title: Utilization and impact of surgical technique on the performance of pelvic lymph node dissection at radical prostatectomy: Results from the Shared Equal Access Regional Cancer Hospital database.
abstract: OBJECTIVE
  To evaluate performance of pelvic lymph node dissection during radical prostatectomy within an equal access care setting over a period of time, and stratified by prostate cancer risk group and surgical technique.
  
  
  METHODS
  We identified men in the Shared Equal Access Regional Cancer Hospital database who had open or robotic-assisted radical prostatectomy from 2006 to 2013. Univariable logistic regression was used to test the association between age, race, body mass index, total biopsy cores, number of positive biopsy cores, risk group, year, center, surgical volume and surgical technique on pelvic lymph node dissection use. Multivariable logistic analysis was used to examine surgical technique and pelvic lymph node dissection performance. Spearman's correlation examined temporal changes in pelvic lymph node dissection utilization stratified by risk group and surgical technique.
  
  
  RESULTS
  A total of 1425 men met inclusion criteria; 67% of them underwent pelvic lymph node dissection. On multivariable analysis, robotic-assisted radical prostatectomy was associated with an 92% decreased use of pelvic lymph node dissection in low-risk, 84% decreased in intermediate-risk and 91% decreased in high-risk men (all P < 0.001). In robotic-assisted radical prostatectomy, there was a trend for increased pelvic lymph node dissection utilization over time in high-risk men (Spearman; P = 0.077) reaching ~85% in 2012-2013, which was accompanied by increased use in low-risk men (P = 0.016). For open radical prostatectomy, fewer pelvic lymph node dissections were carried out in low-risk men over time, decreasing to ~35% (P = 0.047) in 2012-2013, whereas rates remained high for high-risk men throughout (~95%; P = 0.621).
  
  
  CONCLUSIONS
  Regardless of risk group, pelvic lymph node dissection is carried out significantly less during robotic-assisted radical prostatectomy. For robotic-assisted radical prostatectomy, pelvic lymph node dissection utilization increased over time for high-risk men, but rates also increased for low-risk men. Further attention to the discrepancy between provided and guideline recommended pelvic lymph node dissection performance is required to improve prostate cancer care.
authors.affiliation: Division of Urology, Department of Surgery, Duke University, Durham, North Carolina, USA.|Division of Urology, Department of Surgery, Veterans Affairs Medical Center, Durham, North Carolina, USA.
authors.forename: Kathleen F
authors.initials: KF
authors.lastname: McGinley
authors.affiliation: Division of Urology, Department of Surgery, Veterans Affairs Medical Center, Durham, North Carolina, USA.|Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA.
authors.forename: Xizi
authors.initials: X
authors.lastname: Sun
authors.affiliation: Division of Urology, Department of Surgery, Veterans Affairs Medical Center, Durham, North Carolina, USA.|Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA.
authors.forename: Lauren E
authors.initials: LE
authors.lastname: Howard
authors.affiliation: Urology Section, Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.|Department of Urology, UCLA School of Medicine, Los Angeles, California, USA.
authors.forename: William J
authors.initials: WJ
authors.lastname: Aronson
authors.affiliation: Section of Urology, Veterans Affairs Medical Center, Augusta, Georgia, USA.|Department of Urology, Georgia Regents University, Augusta, Georgia, USA.
authors.forename: Martha K
authors.initials: MK
authors.lastname: Terris
authors.affiliation: Urology Department, University of California San Diego Health System, San Diego, California, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Kane
authors.affiliation: Department of Urology, Oregon Health and Science University, Portland, Oregon, USA.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Amling
authors.affiliation: Department of Urology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Cooperberg
authors.affiliation: Division of Urology, Department of Surgery, Veterans Affairs Medical Center, Durham, North Carolina, USA.|Division of Urology, Department of Surgery, Samuel Oschin Comprehensive Cancer Center, Cedars Sinai Medical Center, Los Angeles, California, USA.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Freedland
mesh_terms: D000368:Aged; D002173:Cancer Care Facilities / Q000706:statistics & numerical data; D016208:Databases, Factual; D006755:Hospital Shared Services; D006801:Humans; D016015:Logistic Models; D008197:Lymph Node Excision / Q000379:methods* / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010388:Pelvis / Q000601:surgery*; D017410:Practice Guidelines as Topic; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D065287:Robotic Surgical Procedures / Q000379:methods*; D014481:United States
keywords: lymph node excision; prostatectomy; prostatic neoplasms; quality of health care; robotic surgical procedures