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Laparoscopic radical prostatectomy demonstrates less morbidity than open radical prostatectomy: an analysis of the American College of Surgeons-National Surgical Quality Improvement Program database with a focus on surgical trainee involvement.

INTRODUCTION
Complication rates of open radical prostatectomies (ORPs) and laparoscopic radical prostatectomies (LRPs) performed by highly experienced surgeons in centers of excellence are well known. Using a standardized, national, risk-adjusted surgical database, we compared 30-day outcomes following ORP and LRP and analyzed how trainee involvement influenced outcomes.


METHODS
The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) is a risk-adjusted data collection analyzing preoperative risk factors, demographics, and 30-day postoperative outcomes. From 2005 to 2011, we identified 10,669 total prostatectomies. Of these, 2278 were ORP and 8391 were LRP. Data on trainee involvement were available on 63% of cases.


RESULTS
Comparison of all 10,669 prostatectomies showed a decreased incidence of overall morbidity, serious morbidity, surgical site infections, mortality, wound disruption, urinary tract infection, bleeding, and sepsis or septic shock (p<0.05) for LRP compared with ORP. Trainee involvement was associated with a higher incidence of bleeding, overall and serious morbidity (p<0.001). This difference is isolated to postgraduate year (PGY) 6-10 trainees performing ORP (p<0.001). Overall and serious morbidity was equivalent between PGY groups 1-10 versus attending without trainee performing LRP and PGY groups 1-5 versus attending without trainee performing ORP. Operative times were shorter for ORP versus LRP by an average of 38 minutes (p<0.05), and in cases involving trainees, operative times decreased with trainee experience for both procedures. The length of stay was shorter for LRP compared with ORP (3.2 vs. 1.8 days, p<0.001).


CONCLUSIONS
The large sample size, standardized data definitions, and quality control measures of the ACS-NSQIP database allow for in-depth analysis of subtle, but significant differences in outcomes between groups. Trainee involvement in LRP appears safe to patients. However, the increased morbidity in ORP involving trainees may be mitigated by awareness, simulation laboratories, and standardized competency assessment.