Impact of a multidisciplinary continuous quality improvement program on the positive surgical margin rate after laparoscopic radical prostatectomy

Objective: Outcome after radical prostatectomy is highly sensitive to fine nuances in the surgical techniques. We sought to determine the impact of a process of continuous control and monitoring on the positive surgical margin rate in a contemporary series of laparoscopic radical prostatectomy. Methods: Between January 2003 and October 2004, 301 men underwent laparoscopic radical prostatectomy for clinically localized prostate cancer (cTl-cT3a). A weekly case review conference involving surgeons, radiologists, and uropathologists was held to discuss the preoperative, intraoperative, and pathologic findings of significant cases. We analyzed the trend of positive surgical margins and compared the clinical and detailed pathologic characteristics of the cancer during the study period. Results: We created logistic regression models with positive margin as the dependent variable and surgical experience as the predictor, adjusting for possible secular changes in disease severity (prostate -specific antigen, pathologic stage, and Gleason grade). There was a decrease in the rate of surgical margins: odds ratio 0.68/100 patients treated (95% confidence interval [CI] 0.44, 1.05; p = 0.08). The predicted probability for a positive surgical margin falls from 17.3% for the first patient to 7.5% for the 301st. These values are close to the observed rates for the first and last 50 patients. There was no important change in surgical risk over the course of the study, and the rate of nerve sparing remained stable throughout the study period. Conclusions: in this contemporary series, which is unaffected by downward stage migration, the decreasing rate of positive surgical margins can be explained by subtle surgical technique modifications and a continuous multidepartmental effort for quality improvement. (c) 2006 Elsevier B.V. All rights reserved.