Bianco FJ, Jr., Vickers AJ, Cronin AM, et al. Variations among experienced surgeons in cancer control after open radical prostatectomy. J Urol. 2010;183:977-82.