Understanding variation in the quality of the surgical treatment of prostate cancer.

More than 80% of men with prostate cancer undergo active treatment, which can be associated with significant morbidity. Outcomes of surgical treatment vary widely depending on who treated the patient and where the patient was treated, implying that there is room for improvement. Factors influencing outcomes include patient characteristics as well as some measure of procedure volume. Although relationships between volume and outcomes for prostatectomy can most likely be explained by differences between surgeons (e.g., experience, technical skill), the hospital environment (e.g., team communication, safety culture) has the potential to either amplify or dampen the effects. Although most patient factors are immutable, these other aspects of surgical care and the delivery environment provide opportunities for quality improvement. Collaborative quality improvement initiatives may prove to be an important vehicle for achieving better prostate cancer care. These grass roots organizations, driven largely by urologists dedicated to providing prostate cancer care, have had initial successes in improving some aspects of quality in prostate cancer care, including reducing unwarranted use of imaging and perioperative morbidity. However, much of the variation in functional outcomes after prostate cancer surgery arises from differences in technical skill. Evaluating and improving intraoperative surgeon performance will inevitably be challenging, as they require acquisition and interpretation of data collected in the operating room. To this end, several methods have been described to objectively assess what happens in the operating room.