Health Outcomes Research Annual Prostatectomy Volume Is Related to Rectal Laceration Rate After Radical Prostatectomy Jan Schmitges, Quoc-Dien Trinh, Maxine Sun, Firas Abdollah, Marco Bianchi, Lars Budäus, Jens Hansen, Christian Eichelberg, Paul Perrotte, Shahrokh F. Shariat, Mani Menon, Francesco Montorsi, Markus Graefen, and Pierre I. Karakiewicz OBJECTIVE To examine the effect of annual prostatectomy volume (APV) on contemporary intraoperative rectal laceration (RL) rates after radical prostatectomy. METHODS From 1999 to 2008, 36 699 radical prostatectomy procedures were performed in Florida. First, logistic regression models predicting the RL rate were fitted. Second, other logistic regression models were used to examine the association between RL and 2 other secondary outcomes: prolonged length of stay (3 days) and increased hospital charges ($37 621). The covariates included APV quintiles, surgical approach (minimally invasive vs open radical prostatectomy), lymph node dissection status, age, year of surgery, race, and baseline Charlson comorbidity index. RESULTS The overall RL rate was 0.7%. The RL rate was 0.3%, 0.6%, 0.7%, 0.9%, and 1.0% for the very high, high, intermediate, low, and very low APV quintiles, respectively (P  .001). In multi- variate analyses predicting RL, patients treated by intermediate (odds ratio 2.39, P = .003), low (odds ratio 2.95, P  .001), and very low (odds ratio 3.26, P  .001) APV surgeons had a greater likelihood of experiencing an RL relative to patients treated by very high APV surgeons. Second, in the multivariate analyses, patients with a RL were 9.1-fold more likely to have a prolonged length of stay (P  .001) and were 3.4-fold more likely to have increased total hospital charges (P  .001). CONCLUSION A greater APV exerts a protective effect on RL rates. Additionally, RL increases the length of stay and hospital charges. UROLOGY 79: 796 – 803, 2012. © 2012 Elsevier Inc. P rostate cancer is the second leading cause of cancer mortality in the United States, and radical prosta- tectomy (RP) is the most common treatment op- tion for clinically localized disease in appropriately se- lected patients. 1 Rectal laceration (RL) during RP converts the case from clean contaminated to contami- nated and thereby predisposes the patient to abscess, rectourethral fistula, and sepsis. Strategies aimed at de- creasing the morbidity of RL consist of preoperative bowel preparation, perioperative antibiotic prophylaxis, intraoperative repair with or without omental interposi- tion between the rectum and vesicourethral anastomosis, and diverting colostomy. 2,3 Moreover, RL during RP can increase the hospital length of stay (LOS) and total hospital charges. A recent report estimated that the rate of RL in open and laparoscopic RP patients ranges from 0.4% to 1.8%. 4 Several risk factors have been shown to increase the risk of RL after RP, including previous prostate or rectal surgery, 5 previous radiotherapy, 6 and a perineal approach. 7,8 To date, the effect of the annual RP volume (APV) on RL has not been examined. To address this limitation, we tested the effect of APV on RL rates within a large population-based cohort undergoing either open or minimally invasive RP (MIRP) in the United States. Because RL can predispose to in-hospital mortal- ity, 9 increased hospital charges, and increased LOS, we also tested the effect of RL on these 3 additional end- points. MATERIAL AND METHODS Data Source We relied on the 1999-2008 Florida Hospital Inpatient Datafile, which provides medical record information from hospital ad- Funding Support: J. Schmitges was supported by the German Federal Ministry of Education and Science in the framework of the program for medical genome research (grant FKZ 01GS08189). From the Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany; Cancer Prognostics and Health Outcomes Unit and Department of Urology, University of Montréal Health Center, Montreal, Quebec, Canada; Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan; Department of Urology, Vita Salute San Raffaele University, Milan, Italy; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Weill Medical College of Cornell University, New York, New York Reprint requests: Jan Schmitges, M.D., Cancer Prognostics and Health Outcomes Unit, University of Montréal Health Center, 1058, Rue Street-Denis, Montreal, QC H2X 3J4 Canada. E-mail: janschmitges@gmx.de Submitted: May 4, 2011, accepted (with revisions): November 15, 2011 796 © 2012 Elsevier Inc. 0090-4295/12/$36.00 All Rights Reserved doi:10.1016/j.urology.2011.11.061