UroToday – In this online publication by Dr. Alberto Briganti and associates that appears in European Urology, the authors hypothesized that surgical volume (SV) is related to the detection rate of lymph node invasion (LNI) in a single-institution cohort of men treated with radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND).

Between 2002 and 2007, 1,020 men undergoing RP with ePLND for clinically localized CaP had their complete clinical and pathologic data analyzed. All patients were treated by one of 6 surgeons, the eldest of whom had the highest SV and the other 5 surgeons who were trained by the senior surgeon. All surgeries were performed using the same surgical approach and ePLND boundaries of dissection. The cumulative number of performed ePLNDs throughout the time range was used to test SV. The association between SV and positive lymph node status was assessed in logistic regression models.

The mean PSA level of the 1,020 patients was 11.4ng/ml, and clinical stages were T1c in 54%, T2 in 38.5% and T3 in 7.5%. Gleason score on biopsy was >6 in 64%, 7 in 25.6%, and 8-10 in 10.1%. Clinical and pathological variables did not differ among patients treated by the 6 different surgeons. Despite the use of the same ePLND template, the most senior surgeon had a statistically higher detection rate of LNI and a significantly higher mean number of total lymph nodes and number of positive nodes removed compared to the other surgeons. SV either continuously coded or categorized according to the most informative cut-off (144 procedures) maintained its significant multivariate association with LNI even after accounting for either preoperative or postoperative variables. In all models established, SV was a statistically significant multivariate predictor of LNI. Yet when the number of nodes removed was included in multivariable analysis, no significant association between SV and LNI was found.

Patients treated by high-volume surgeons were more likely to have LNI than those treated by low volume surgeons. However, after accounting for the extent of nodal dissection, the effect of SV on LNI was lost. Therefore, SV was a strong predictor of LNI without nodal counts, but not when the variable coding of the number of lymph nodes removed was included in multivariate analysis.

Briganti A, Capitanio U, Chun FK, Gallina A, Suardi N, Salonia A, Da Pozzo LF, Colombo R, Di Girolamo V, Bertini R, Guazzoni G, Karakiewicz PI, Montorsi F, Rigatti P
Eur Urol 2008;epub

UroToday Contributing Editor Christopher P. Evans, MD, FACS

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