Prostate Cancer and Prostatic Disease (2014) 17, 227–232 & 2014 Macmillan Publishers Limited All rights reserved 1365-7852/14 www.nature.com/pcan
ORIGINAL ARTICLE
Comparison of outcomes after TURP versus photoselective vaporization of the prostate with respect to trainee involvement utilizing ACS NSQIP SP Olcese1, R Derosa1, SQ Kern1, MB Lustik2, JR Sterbis1 and LP McMann1 BACKGROUND: Large multicenter studies comparing outcomes between TURP and photoselective vaporization of the prostate (PVP) are sparse, with no studies having compared the influence of trainee involvement on these outcomes. Our objectives were to assess 30-day outcomes after TURP and PVP with respect to trainee involvement using an independent national surgical database. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data (2005–2011), 7893 men were identified who underwent TURP or PVP. Regression models were constructed to assess associations between surgical approach, risk-adjusted morbidity and individual complications. Relationships between operative approach, operative duration and duration of stay were also examined and subdivided based upon trainee level. RESULTS: Of 7893 patients, 4950 (62.7%) underwent TURP and 2943 (37.3%) underwent PVP. TURP patients were older, more likely to have diabetes, cancer, history of steroid use and preoperative transfusion compared with PVP patients, who were more likely to have coronary artery disease or bleeding disorders. Risk-adjusted overall morbidity was similar; however, PVP was associated with less pneumonia (0.2% vs 0.5%, Po0.015), bleeding requiring transfusion (0.5% vs 1.8%, Po0.001) and return to the operating room (1.5% vs 2.2%, Po0.022). PVP patients also had shorter length of stay (0.8 vs 2.1 days, Po0.001). There were no significant differences in outcomes when a trainee was involved. Operative duration was similar for TURP and PVP when performed by an attending alone (52 vs 52 min, Po0.001), but was longer with trainee involvement, regardless of post-graduate year (PGY) level (Po0.001). Comparison of operative duration among trainee subgroups demonstrated longer operative times for the PGY 6–9 subgroup performing PVP when compared with other subgroups (Po0.003). CONCLUSIONS: Within ACS NSQIP hospitals, TURP and PVP demonstrated similar risk-adjusted overall morbidity. Despite longer operative times for TURP and PVP with trainee involvement, there were no significant differences in outcomes. Prostate Cancer and Prostatic Disease (2014) 17, 227–232; doi:10.1038/pcan.2014.13; published online 15 April 2014
INTRODUCTION Affecting approximately one-third of men aged 60–70 years, BPH is a common clinical entity, which frequently necessitates surgical intervention.1 Although TURP has historically been the most common surgical intervention for BPH, photoselective vaporization of the prostate (PVP) has emerged as another generally accepted and effective treatment.2,3 However, there are few large, multicenter trials comparing the two.3 Data from previous studies have demonstrated that there is less need for hospitalization with laser treatments, but also less long-term efficacy with PVP when compared with TURP.3 Other smaller studies have documented that the benefits of PVP in comparison with TURP include decreased bleeding, decreased length of hospital stay, capability to treat large glands and patients on anticoagulation therapy, as well as eliminating the risk of transurethral resection syndrome.4–9 Although several studies have compared outcomes between TURP and PVP, none have examined the influence of trainee (resident or fellow) involvement on outcomes using a national, standardized, risk-adjusted database. The objective of this study was to assess the risk factors, demographics and 30-day outcomes associated with TURP vs PVP using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Furthermore, we aimed to
review how these outcomes are affected by trainee involvement during the procedures. MATERIALS AND METHODS Data acquisition Since its inception in 1994 within the Veterans Health Administration System, NSQIP was piloted in the private sector by the ACS in 2001 and now includes over 250 participating hospitals, including those in the Department of Defense. The ACS NSQIP encompasses a national standard database that provides validated, risk-adjusted outcomes from collaborating hospitals within and outside the United States.10 The first 40 cases performed within consecutive 8-day cycles are sampled from multiple specialties including urology. Surgical clinical reviewers extract specific variables from inpatient and outpatient medical records to obtain comprehensive clinical data. Patient demographics, preoperative risks factors and laboratory values, intra-operative data, as well as postoperative outcomes within 30 days of the index operation are collected. The definitions of clinical variables and the collection of these variables are standardized by the ACS to ensure data consistency and reliability throughout all hospitals enrolled in ACS NSQIP.10–12 Procedures were identified using the current procedural terminology codes for PVP (laser coagulation and laser vaporization) (52647, 52648) or TURP (52601) based on International Classifications of Disease Diagnosis Codes (9th edition) and identified from the ACS NSQIP database from
1 Urology Service, Department of Surgery, Tripler Army Medical Center, Honolulu, HI, USA and 2Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI, USA. Correspondence: Dr SP Olcese, Department of Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu 96859, HI, USA. E-mail: [email protected] Received 13 December 2013; revised 7 February 2014; accepted 19 February 2014; published online 15 April 2014
TURP and PVP SP Olcese et al
228 1 January 2005 through 31 December 2011. Intra-operative data including operative times, surgical trainee participation and the level of the most senior surgical trainee were recorded. Cases were subgrouped according to the procedure performed and the seniority level by post-graduate year (PGY). For analysis, cases were grouped by PGY 1–2, PGY 3–5 and PGY 6–9. The subgroup PGY 6–9 were considered to be chief residents and fellows.
were done to estimate odds ratios for overall morbidity and serious morbidity adjusted for significant risk factors. The logistic regression analyses also examined interactions to evaluate whether the outcome of the surgical procedure varied with trainee involvement. Error bars in charts represent 95% confidence intervals based on s.e.m. for continuous variables and on the exact binomial distribution for categorical outcomes. A significance level of Po0.05 was used for all analyses.
Outcomes The primary outcomes of interest were 30-day overall morbidity, serious morbidity, non-serious morbidity, surgical site infection (SSI; superficial SSI, deep SSI and organ space SSI), wound disruption and mortality. Secondary outcomes of interest included bleeding, urinary tract infection, deep venous thrombosis and renal failure. Serious morbidity was defined as having documentation of at least one of the following ACS NSQIP outcomes: mortality, organ space SSI, wound disruption, neurological event (stroke or cerebrovascular accident with or without neurologic deficit, or coma lasting 424 h), cardiac arrest, myocardial infarction, bleeding requiring transfusion during a period from the surgical start time up to and including 72 h postoperatively, pulmonary embolism, ventilator dependence 448 h, progressive or acute renal insufficiency, and sepsis or septic shock. Overall morbidity was defined as having documentation of a serious morbidity, mortality or at least one of the following ACS NSQIP outcomes: superficial SSI, deep SSI, pneumonia, peripheral neurological deficit, unplanned intubation, urinary tract infection and deep vein thrombosis. Non-serious morbidity was defined as at least one or more individual outcomes not considered a serious morbidity. Patients could experience more than one of the listed outcomes. However, outcomes present at the time of surgery were excluded in the postoperative outcome analysis.
Risk adjustment factors Variables for risk of 30-day outcomes included type of surgery (TURP or PVP), patient demographics, comorbidities and preoperative laboratory values. Patient demographic variables included age, gender and race/ ethnicity. The patient’s preoperative risk was also evaluated based on the body mass index, American Society of Anesthesiology class and preoperative functional status assessed by the patient’s ability to perform activities of daily living and stratified as independent, partially dependent, totally dependent and unknown. Comorbidities included diabetes (requiring oral medications or insulin vs none), renal disease (dialysis or acute renal failure with an increase in blood urea nitrogen and creatinine 43 mg dl–1 by 1–2 lab measurements as determined by preoperative documentation of renal failure by the surgeon), dyspnea, ascites, chronic obstructive pulmonary disease, current pneumonia, ventilator dependence, chronic steroid use, bleeding disorders, heart failure (within 30 days before index operation), hypertension, coronary artery disease (including angina, myocardial infarction within 6 months of the index operation, percutaneous cardiac intervention, or cardiac operation), peripheral vascular disease (including revascularization for peripheral vascular disease, claudication, rest pain, amputation or gangrene), disseminated cancer, weight loss (410% body weight within 6 months of index operation), current chemotherapy within 30 days or radiotherapy within 90 days, neurologic deficit (including stroke with or without neurologic deficit, transient ischemic attacks, hemiplegia, paraplegia, quadriplegia or impaired sensorium), preoperative transfusion within 72 h of the index operation and preoperative systemic inflammatory syndrome/sepsis. Social risk factors of alcohol use (42 drinks per day) and smoking status (within 1 year before the index operation) were also included. Thirteen preoperative serum laboratory values were also included (serum albumin, alkaline phosphatase, aspartate aminotransferase, glutamic-oxaloacetic acid, bilirubin, white blood cell count, hematocrit, platelet count, prothrombin time, partial thromboplastin time, creatinine, blood urea nitrogen and sodium).
Statistical analyses All statistical analyses were conducted in SAS v. 9.2 (SAS Institute, Cary, NC, USA). Fisher’s exact tests (two-sided) and w2 tests were used to assess associations between type of surgical approach and categorical variables. Two-sided t-tests were used to assess mean differences between TURP and PVP for continuous outcomes. An analysis of variance was used to compare means among the three experience-level subgroups. Hospital length of stay was transformed to the log scale to enhance normality for analysis. Stepwise logistic regression analyses using an inclusion criterion of Po0.05 Prostate Cancer and Prostatic Disease (2014), 227 – 232
RESULTS During the study period, a total of 7893 patients underwent treatment for BPH with either TURP or PVP across 109 participating NSQIP hospitals from 2005 to 2011. Specific data on trainee and attending involvement was included on 5307 patients (67.2%). Trainees were involved in 1271 cases and 4036 cases were performed with only the attending involved in the cases. There were 289 cases involving PGY 1–2, 877 cases involving PGY 3–5, 105 cases involving PGY 6 and fellows. TURP comprised 4950 (62.7%) patients. PVP comprised 2943 (37.3%) patients. Patients who underwent TURP were slightly older (mean age 72 vs 71 years, Po0.001), more likely to be Caucasian (P ¼ 0.007), have a dependent or partially dependent functional status (Po0.001), on diabetes medication (P ¼ 0.010), steroid users (P ¼ 0.041), have disseminated cancer (P ¼ 0.035), suffer preoperative sepsis (Po0.001), require postoperative blood transfusion (P ¼ 0.001) and were inpatient at the time of surgery (P ¼ 0.001). In comparison, PVP patients were more likely to be coagulopathic (P ¼ 0.034) or suffer from coronary artery disease (P ¼ 0.025; Table 1). Unadjusted overall morbidity and serious morbidity were significantly greater among patients undergoing TURP vs PVP (8.6% vs 7.2%, P ¼ 0.029; 4% vs 1.9%, Po0.001), in addition to postoperative pneumonia, bleeding and procedures requiring return to the operating room (Table 2). Logistic regression analyses determined several variables were associated with overall morbidity and serious morbidity to include: blood transfusion, older age, sepsis, disseminated cancer, renal failure, higher American Society of Anesthesiology class and dependent functional status. After covariate adjustment, overall morbidity did not differ significantly between PVP and TURP (odds ratio 0.9, 95% confidence interval 0.76–1.08), but a significant association remained for serious morbidity (odds ratio 0.49, 95% confidence interval 0.36–0.68, Po0.001; Table 3). Length of stay was significantly shorter for PVP than for TURP (0.9 vs 2.4 days, Po0.001). With respect to trainee involvement, there were no differences in 30-day outcomes in overall and serious morbidity, mortality, pneumonia, and bleeding, when comparing PGY 1–9 with attending alone (Figure 1). No significant differences were noted in the complication rates among the different levels of experience when comparing resident-level trainees to fellow-level trainees. The PGY 1–2, PGY 3–5 and PGY 6–9 subgroups were similar with respect to 30-day outcomes in these categories with no significant differences noted in the complication rates among the different levels of experience. Operative times were also analyzed among resident subgroups and attending alone performing TURP or PVP. TURP performed only by attending surgeons had significantly shorter operative times (52±34 min, (mean±s.d.); Po0.001, respectively) when compared with TURPs performed by both PGY 1–5 and PGY 6–9 subgroups (68±40 min and 69±31 min, Po0.001). PGY 6–9 had significantly longer PVP operative times (96±56 min, P ¼ 0.003) than PGY 1–2 and PGY 3–5 subgroups (75±38 and 74±36, P ¼ 0.003), while there were no significant differences in operative time between resident subgroups for TURP. Attendings who performed TURP alone were faster than attendings working with trainees (52±34 vs 68±40 min, Po0.001) and trainees operating with the attendings not present, but available (70±37 min, Po0.001). PVP was performed faster by attendings operating & 2014 Macmillan Publishers Limited
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229 Table 1.
Demographics of patients undergoing prostatectomy in ACS NSQIP hospitals (2005–2011)
Variable
TURP CPT ¼ 52601 (n ¼ 4950; 62.7%)
Photovaporization CPT ¼ 52647, 52648 (n ¼ 2943; 37.3%)
P-value
n
%
n
%
Age 17–49 50–64 X65
72 965 3913
1.5 19.5 79.1
36 686 2221
1.2 23.3 75.5
o0.001
Race/Hispanic White Black Hispanic Other
3376 243 373 99
82.5 5.9 9.1 2.4
2248 136 184 65
85.4 5.2 7.0 2.5
0.007
BMI Underweighto18.5 Normal 18.5–o25 Oveweight 25–o30 Obese X30
72 1344 1993 1455
1.5 27.6 41.0 29.9
34 789 1242 837
1.2 27.2 42.8 28.8
0.313
ASA class No disturb Mild disturb Severe disturb Life threat
139 2059 2504 238
2.8 41.7 50.7 4.8
94 1304 1419 124
3.2 44.3 48.2 4.2
0.055
Functional status before surgery Independent Partially dependent Totally dependent Diabetes (on meds) Renal failure
4634 238 33 1033 52
94.5 4.9 0.7 20.9 1.1
2828 87 11 543 29
96.7 3.0 0.4 18.5 1.0
o0.001
Dyspnea At rest Moderate exertion Ascites Alcohol use Current smoker COPD Pneumonia Steroid use Bleeding disorder CHF HTN requiring meds Coronary artery diseasea Peripheral vascular diseaseb Disseminated cancer Weight loss (410% loss in last 6 months) Chemotherapy within 30 days Radiotherapy in last 90 days Neurologic disorderc Preoperative sepsisd Dialysis
48 409 2 103 535 374 0 125 162 42 3138 788 73 64 38 20 10 402 72 30
1.0 8.3 0.0 2.8 10.8 7.6 0.0 2.5 3.3 0.8 63.4 15.9 1.5 1.3 0.8 0.5 0.3 8.1 1.5 0.6
26 270 6 64 297 221 3 53 124 16 1816 526 43 23 16 13 4 241 15 17
0.9 9.2 0.2 2.7 10.1 7.5 0.1 1.8 4.2 0.5 61.7 17.9 1.5 0.8 0.5 0.6 0.2 8.2 0.5 0.6
0.355
Inpatient/outpatient Inpatient Outpatient Transfusione
3319 1631 50
67.1 32.9 1.0
590 2353 10
20.0 80.0 0.3
0.010 0.818
0.059 1.000 0.325 0.965 0.057 0.041 0.034 0.135 0.136 0.025 1.000 0.035 0.262 1.000 0.586 0.932 o0.001 1.000 o0.001 0.001
Abbreviations: ACS NSQIP, American College of Surgeons National Surgical Quality Improvement Program; ASA, American Society of Anesthesiology; BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CPT, current procedural terminology; HTN, hypertension. a History of angina in the month before the index operation, history of myocardial infarction 6 months before the index operation, previous percutaneous cardiac intervention or previous cardiac surgery. b History of revascularization/amputation for peripheral vascular disease and rest pain or gangrene. c Cerebral vascular accident/stroke with or without neurologic deficit, history of transient ischemic attacks, hemiplegia, paraplegia, impaired sensorium, quadriplegia. d Preoperative systemic inflammatory response syndrome or sepsis. e Transfusion of packed red blood cells up to 72 h before surgery. Bold values indicate statistically significant P-value
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230 alone (52±33 min, Po0.001) than by trainees operating in conjunction with attendings (78±43 min, Po0.001) and trainees operating while attendings were not present, yet available (71±33 min, Po0.001). Table 2. Comparison of unadjusted 30-day outcomes for TURP and PVP at ACS NSQIP hospitals (2005–2011) 30-Day outcome
Overall morbidity Serious morbidity Non-serious morbidity SSI Mortality Superficial SSI Deep incisional SSI Organ space SSI Wound disruption Pneumonia Unplanned intubation Pulmonary embolism Failure to wean Renal failure Urinary tract infection Neurologic eventa Cardiac arrest requiring CPR Myocardial infarction Bleedingb DVT Sepsis or septic shock Return to OR
TURP CPT ¼ 52601 (n ¼ 4950; 62.7%)
PVP CPT ¼ 52647, 52648 (n ¼ 2943; 37.3%)
P-value
n
%
n
%
424 198 293
8.6 4.0 5.9
211 55 177
7.2 1.9 6.0
0.029 o0.001 0.883
9 28 5 2 2 2 26 13
0.2 0.6 0.1 0.0 0.0 0.0 0.5 0.3
4 15 1 2 1 2 5 5
0.1 0.5 0.0 0.1 0.0 0.1 0.2 0.2
0.778 0.875 0.422 0.632 1.000 0.632 0.015 0.473
5 3 9 241
0.1 0.1 0.2 4.9
1 2 2 157
0.0 0.1 0.1 5.3
0.422 1.000 0.229 0.366
14 5
0.3 0.1
4 4
0.1 0.1
0.228 0.735
12 88 20 55 109
0.2 1.8 0.4 1.1 2.2
3 14 10 21 43
0.1 0.5 0.3 0.7 1.5
0.192 o0.001 0.709 0.095 0.022
Abbreviations: ACS NSQIP, American College of Surgeons National Surgical Quality Improvement Program; CPR, cardiopulmonary resuscitation; CPT, current procedural terminology; DVT, deep vein thrombosis; OR, operating room; PVP, photoselective vaporization of the prostate; SSI, surgical site infection. a Stroke or cerebrovascular accident, coma lasting 424 h, or peripheral neurological deficit. b Bleeding requiring transfusion from surgical start time to 72 h postoperatively. Bold values indicate statistically significant P-value.
DISCUSSION This study examines the incidence of, and risk factors associated with, 30-day overall mortality and morbidity outcomes of TURP and PVP, utilizing the ACS NSQIP. Trainee involvement and its association with these 30-day postsurgical outcomes and operative times for TURP and PVP were also analyzed. The body of literature comparing TURP to PVP is rapidly expanding, and while there have been several reviews comparing outcomes of these procedures, few have done so on the scale of our study. We confirmed many of the findings demonstrated in previous studies, to include decreased incidence of bleeding requiring transfusion, as well as decreased length of hospital stay for PVP.3,7 The mean duration of hospital stay following PVP in our study was 0.9 vs 2.4 days for TURP. This finding is comparable to other studies but has never been shown before utilizing a standardized, national database with such a large volume of hospitals.3,13 The overall morbidity was similar for both procedures after controlling for comorbidities, which is also consistent with prior studies.3 However, risk-adjusted serious morbidity was greater for TURP, presumably because of more bleeding requiring transfusion and need to return to the operating room, despite PVP patients being more likely to have a bleeding disorder preoperatively. We feel that this finding further strengthens the available data demonstrating the safety of PVP for patients on anticoagulants.7 However, there are several technical variations with respect to both procedures. TURP can be performed with and without bipolar cautery using a resectoscope loop or button. Laser treatments encompass non-contact and contact laser coagulation of the prostate with a variety of approaches, including holmium laser resection of the prostate, holmium laser enucleation of the prostate, transurethral side firing laser ablation or holmium laser ablation of the prostate, as well as photovaporization of the prostate.2 In addition, there are several variations with respect to laser energy source, power setting and laser wavelength. Although there is no specific coding for TURP using bipolar, the current review encompasses laser procedures coded as either ‘non-contact’ or ‘contact’ laser coagulation of the prostate. Despite the perception that many laser procedures have appeared to require more extensive training and experience with a steep learning curve,9,14 mean operating times between PVP and TURP were identical when performed by attending alone in this study. This finding contrasts with multiple other studies, which have demonstrated significantly shorter operating times for
Table 3. Risk-adjusted 30-day postoperative outcomes for TURP vs PVP with respect to resident and fellow involvement at ACS NSQIP Hospitals (2005–2011) Unadjusted OR (95% CI) for TURP vs PVP
Risk-adjusted OR (95% CI) for TURP vs PVP
OR
P-value
OR
P-value
Overall morbidity outcomea All cases Trainee involvement Attending interaction only
1.21 (1.02–1.44) 0.79 (0.52–1.21) 1.31 (1.04–1.64)
0.028 0.281 0.021
1.1 (0.93–1.32) 0.73 (0.47–1.13) 1.23 (0.97–1.56)
0.254 0.156 0.080
Serious morbidity outcomez All cases Trainee involvement Attending interaction only
2.19 (1.62–2.96) 1.16 (0.58–2.33) 2.52 (1.66–3.83)
o0.001 0.673 o0.001
1.08 (1.47–2.79) 2.44 (0.52–2.25) 2.44 (1.58–3.38)
o0.001 0.843 o0.001
Abbreviations: ACS NSQIP, American College of Surgeons National Surgical Quality Improvement Program; ASA, American Society of Anesthesiology; BMI, body mass index; CI, confidence interval; OR, odds ratio; PVP, photoselective vaporization of the prostate. Overall morbidity adjusted for age, renal failure, history of chronic obstructive pulmonary disease, ASA class, disseminated cancer, transfusion, bleeding disorder and functional status. Serious morbidity adjusted for all of the above in addition to BMI and weight loss. a Interaction P-value ¼ 0.039 unadjusted and 0.037 adjusted. zInteraction P-value ¼ 0.160 unadjusted and 0.137 adjusted. Bold values are highlight statistically significant P -value.
Prostate Cancer and Prostatic Disease (2014), 227 – 232
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231
Figure 1. Thirty-day postsurgical outcomes for TURP and photoselective vaporization of the prostate (PVP) using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), 2005–2011. In these categories, there were no statistically significant differences appreciated between trainees and attendings, P40.05.
TURP.8,13,15 Whether this reflects increasing surgeon familiarity with PVP or a difference in gland size is difficult to elucidate as there are no data regarding gland size in the current review. Evolution in technology and technique may also account for shorter operating times as well—that is, with the introduction of the holmium laser and transurethral soft tissue morcellators, which permit complete enucleation of the median and both lateral lobes en bloc.16,17 As expected, operative times for both TURP and PVP were significantly longer when a trainee was involved. The influence of trainee involvement in surgical outcomes has been well documented.18,19 With the exception of a small single institution review of trainee involvement in PVP performed in ambulatory surgical centers, we believe this is the only study to compare the influence of trainee involvement on outcomes with regard to these specific procedures on a large scale.20 Despite longer operative times with trainee involvement, there was no increased incidence of adverse outcomes when trainees were involved. We also found that there was no significant difference in morbidity based upon training level—suggesting these procedures are generally safe even when performed by junior residents. This finding contrasts with results from the general surgery literature, which have demonstrated that trainee involvement is frequently associated with increased morbidity.18,19 When examining operative times with respect to training level, we failed to appreciate any considerable improvement in operating room times, and found that the fellow subgroup had significantly longer operating room times than the PGY 1–5 group. Although it is unlikely that fellow-level trainees are actually slower in the operating room than junior-level residents, this highlights limitations of this study—in that there is no accounting for the extent of attending involvement, or gland size and case difficulty—all factors that likely contributed to this finding.
significance. Therefore, subtle differences that are discovered need to be evaluated with a critical eye. In addition, the ACS NSQIP variables are standardized in the database and therefore do not allow for procedure-specific outcomes of interest, such as the incidence of transurethral resection syndrome. However, the benefit of using normal saline instead of hypo-osmotic irrigation fluid during prostate resection is well known. CONCLUSIONS Using a risk-adjusted, nationally standardized surgical clinical database collection system, we evaluated the 30-day outcomes of almost 8000 patients undergoing surgery for BPH from 2005 to 2011. Specifically, we analyzed how these outcomes are impacted by the involvement of surgical residents and fellows. To our knowledge, this represents the first usage of the ACS NSQIP database to evaluate resident and fellow involvement relating to TURP and PVP, as well as the largest study comparing these two procedures in the literature. We conclude that PVP appears to be a slightly safer procedure with respect to 30-day outcomes, with less serious morbidity and bleeding as well as shorter length of hospital stay regardless of resident or fellow involvement with the case. Although operative times are longer when a trainee is involved in both TURP and PVP, there is no increased risk of adverse events in either procedure. This is an important aspect to consider as surgical educators strive to balance providing safe patient care with realistic surgical training. Although these procedures are generally safe, future morbidity may be diminished with increased awareness of potential complications, standardized competency assessment of trainees and strong mentorship from experienced attending surgeons. CONFLICT OF INTEREST The authors declare no conflict of interest.
Limitations One of the strengths of the ACS NSQIP is its generalized and standardized variable collection system. However, owing to this quality, we lose the ability to evaluate disease-specific variables of interest, that is, gland size and previous BPH operation. Furthermore, qualitative and quantitative peri-operative data important for long-term management are not included into the database, such as urine flow rates or the patient international prostate symptom score questionnaire; albeit NSQIP is designed for review of 30-day postoperative outcomes. Also, it does not quantify the extent of resident involvement. The robust sample size of the ACS NSQIP has the potential for over interpretation, lending statistical significance to findings, but perhaps not clinical & 2014 Macmillan Publishers Limited
ACKNOWLEDGEMENTS We are appreciative of the Tripler Army Medical Center NSQIP Surgical Clinical Nurse Reviewer, Melanie S Alano, BSN, PHN, LNC, for her assistance throughout this project.
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ORIGINAL ARTICLE
Comparison of outcomes after TURP versus photoselective vaporization of the prostate with respect to trainee involvement utilizing ACS NSQIP SP Olcese1, R Derosa1, SQ Kern1, MB Lustik2, JR Sterbis1 and LP McMann1 BACKGROUND: Large multicenter studies comparing outcomes between TURP and photoselective vaporization of the prostate (PVP) are sparse, with no studies having compared the influence of trainee involvement on these outcomes. Our objectives were to assess 30-day outcomes after TURP and PVP with respect to trainee involvement using an independent national surgical database. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data (2005–2011), 7893 men were identified who underwent TURP or PVP. Regression models were constructed to assess associations between surgical approach, risk-adjusted morbidity and individual complications. Relationships between operative approach, operative duration and duration of stay were also examined and subdivided based upon trainee level. RESULTS: Of 7893 patients, 4950 (62.7%) underwent TURP and 2943 (37.3%) underwent PVP. TURP patients were older, more likely to have diabetes, cancer, history of steroid use and preoperative transfusion compared with PVP patients, who were more likely to have coronary artery disease or bleeding disorders. Risk-adjusted overall morbidity was similar; however, PVP was associated with less pneumonia (0.2% vs 0.5%, Po0.015), bleeding requiring transfusion (0.5% vs 1.8%, Po0.001) and return to the operating room (1.5% vs 2.2%, Po0.022). PVP patients also had shorter length of stay (0.8 vs 2.1 days, Po0.001). There were no significant differences in outcomes when a trainee was involved. Operative duration was similar for TURP and PVP when performed by an attending alone (52 vs 52 min, Po0.001), but was longer with trainee involvement, regardless of post-graduate year (PGY) level (Po0.001). Comparison of operative duration among trainee subgroups demonstrated longer operative times for the PGY 6–9 subgroup performing PVP when compared with other subgroups (Po0.003). CONCLUSIONS: Within ACS NSQIP hospitals, TURP and PVP demonstrated similar risk-adjusted overall morbidity. Despite longer operative times for TURP and PVP with trainee involvement, there were no significant differences in outcomes. Prostate Cancer and Prostatic Disease (2014) 17, 227–232; doi:10.1038/pcan.2014.13; published online 15 April 2014
INTRODUCTION Affecting approximately one-third of men aged 60–70 years, BPH is a common clinical entity, which frequently necessitates surgical intervention.1 Although TURP has historically been the most common surgical intervention for BPH, photoselective vaporization of the prostate (PVP) has emerged as another generally accepted and effective treatment.2,3 However, there are few large, multicenter trials comparing the two.3 Data from previous studies have demonstrated that there is less need for hospitalization with laser treatments, but also less long-term efficacy with PVP when compared with TURP.3 Other smaller studies have documented that the benefits of PVP in comparison with TURP include decreased bleeding, decreased length of hospital stay, capability to treat large glands and patients on anticoagulation therapy, as well as eliminating the risk of transurethral resection syndrome.4–9 Although several studies have compared outcomes between TURP and PVP, none have examined the influence of trainee (resident or fellow) involvement on outcomes using a national, standardized, risk-adjusted database. The objective of this study was to assess the risk factors, demographics and 30-day outcomes associated with TURP vs PVP using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Furthermore, we aimed to
review how these outcomes are affected by trainee involvement during the procedures. MATERIALS AND METHODS Data acquisition Since its inception in 1994 within the Veterans Health Administration System, NSQIP was piloted in the private sector by the ACS in 2001 and now includes over 250 participating hospitals, including those in the Department of Defense. The ACS NSQIP encompasses a national standard database that provides validated, risk-adjusted outcomes from collaborating hospitals within and outside the United States.10 The first 40 cases performed within consecutive 8-day cycles are sampled from multiple specialties including urology. Surgical clinical reviewers extract specific variables from inpatient and outpatient medical records to obtain comprehensive clinical data. Patient demographics, preoperative risks factors and laboratory values, intra-operative data, as well as postoperative outcomes within 30 days of the index operation are collected. The definitions of clinical variables and the collection of these variables are standardized by the ACS to ensure data consistency and reliability throughout all hospitals enrolled in ACS NSQIP.10–12 Procedures were identified using the current procedural terminology codes for PVP (laser coagulation and laser vaporization) (52647, 52648) or TURP (52601) based on International Classifications of Disease Diagnosis Codes (9th edition) and identified from the ACS NSQIP database from
1 Urology Service, Department of Surgery, Tripler Army Medical Center, Honolulu, HI, USA and 2Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI, USA. Correspondence: Dr SP Olcese, Department of Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu 96859, HI, USA. E-mail: [email protected] Received 13 December 2013; revised 7 February 2014; accepted 19 February 2014; published online 15 April 2014
TURP and PVP SP Olcese et al
228 1 January 2005 through 31 December 2011. Intra-operative data including operative times, surgical trainee participation and the level of the most senior surgical trainee were recorded. Cases were subgrouped according to the procedure performed and the seniority level by post-graduate year (PGY). For analysis, cases were grouped by PGY 1–2, PGY 3–5 and PGY 6–9. The subgroup PGY 6–9 were considered to be chief residents and fellows.
were done to estimate odds ratios for overall morbidity and serious morbidity adjusted for significant risk factors. The logistic regression analyses also examined interactions to evaluate whether the outcome of the surgical procedure varied with trainee involvement. Error bars in charts represent 95% confidence intervals based on s.e.m. for continuous variables and on the exact binomial distribution for categorical outcomes. A significance level of Po0.05 was used for all analyses.
Outcomes The primary outcomes of interest were 30-day overall morbidity, serious morbidity, non-serious morbidity, surgical site infection (SSI; superficial SSI, deep SSI and organ space SSI), wound disruption and mortality. Secondary outcomes of interest included bleeding, urinary tract infection, deep venous thrombosis and renal failure. Serious morbidity was defined as having documentation of at least one of the following ACS NSQIP outcomes: mortality, organ space SSI, wound disruption, neurological event (stroke or cerebrovascular accident with or without neurologic deficit, or coma lasting 424 h), cardiac arrest, myocardial infarction, bleeding requiring transfusion during a period from the surgical start time up to and including 72 h postoperatively, pulmonary embolism, ventilator dependence 448 h, progressive or acute renal insufficiency, and sepsis or septic shock. Overall morbidity was defined as having documentation of a serious morbidity, mortality or at least one of the following ACS NSQIP outcomes: superficial SSI, deep SSI, pneumonia, peripheral neurological deficit, unplanned intubation, urinary tract infection and deep vein thrombosis. Non-serious morbidity was defined as at least one or more individual outcomes not considered a serious morbidity. Patients could experience more than one of the listed outcomes. However, outcomes present at the time of surgery were excluded in the postoperative outcome analysis.
Risk adjustment factors Variables for risk of 30-day outcomes included type of surgery (TURP or PVP), patient demographics, comorbidities and preoperative laboratory values. Patient demographic variables included age, gender and race/ ethnicity. The patient’s preoperative risk was also evaluated based on the body mass index, American Society of Anesthesiology class and preoperative functional status assessed by the patient’s ability to perform activities of daily living and stratified as independent, partially dependent, totally dependent and unknown. Comorbidities included diabetes (requiring oral medications or insulin vs none), renal disease (dialysis or acute renal failure with an increase in blood urea nitrogen and creatinine 43 mg dl–1 by 1–2 lab measurements as determined by preoperative documentation of renal failure by the surgeon), dyspnea, ascites, chronic obstructive pulmonary disease, current pneumonia, ventilator dependence, chronic steroid use, bleeding disorders, heart failure (within 30 days before index operation), hypertension, coronary artery disease (including angina, myocardial infarction within 6 months of the index operation, percutaneous cardiac intervention, or cardiac operation), peripheral vascular disease (including revascularization for peripheral vascular disease, claudication, rest pain, amputation or gangrene), disseminated cancer, weight loss (410% body weight within 6 months of index operation), current chemotherapy within 30 days or radiotherapy within 90 days, neurologic deficit (including stroke with or without neurologic deficit, transient ischemic attacks, hemiplegia, paraplegia, quadriplegia or impaired sensorium), preoperative transfusion within 72 h of the index operation and preoperative systemic inflammatory syndrome/sepsis. Social risk factors of alcohol use (42 drinks per day) and smoking status (within 1 year before the index operation) were also included. Thirteen preoperative serum laboratory values were also included (serum albumin, alkaline phosphatase, aspartate aminotransferase, glutamic-oxaloacetic acid, bilirubin, white blood cell count, hematocrit, platelet count, prothrombin time, partial thromboplastin time, creatinine, blood urea nitrogen and sodium).
Statistical analyses All statistical analyses were conducted in SAS v. 9.2 (SAS Institute, Cary, NC, USA). Fisher’s exact tests (two-sided) and w2 tests were used to assess associations between type of surgical approach and categorical variables. Two-sided t-tests were used to assess mean differences between TURP and PVP for continuous outcomes. An analysis of variance was used to compare means among the three experience-level subgroups. Hospital length of stay was transformed to the log scale to enhance normality for analysis. Stepwise logistic regression analyses using an inclusion criterion of Po0.05 Prostate Cancer and Prostatic Disease (2014), 227 – 232
RESULTS During the study period, a total of 7893 patients underwent treatment for BPH with either TURP or PVP across 109 participating NSQIP hospitals from 2005 to 2011. Specific data on trainee and attending involvement was included on 5307 patients (67.2%). Trainees were involved in 1271 cases and 4036 cases were performed with only the attending involved in the cases. There were 289 cases involving PGY 1–2, 877 cases involving PGY 3–5, 105 cases involving PGY 6 and fellows. TURP comprised 4950 (62.7%) patients. PVP comprised 2943 (37.3%) patients. Patients who underwent TURP were slightly older (mean age 72 vs 71 years, Po0.001), more likely to be Caucasian (P ¼ 0.007), have a dependent or partially dependent functional status (Po0.001), on diabetes medication (P ¼ 0.010), steroid users (P ¼ 0.041), have disseminated cancer (P ¼ 0.035), suffer preoperative sepsis (Po0.001), require postoperative blood transfusion (P ¼ 0.001) and were inpatient at the time of surgery (P ¼ 0.001). In comparison, PVP patients were more likely to be coagulopathic (P ¼ 0.034) or suffer from coronary artery disease (P ¼ 0.025; Table 1). Unadjusted overall morbidity and serious morbidity were significantly greater among patients undergoing TURP vs PVP (8.6% vs 7.2%, P ¼ 0.029; 4% vs 1.9%, Po0.001), in addition to postoperative pneumonia, bleeding and procedures requiring return to the operating room (Table 2). Logistic regression analyses determined several variables were associated with overall morbidity and serious morbidity to include: blood transfusion, older age, sepsis, disseminated cancer, renal failure, higher American Society of Anesthesiology class and dependent functional status. After covariate adjustment, overall morbidity did not differ significantly between PVP and TURP (odds ratio 0.9, 95% confidence interval 0.76–1.08), but a significant association remained for serious morbidity (odds ratio 0.49, 95% confidence interval 0.36–0.68, Po0.001; Table 3). Length of stay was significantly shorter for PVP than for TURP (0.9 vs 2.4 days, Po0.001). With respect to trainee involvement, there were no differences in 30-day outcomes in overall and serious morbidity, mortality, pneumonia, and bleeding, when comparing PGY 1–9 with attending alone (Figure 1). No significant differences were noted in the complication rates among the different levels of experience when comparing resident-level trainees to fellow-level trainees. The PGY 1–2, PGY 3–5 and PGY 6–9 subgroups were similar with respect to 30-day outcomes in these categories with no significant differences noted in the complication rates among the different levels of experience. Operative times were also analyzed among resident subgroups and attending alone performing TURP or PVP. TURP performed only by attending surgeons had significantly shorter operative times (52±34 min, (mean±s.d.); Po0.001, respectively) when compared with TURPs performed by both PGY 1–5 and PGY 6–9 subgroups (68±40 min and 69±31 min, Po0.001). PGY 6–9 had significantly longer PVP operative times (96±56 min, P ¼ 0.003) than PGY 1–2 and PGY 3–5 subgroups (75±38 and 74±36, P ¼ 0.003), while there were no significant differences in operative time between resident subgroups for TURP. Attendings who performed TURP alone were faster than attendings working with trainees (52±34 vs 68±40 min, Po0.001) and trainees operating with the attendings not present, but available (70±37 min, Po0.001). PVP was performed faster by attendings operating & 2014 Macmillan Publishers Limited
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229 Table 1.
Demographics of patients undergoing prostatectomy in ACS NSQIP hospitals (2005–2011)
Variable
TURP CPT ¼ 52601 (n ¼ 4950; 62.7%)
Photovaporization CPT ¼ 52647, 52648 (n ¼ 2943; 37.3%)
P-value
n
%
n
%
Age 17–49 50–64 X65
72 965 3913
1.5 19.5 79.1
36 686 2221
1.2 23.3 75.5
o0.001
Race/Hispanic White Black Hispanic Other
3376 243 373 99
82.5 5.9 9.1 2.4
2248 136 184 65
85.4 5.2 7.0 2.5
0.007
BMI Underweighto18.5 Normal 18.5–o25 Oveweight 25–o30 Obese X30
72 1344 1993 1455
1.5 27.6 41.0 29.9
34 789 1242 837
1.2 27.2 42.8 28.8
0.313
ASA class No disturb Mild disturb Severe disturb Life threat
139 2059 2504 238
2.8 41.7 50.7 4.8
94 1304 1419 124
3.2 44.3 48.2 4.2
0.055
Functional status before surgery Independent Partially dependent Totally dependent Diabetes (on meds) Renal failure
4634 238 33 1033 52
94.5 4.9 0.7 20.9 1.1
2828 87 11 543 29
96.7 3.0 0.4 18.5 1.0
o0.001
Dyspnea At rest Moderate exertion Ascites Alcohol use Current smoker COPD Pneumonia Steroid use Bleeding disorder CHF HTN requiring meds Coronary artery diseasea Peripheral vascular diseaseb Disseminated cancer Weight loss (410% loss in last 6 months) Chemotherapy within 30 days Radiotherapy in last 90 days Neurologic disorderc Preoperative sepsisd Dialysis
48 409 2 103 535 374 0 125 162 42 3138 788 73 64 38 20 10 402 72 30
1.0 8.3 0.0 2.8 10.8 7.6 0.0 2.5 3.3 0.8 63.4 15.9 1.5 1.3 0.8 0.5 0.3 8.1 1.5 0.6
26 270 6 64 297 221 3 53 124 16 1816 526 43 23 16 13 4 241 15 17
0.9 9.2 0.2 2.7 10.1 7.5 0.1 1.8 4.2 0.5 61.7 17.9 1.5 0.8 0.5 0.6 0.2 8.2 0.5 0.6
0.355
Inpatient/outpatient Inpatient Outpatient Transfusione
3319 1631 50
67.1 32.9 1.0
590 2353 10
20.0 80.0 0.3
0.010 0.818
0.059 1.000 0.325 0.965 0.057 0.041 0.034 0.135 0.136 0.025 1.000 0.035 0.262 1.000 0.586 0.932 o0.001 1.000 o0.001 0.001
Abbreviations: ACS NSQIP, American College of Surgeons National Surgical Quality Improvement Program; ASA, American Society of Anesthesiology; BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CPT, current procedural terminology; HTN, hypertension. a History of angina in the month before the index operation, history of myocardial infarction 6 months before the index operation, previous percutaneous cardiac intervention or previous cardiac surgery. b History of revascularization/amputation for peripheral vascular disease and rest pain or gangrene. c Cerebral vascular accident/stroke with or without neurologic deficit, history of transient ischemic attacks, hemiplegia, paraplegia, impaired sensorium, quadriplegia. d Preoperative systemic inflammatory response syndrome or sepsis. e Transfusion of packed red blood cells up to 72 h before surgery. Bold values indicate statistically significant P-value
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230 alone (52±33 min, Po0.001) than by trainees operating in conjunction with attendings (78±43 min, Po0.001) and trainees operating while attendings were not present, yet available (71±33 min, Po0.001). Table 2. Comparison of unadjusted 30-day outcomes for TURP and PVP at ACS NSQIP hospitals (2005–2011) 30-Day outcome
Overall morbidity Serious morbidity Non-serious morbidity SSI Mortality Superficial SSI Deep incisional SSI Organ space SSI Wound disruption Pneumonia Unplanned intubation Pulmonary embolism Failure to wean Renal failure Urinary tract infection Neurologic eventa Cardiac arrest requiring CPR Myocardial infarction Bleedingb DVT Sepsis or septic shock Return to OR
TURP CPT ¼ 52601 (n ¼ 4950; 62.7%)
PVP CPT ¼ 52647, 52648 (n ¼ 2943; 37.3%)
P-value
n
%
n
%
424 198 293
8.6 4.0 5.9
211 55 177
7.2 1.9 6.0
0.029 o0.001 0.883
9 28 5 2 2 2 26 13
0.2 0.6 0.1 0.0 0.0 0.0 0.5 0.3
4 15 1 2 1 2 5 5
0.1 0.5 0.0 0.1 0.0 0.1 0.2 0.2
0.778 0.875 0.422 0.632 1.000 0.632 0.015 0.473
5 3 9 241
0.1 0.1 0.2 4.9
1 2 2 157
0.0 0.1 0.1 5.3
0.422 1.000 0.229 0.366
14 5
0.3 0.1
4 4
0.1 0.1
0.228 0.735
12 88 20 55 109
0.2 1.8 0.4 1.1 2.2
3 14 10 21 43
0.1 0.5 0.3 0.7 1.5
0.192 o0.001 0.709 0.095 0.022
Abbreviations: ACS NSQIP, American College of Surgeons National Surgical Quality Improvement Program; CPR, cardiopulmonary resuscitation; CPT, current procedural terminology; DVT, deep vein thrombosis; OR, operating room; PVP, photoselective vaporization of the prostate; SSI, surgical site infection. a Stroke or cerebrovascular accident, coma lasting 424 h, or peripheral neurological deficit. b Bleeding requiring transfusion from surgical start time to 72 h postoperatively. Bold values indicate statistically significant P-value.
DISCUSSION This study examines the incidence of, and risk factors associated with, 30-day overall mortality and morbidity outcomes of TURP and PVP, utilizing the ACS NSQIP. Trainee involvement and its association with these 30-day postsurgical outcomes and operative times for TURP and PVP were also analyzed. The body of literature comparing TURP to PVP is rapidly expanding, and while there have been several reviews comparing outcomes of these procedures, few have done so on the scale of our study. We confirmed many of the findings demonstrated in previous studies, to include decreased incidence of bleeding requiring transfusion, as well as decreased length of hospital stay for PVP.3,7 The mean duration of hospital stay following PVP in our study was 0.9 vs 2.4 days for TURP. This finding is comparable to other studies but has never been shown before utilizing a standardized, national database with such a large volume of hospitals.3,13 The overall morbidity was similar for both procedures after controlling for comorbidities, which is also consistent with prior studies.3 However, risk-adjusted serious morbidity was greater for TURP, presumably because of more bleeding requiring transfusion and need to return to the operating room, despite PVP patients being more likely to have a bleeding disorder preoperatively. We feel that this finding further strengthens the available data demonstrating the safety of PVP for patients on anticoagulants.7 However, there are several technical variations with respect to both procedures. TURP can be performed with and without bipolar cautery using a resectoscope loop or button. Laser treatments encompass non-contact and contact laser coagulation of the prostate with a variety of approaches, including holmium laser resection of the prostate, holmium laser enucleation of the prostate, transurethral side firing laser ablation or holmium laser ablation of the prostate, as well as photovaporization of the prostate.2 In addition, there are several variations with respect to laser energy source, power setting and laser wavelength. Although there is no specific coding for TURP using bipolar, the current review encompasses laser procedures coded as either ‘non-contact’ or ‘contact’ laser coagulation of the prostate. Despite the perception that many laser procedures have appeared to require more extensive training and experience with a steep learning curve,9,14 mean operating times between PVP and TURP were identical when performed by attending alone in this study. This finding contrasts with multiple other studies, which have demonstrated significantly shorter operating times for
Table 3. Risk-adjusted 30-day postoperative outcomes for TURP vs PVP with respect to resident and fellow involvement at ACS NSQIP Hospitals (2005–2011) Unadjusted OR (95% CI) for TURP vs PVP
Risk-adjusted OR (95% CI) for TURP vs PVP
OR
P-value
OR
P-value
Overall morbidity outcomea All cases Trainee involvement Attending interaction only
1.21 (1.02–1.44) 0.79 (0.52–1.21) 1.31 (1.04–1.64)
0.028 0.281 0.021
1.1 (0.93–1.32) 0.73 (0.47–1.13) 1.23 (0.97–1.56)
0.254 0.156 0.080
Serious morbidity outcomez All cases Trainee involvement Attending interaction only
2.19 (1.62–2.96) 1.16 (0.58–2.33) 2.52 (1.66–3.83)
o0.001 0.673 o0.001
1.08 (1.47–2.79) 2.44 (0.52–2.25) 2.44 (1.58–3.38)
o0.001 0.843 o0.001
Abbreviations: ACS NSQIP, American College of Surgeons National Surgical Quality Improvement Program; ASA, American Society of Anesthesiology; BMI, body mass index; CI, confidence interval; OR, odds ratio; PVP, photoselective vaporization of the prostate. Overall morbidity adjusted for age, renal failure, history of chronic obstructive pulmonary disease, ASA class, disseminated cancer, transfusion, bleeding disorder and functional status. Serious morbidity adjusted for all of the above in addition to BMI and weight loss. a Interaction P-value ¼ 0.039 unadjusted and 0.037 adjusted. zInteraction P-value ¼ 0.160 unadjusted and 0.137 adjusted. Bold values are highlight statistically significant P -value.
Prostate Cancer and Prostatic Disease (2014), 227 – 232
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231
Figure 1. Thirty-day postsurgical outcomes for TURP and photoselective vaporization of the prostate (PVP) using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), 2005–2011. In these categories, there were no statistically significant differences appreciated between trainees and attendings, P40.05.
TURP.8,13,15 Whether this reflects increasing surgeon familiarity with PVP or a difference in gland size is difficult to elucidate as there are no data regarding gland size in the current review. Evolution in technology and technique may also account for shorter operating times as well—that is, with the introduction of the holmium laser and transurethral soft tissue morcellators, which permit complete enucleation of the median and both lateral lobes en bloc.16,17 As expected, operative times for both TURP and PVP were significantly longer when a trainee was involved. The influence of trainee involvement in surgical outcomes has been well documented.18,19 With the exception of a small single institution review of trainee involvement in PVP performed in ambulatory surgical centers, we believe this is the only study to compare the influence of trainee involvement on outcomes with regard to these specific procedures on a large scale.20 Despite longer operative times with trainee involvement, there was no increased incidence of adverse outcomes when trainees were involved. We also found that there was no significant difference in morbidity based upon training level—suggesting these procedures are generally safe even when performed by junior residents. This finding contrasts with results from the general surgery literature, which have demonstrated that trainee involvement is frequently associated with increased morbidity.18,19 When examining operative times with respect to training level, we failed to appreciate any considerable improvement in operating room times, and found that the fellow subgroup had significantly longer operating room times than the PGY 1–5 group. Although it is unlikely that fellow-level trainees are actually slower in the operating room than junior-level residents, this highlights limitations of this study—in that there is no accounting for the extent of attending involvement, or gland size and case difficulty—all factors that likely contributed to this finding.
significance. Therefore, subtle differences that are discovered need to be evaluated with a critical eye. In addition, the ACS NSQIP variables are standardized in the database and therefore do not allow for procedure-specific outcomes of interest, such as the incidence of transurethral resection syndrome. However, the benefit of using normal saline instead of hypo-osmotic irrigation fluid during prostate resection is well known. CONCLUSIONS Using a risk-adjusted, nationally standardized surgical clinical database collection system, we evaluated the 30-day outcomes of almost 8000 patients undergoing surgery for BPH from 2005 to 2011. Specifically, we analyzed how these outcomes are impacted by the involvement of surgical residents and fellows. To our knowledge, this represents the first usage of the ACS NSQIP database to evaluate resident and fellow involvement relating to TURP and PVP, as well as the largest study comparing these two procedures in the literature. We conclude that PVP appears to be a slightly safer procedure with respect to 30-day outcomes, with less serious morbidity and bleeding as well as shorter length of hospital stay regardless of resident or fellow involvement with the case. Although operative times are longer when a trainee is involved in both TURP and PVP, there is no increased risk of adverse events in either procedure. This is an important aspect to consider as surgical educators strive to balance providing safe patient care with realistic surgical training. Although these procedures are generally safe, future morbidity may be diminished with increased awareness of potential complications, standardized competency assessment of trainees and strong mentorship from experienced attending surgeons. CONFLICT OF INTEREST The authors declare no conflict of interest.
Limitations One of the strengths of the ACS NSQIP is its generalized and standardized variable collection system. However, owing to this quality, we lose the ability to evaluate disease-specific variables of interest, that is, gland size and previous BPH operation. Furthermore, qualitative and quantitative peri-operative data important for long-term management are not included into the database, such as urine flow rates or the patient international prostate symptom score questionnaire; albeit NSQIP is designed for review of 30-day postoperative outcomes. Also, it does not quantify the extent of resident involvement. The robust sample size of the ACS NSQIP has the potential for over interpretation, lending statistical significance to findings, but perhaps not clinical & 2014 Macmillan Publishers Limited
ACKNOWLEDGEMENTS We are appreciative of the Tripler Army Medical Center NSQIP Surgical Clinical Nurse Reviewer, Melanie S Alano, BSN, PHN, LNC, for her assistance throughout this project.
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