Venous thromboembolism after radical prostatectomy: the effect of surgical caseload

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Several risk factors increase VTE after RP: advanced age, comorbidities such as cardiopulmonary disease, rheumatologic diseases, prior history of VTE, more advanced prostate cancer, and simultaneous pelvic lymph node dissection. To date, the effect of annual surgical caseload (ASC), an established determinant of various RP outcomes, has not been tested. A previous study showed in adjusted analyses that patients operated for colorectal cancer by very high ASC surgeons were 60% less likely to suffer a VTE than those operated by low ASC surgeons. Moreover, some authors hypothesized that laparoscopy may contribute to a higher risk of VTE, due to peritoneal insufflation, reverse Trendelenburg position and prolonged operative time. The VTE rates reported in the current population‐based study closely reflect those reported in institutional series. Moreover, we validated the practice‐makes‐perfect concept, since ASC was linked to VTE. We could not detect statistically significantly differences between minimally invasive radical prostatectomy (MIRP) patients and others. Our results indicate that lower rates of VTE should be expected in patients treated by high ASC surgeons. Our findings suggest that VTE‐specific processes of care need to be improved, with the intent of reaching the level recorded in patients treated by high ASC surgeons. Finally, MIRP seems to be no risk factor for VTE. OBJECTIVE To examine the effect of annual surgical caseload (ASC) on the likelihood of venous thromboembolism (VTE) after radical prostatectomy (RP). PATIENTS AND METHODS Between 1999 and 2008, 36 699 RPs were performed in the state of Florida. Logistic regression models predicting the likelihood of VTE were fitted. Covariates included year of surgery, age, race, baseline Charlson Comorbidity Index (CCI), lymph node dissection, ASC and surgical approach. RESULTS The overall VTE rate was 0.3%. It was higher in patients operated within the low (0.4%) and intermediate (0.3%) ASC tertile than in those operated within the high‐ASC tertile (0.1%, P < 0.001). Mortality rate was 6.0% in patients with VTE vs 0.1% in others ( P < 0.001). Median length of stay and median total hospital charges were 9 vs 3 days ( P < 0.001) and $51 571 vs $24 943 ( P < 0.001) in patients with VTE vs others, respectively. In multivariable analyses predicting VTE, patients operated on by low‐ASC surgeons were at higher risk of VTE than those operated on by high‐ASC surgeons (odds ratio [OR]= 3.78, P < 0.001). Additionally, black patients were more likely to experience a VTE (OR = 1.80, P = 0.023). Patients with CCI ≥ 1 were also more likely to experience a VTE than others (OR = 1.65, P = 0.016). Conversely, patients who had undergone minimally invasive radical prostatectomy were not more likely to experience a VTE than those who had undergone open RP (OR = 1.97, P = 0.086). CONCLUSIONS RP by high‐ASC surgeons exerts a protective effect on the likelihood of VTE. Additionally, VTE is associated with higher mortality, prolonged length of stay and increased hospital charges.