Figure. Number of robotic vs open radical prostatectomies per urologist per year. RALP indicates robotic-assisted laparoscopic prostatectomy.

Although many aspects of the radical prostatectomy have changed over the past 40 years,¹ it remains a complex and challenging procedure. Many studies have demonstrated that more extensive surgical experience and higher prostatectomy volumes are associated with better overall survival, fewer complications, and improved patient functional outcomes.^2-4 Yet, a prior assessment found that the majority of surgeons performing radical prostatectomy in the US did less than 10 of them each year.⁵ Many things have changed over the past 10 years, including the utilization of advanced imaging to detect metastatic disease, broadened criteria for active surveillance, widespread diffusion of robotic surgery, and changing prostate cancer screening recommendations. However, the current practice patterns of radical prostatectomy have not been well characterized, and real-world evidence of contemporary national trends is lacking.

We sought to evaluate the average number of radical prostatectomies performed per surgeon per year over time. Using the AUA Quality (AQUA) Registry, we measured the proportion of robotic-assisted laparoscopic prostatectomies compared to open radical prostatectomies (ORP) performed per urologic surgeon per year. Surgeons were included if they performed at least 1 prostatectomy and had more than 10 separate outpatient encounters in the corresponding year in the AQUA Registry from 2014-2021.

Over the 8-year period, the average number of radical prostatectomies per year remained relatively steady, ranging from 8.7-13.9 prostatectomies per surgeon per year (see Figure). The average number of ORP per surgeon has also remained relatively steady, ranging from 2.3-4.7 ORP per surgeon per year. In our cohort of surgeons in the AQUA Registry, the proportion of surgeons performing open vs robotic prostatectomies has declined every year, from 46% in 2014 to 23% in 2021. With respect to volume, 60% of urologists performing a radical prostatectomy will do fewer than 5 prostatectomies per year, and 30% will do only 1 prostatectomy per year. Only 20% of surgeons in the AQUA Registry performing prostatectomies do 15 or more prostatectomies per year. The percentage of prostatectomies performed per year with a robotic approach compared to the total number of prostatectomies increased from 83% in 2014 to 94.8% in 2021.

There are several notable findings from this analysis. First, the large majority of urologists performing prostatectomies have low annual volumes. These data confirm and expand on the study by Savage et al,⁵ which looked at data from a single year in 2005 in New York State, whereas the AQUA Registry provides data from more than 200 practices and 2,100 urologists around the country. Second, there has been a dramatic decrease in the proportion of AQUA urologists performing ORP during the study period. Potentially hastened by the retirement of older surgeons during the COVID-19 pandemic, this decrease likely reflects a more general trend since the adoption of robotic surgery. While robotic-assisted laparoscopic prostatectomy accounts for 80%-90% of all prostatectomies performed in this nationwide quality data registry, the percent of surgeons still doing ORP has dropped significantly and continues to decrease. This change in practice patterns has significant implications on access to surgeons comfortable with open procedures, residency training, and competency as robotic procedures become more prevalent in residency, and health care policy, where the constant pressures to improve outcomes and efficiency need to consider regionalization and reduced access. Although our analysis is limited by potential selection bias for only those urologists included in the AQUA Registry, this is the largest national quality registry in urology across multiple geographic and practice settings. Future analyses with the AQUA Data Registry will examine how these trends vary by region and surgeon characteristics and ultimately impact patient —outcomes.