BJU International

(2002),

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© 2002 BJU International

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doi:10.1046/j.1464-4096.2002.02906.x

Blackwell Science, LtdOxford, UKBJUBJU International1464-4096BJU International

902906

RADICAL PROSTATECTOMY IN BRITAIN AND IRELANDS. RAVICHANDRAN

et al.10.1046/j.1464-4096.2002.02906.x

Original Article420423BEES SGML

Accepted for publication 10 May 2002

Radical prostatectomy in Britain and Ireland at the millennium

S. RAVICHANDRAN, P. DASGUPTA* and C.M. BOOTH†

Preston Royal Hospital, Preston, Lancs, *Guy’s Hospital, London, and †Colchester General Hospital, Colchester, Essex, UK

Objective

To report a national questionnaire survey of allconsultant urologists, providing a ‘snapshot’ of atti-tudes, current practice and referral patterns for radicalprostatectomy (RP) in Britain and Ireland at themillennium.

Methods

During 1999/2000 a simple questionnaireabout RP was sent to the 487 urologists registered asfull BAUS members. From 418 (86%) returns ninewere excluded, to leave a study group of 409 urologists.

Results

In all, 157 (38%) consultants were undertakingRP, whilst 252 (62%) were not; 29 (18.5%) performed

>

20 operations/year, 44 (28%) undertook 11–20, but84 (53.5%) carried out

≤

10. During the survey period,

741 (51%) RPs were conducted in teaching hospitalsand 724 (49%) in district general hospitals. Of the 252not undertaking RP, 23 (9%) stated they wished tolearn the technique.

Conclusions

This questionnaire suggests that the numberof urologists undertaking RP in the UK and Irelandhas stabilized but confirms that over half perform

£

10/year; outcome data are now required. Any changetowards concentrating cases will have significant con-sequences for patient distribution and resources.

Keywords

radical prostatectomy, questionnaire, UK,practice

Introduction

In 1997 a report indicated that fewer than 20 urologistsin the UK had the necessary experience to undertakeradical prostatectomy (RP) [1] but shortly after, aquestionnaire-based study from Donovan

et al.

[2] indi-cated that most consultant urologists in the UK were offer-ing radical treatments to their patients with localizedprostate cancer. Younger patients were more likely to beoffered RP, while the older ones more likely to be offeredradical radiotherapy. Unfortunately only 244 consultantsresponded to the questionnaire and only 98 had per-formed RP; of these, only 12 of 244 (5%) performed

≥

20 RPs/year. It was not clear from that study whetherthe consultants undertaking fewer than 20 RPs/year, i.e.86 (35%), were merely offering the treatment to theirpatients or undertaking the procedure infrequently. Inan editorial accompanying this questionnaire survey,Emberton suggested that the procedure is probably beingconcentrated in a few hands [3], but recent audits fromthe Oncology Section of the BAUS suggest otherwise [4].We therefore conducted a national questionnaire surveyof all consultant urologists to provide a snapshot of atti-tudes, current practice and referral patterns for RP inBritain and Ireland at the millennium.

Methods

During 1999/2000 a simple questionnaire (Appendix)was sent to all consultant urologists registered as fullmembers of the BAUS. This initially resulted in a 70%response rate and the results were presented at the BAUSannual meeting in June 2000 [5] where there was a con-sensus recommendation to re-poll the remaining 30% notresponding, before collating the final data.

Results

Of 487 questionnaires sent, 418 (86%) were returnedafter the second poll (Table 1). Nine returns were fromurologists who had retired (four), were not clinically active(three), or who had a paediatric practice (two), and thesewere excluded. This left a study group of 409 urologistspractising adult clinical urology; 157 (38%) were per-forming RPs while 252 (62%) were not, and 1465 RPswere recorded during the 12-month study period, ofwhich 741 (51%) were in teaching hospitals and 724(49%) in district general hospitals.

The distribution of RPs/year among the 157 urologistsundertaking RP is shown in Table 1, and the geographicallocation of centres undertaking

>

20 RPs/year is shown inFig. 1; Table 1 also shows the number using each route.The referral patterns among the 252 not undertaking RPare also shown; nine urologists (4%) did not believe thatthere was a case for RP and hence did not refer their

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patients for this operation. At present, 23 (9%) urologistswho do not undertake RP stated they were keen to learnand practise it in future.

Discussion

In recent years the popularity of RP has increased rapidlyin Europe, but it remains a technically difficult major op-eration carrying a significant morbidity and occasionalmortality [5]. Furthermore, it has still not been confirmedto be superior to alternative treatments in adequate clini-cal trials. Perhaps for these reasons it has been argued thatRP should be restricted to only a few centres carrying outmany procedures. However, this survey shows that whilethe number of operations seems to be evenly distributedbetween teaching and district general hospitals, only 18%of urologists undertaking RP are doing > 20 procedures/year, with more than half doing

≤

10.In a similar unpublished survey in 1995 (Booth CM and

Sheriff M, Radical prostatectomy in Britain and Ireland1995) a third of British urologists were performing RP anda third intended to start, compared with currently 38%using RP and 62% not, of whom only 9% still intend tostart. These latest values suggest a stabilization in thenumber of urologists using RP and of centres sufficient fora meaningful audit of outcomes, essential if the conceptsof ‘cancer centres’ are to be confirmed and there are tobe comparisons with other methods of treatment. Auditsmight also examine other issues of quality in the supportservices, e.g. in specialist uroradiology and uropathology,as well as surgical training opportunities. However, anysignificant change towards a concentration of cases in

such centres would have clear resource and clinical-practice implications for those using RP, those not, andtheir departments.

Finally, the results of this survey can be usefully collatedwith data from the BAUS Oncology Section [4] to completethe picture of RP in Britain and Ireland at the millennium,and establish baselines for the future.

References

1 Chamberlain J, Melia J, Moss S, Brown J. The diagnosis, man-agement, treatment and costs of prostate cancer in Englandand Wales.

Health Technol Assess

1997;

1

(3)2 Donovan JL, Frankel SJ, Faulkner A, Selley S, Gillat D, Hamdy

FC. Dilemmas in treatment early prostate cancer. the evidenceand a questionnaire survey of consultant urologists in theUnited Kingdom.

BMJ

1999;

318

: 299–3003 Emberton M. What urologists say they do for men with pros-

tate cancer.

BMJ

1999;

318

: 2764 BAUS Section of Oncology. Minimum Data Sets 2000. Novem-

ber 20015 Ravichandran S, Dasgupta P, Booth CM. Radical prostatec-

tomy – current practice in Britain and Ireland.

BJU Int

2000;

85

(Suppl. 5): 636 Walsh PC. Anatomic radical prostatectomy. evolution of the

surgical technique.

J Urol

1998;

160

: 2418–24

Authors

S. Ravichandran, MS, MCh, FRCS(Ed), Senior House Officer.P. Dasgupta, MSc(Urol), FRCS(Urol), Specialist Registrar.C.M. Booth, MBBS, FRCS, Consultant Urologist.Correspondence: C.M. Booth, Department of Urology, ColchesterGeneral Hospital, Colchester, Essex CO4 5JL, UK.e-mail: marie.taylor2@essexrivers.nhs.uk

Abbreviations:

RP

, radical prostatectomy.

Table 1

The results of the survey

Questions N (%)

Those performing RP

157 (38)1a. retropubic route 145 (92.5)1b. perineal route 5 (3.0)1c. both routes 7 (4.5)Subtotal 157 (100)1d. operations/surgeon per year> 20 29 (18.5)11–20 44 (28.0)1–10 84 (53.5)Total RPs 1465

Those not performing RP

252 (62)1e. refer in own unit 126 (50)1f. refer to regional unit 106 (41)refer to both 12 (5)3b. do not believe in RP 9 (4)Subtotal 252 (100)4. Intend to learn RP 23 (9)Overall total 409 (100)

Fig. 1.

Centres undertaking

>

20 RPs/year.

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Appendix

The questionnaire sent to 487 BAUS Full Members1. Do you personally perform radical prostatectomy?IF YESa. Retropubic prostatectomy? [Y], [N]b. Perineal prostatectomy? [Y], [N]c. Both? [Y], [N]d. Number in last 12 months? . . . . . . . . . . . . .IF NOe. Do you refer potential cases within your unit? [Y], [N]f. Do you refer potential cases to another centre? [Y], [N]g. If so, which centre . . . . . . . . . . . . .2. How many have you referred in the last 12 months?. . . . . . . . . . . . .3. If the answer to Q2 is ‘none’, is it . . .a. because you do not see such patients in your practice[Y], [N]b. because you are not convinced by the case for radicalprostatectomy? [Y], [N]Do you intend to start doing radical prostatectomy? [Y],[N]

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Original ArticleBEES SGML

Editorial comment

This questionnaire-based paper reports that although38% of BAUS consultants now perform RP, only 7% ofthe consultant workforce are undertaking

>

20 RPs/year,while 20.5% do fewer than 10, with nine consultants notbelieving in the operation. With the imminent publicationof NICE guidelines, the ‘numbers game’ has been well andtruly placed under the spotlight, and many urologists areconcerned that in the near future they might be excludedfrom having free license to undertake the occasional RP.Is it right that on the basis of numbers alone there is a rea-son for resources to be concentrated amongst a selectedfew, and do large numbers automatically guarantee aquality outcome for the patient?

Of all the organs that urologists operate on, the ana-tomical location of the prostate and the cancer within issuch that the margin for technical error is small. RP isundoubtedly technically challenging surgery, with sig-nificant potential for morbidity [1] and even in ‘experi-enced hands’ (as our colleagues in North America haveshown), outcomes are highly variable between com-munity [2] and university-based sub-specialized urologists[3,4]. However, even the latter are constantly workingtowards technical adjustments to reduce positive marginsand morbidity [3]. Earlier diagnosis with the present useof PSA assay has further fuelled these changes. The lureof fewer surgeons undertaking more cases is strong indeed,for there is the prospect of reducing variability of outcomesand morbidity, but unfortunately numbers alone do notguarantee excellent outcomes for most patients, as they

cannot compensate for a lack of sub-specialist training.Quality outcomes can only be founded first on the bedrockof formal training and systems of constant audit, and sec-ond on the efficient working of a multidisciplinary teamthat enhances the patient’s journey from diagnosis to fol-low-up, refines patient selection, and engages in clinicalresearch for contentious areas of clinical practice.

The training of individual sub-specialist surgeonsrequires formal theoretical and anatomical education ofmale pelvic anatomy (both normal and common variants)and imaging techniques (e.g. TRUS). It requires observa-tion of experienced sub-specialists (sabbaticals and travel-ling fellowships), didactic teaching of technique andsalvaging of complications in the ‘Masterclass’ context,followed by a formal training in a clinical apprenticeshipprogramme (fellowship), and finally, mentoring whilegaining experience. This rigorous and comprehensive pro-cess requires that training centres have a sufficient case-load (which is where the numbers are important) andthose undertaking fewer cases would do well to develop anassociation with such a centre for the purposes of regularbench-marking and multidisciplinary working. Anational programme of investment in such centres (co-ordinated with the Cancer Network, Cancer ServicesCollaborative, Postgraduate Deanery, STC and the BAUSSection of Oncology) for both human and hardwareresources, is badly needed now, for this will provide thenucleus for the dissemination of clinical and technicalexpertise, and the expansion of accrual into multi-centrenational and international clinical trials.

Through the aegis of the local cancer network, the sub-specialist prostate cancer team should be actively engagedin analysing and eliminating inefficiencies from thepatient journey, as well as developing local practice guide-lines for all stages of that journey. At the same time sys-tems for independently evaluating outcomes must be putinto place to assure quality in key indicators like surgicalmargins, transfusion rates, morbidity rates, the number ofpatients requiring secondary salvage therapy after failureof primary surgery, etc. This requires an audit of the indi-vidual surgeon and unit, with regular regional andnational bench-marking; once this can be achieved wewill be in a position to establish realistic NICE guidelines,to adopt new techniques, and to identify those who wouldbenefit from a period of re-training and further mentoring.

This paper reminds us how much work is yet to be doneif we are to meet the challenge of improving the clinicaloutcomes for patients across the board and establish aplatform for meaningful cross-disciplinary translationalbasic science research.

A. PatelConsultant Urological Surgeon, Department of Urology,

St Mary’s Hospital, London, UK

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1 Lu-Yao GL, McLerran D, Wasson J, Wennberg JE. An assess-ment of radical prostatectomy. Time trends, geographic vari-ation, and outcomes. The Prostate Patient Outcomes ResearchTeam.

JAMA

1993;

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: 2633–62 Fowler FJ Jr, Barry MJ, Lu-Yao G, Roman A, Wasson J,

Wennberg JE. Patient-reported complications and follow-uptreatment after radical prostatectomy. The National Medicare

Experience: 1988-1990 (updated June 1993).

Urology

1993;

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: 622–93 Walsh PC. Radical prostatectomy for localized prostate cancer

provides durable cancer control with excellent quality of life:a structured debate.

J Urol

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: 1802–74 Catalona WJ, Ramos CG, Carvalhal GF. Contemporary results

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