title: Surgeon experience is strongly associated with biochemical recurrence after radical prostatectomy for all preoperative risk categories.
abstract: OBJECTIVE
  We have previously reported that there is a learning curve for open radical prostatectomy. In the current study we determined whether the effects of the learning curve are modified by patient risk, as defined by preoperative tumor characteristics.
  
  
  METHODS
  The study included 7,683 eligible patients with prostate cancer treated with open radical prostatectomy by 1 of 72 surgeons. Surgeon experience was coded as the total prior number of radical prostatectomies done by the surgeon before a patient surgery. Multivariate survival time regression models were used to evaluate the association between surgeon experience and biochemical recurrence separately in each preoperative risk group.
  
  
  RESULTS
  We saw no evidence that patient risk affected the learning curve. There was a statistically significant association between biochemical recurrence and surgeon experience on all analyses. The absolute risk difference in a patient receiving treatment from a surgeon with 10 vs 250 prior radical prostatectomies was 6.6% (95% CI 3.4-10.3), 12.0% (95% CI 6.9-18.2) and 9.7% (95% CI 1.2-18.2) in patients at low, medium and high preoperative risk. Recurrence-free probability in patients with low risk disease approached 100% for the most experienced surgeons.
  
  
  CONCLUSIONS
  Cancer control after radical prostatectomy improves with increasing surgeon experience irrespective of patient risk. Excellent rates of cancer control in patients with low risk disease treated by the most experienced surgeons suggest that the primary reason that recurrence develops in such patients is inadequate surgical technique. The results have significant implications for clinical care.
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA. kleine@ccf.org
authors.forename: Eric A
authors.initials: EA
authors.lastname: Klein
authors.forename: Fernando J
authors.initials: FJ
authors.lastname: Bianco
authors.forename: Angel M
authors.initials: AM
authors.lastname: Serio
authors.forename: James A
authors.initials: JA
authors.lastname: Eastham
authors.forename: Michael W
authors.initials: MW
authors.lastname: Kattan
authors.forename: J Edson
authors.initials: JE
authors.lastname: Pontes
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Vickers
authors.forename: Peter T
authors.initials: PT
authors.lastname: Scardino
mesh_terms: D000368:Aged; D002983:Clinical Competence; D013502:General Surgery / Q000193:education* / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000097:blood / Q000453:epidemiology; D011300:Preoperative Care; D011468:Prostatectomy / Q000193:education* / Q000706:statistics & numerical data*; D011471:Prostatic Neoplasms / Q000097:blood / Q000601:surgery*; D012307:Risk Factors