Just as with other elective surgical procedures, outcomes for men who undergo surgery for benign prostatic hyperplasia (BPH) may differ by the day of the week that the surgery is performed.
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In a new retrospective review of data for nearly 3,000 men who underwent first-time BPH operations by high-volume Cleveland Clinic surgeons over a 15-year period, lower rates of repeat urologic operations and of subsequent diagnoses of urinary tract infections were found for surgeries on Fridays compared to Mondays.
“There appears to be some variability by day of the week for BPH treatment outcomes. The exact driving factors underlying this are unclear but definitely warrant investigation so we’re able to achieve consistency throughout the week,” says co-investigator Bradley C. Gill, MD, MS, staff in the Glickman Urological and Kidney Institute.
Unpacking theories about variability in outcomes
Dr. Gill reported the findings in a poster at the 2019 annual meeting of the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Variability in surgical outcomes by day of the week has been reported for non-emergent surgeries in other surgical fields, but this is the first time the issue has been examined in urology. Also, the current study controlled for surgeon and surgical experience, which has not been done in most prior studies.
Although the reasons for the variation aren’t known, there are theories.
“One hypothesis is that surgeons may book easier cases on Friday. Heading into the weekend, when hospitals and health systems are not fully staffed, one may not want to do an overly complex case that could require intensive postoperative care,” Dr. Gill speculates.
At the same time, surgeons might book more challenging cases on Monday, anticipating that patients might need to be hospitalized for the week.
“One limitation of the dataset is that we don’t have information on prostate size or duration of surgery,” he notes.
The study involved a total of 2,932 men who underwent first-time transurethral resection of the prostate and laser prostatectomy for BPH during 2001-2016 by high-volume surgeons (>75 procedures total) across Cleveland Clinic health system.
The number of BPH procedures was higher on Mondays (746), Tuesdays (778), and Fridays (728) than on either Wednesdays (338) or Thursdays (342).
Dr. Gill and colleagues performed a multivariate analysis accounting for patient age, smoking, alcohol abuse, type 2 diabetes, coronary artery disease, hypertension, chronic obstructive pulmonary disease, asthma, stroke, peripheral vascular disease, surgeon experience and procedure type.
Using Mondays as the reference, significant differences were found from other days of the week for two outcomes. Subsequent endoscopic surgeries were significantly less likely for initial procedures performed on Tuesdays (odds ratio 0.68, p=.02) and Fridays (0.66, p=0.01), and were over twice as likely for initial procedures done on Wednesdays (2.16, p<0.01).
And subsequent diagnoses of urinary tract infections were significantly less common when the BPH procedures were performed on Fridays compared to Mondays (0.73, p=0.01).
There were no statistically significant differences in length of stay greater than one day, subsequent development of overactive bladder, or 30-day mortality.
Dr. Gill points out that there could be multiple factors contributing to this phenomenon, some of which may be institution-specific. These include scheduling practices, presence or absence of trainees on certain days, or other personnel issues.
Clinical data may clarify findings
Clinical data on case characteristics and prostate specifics, not available from this analysis, could prove revealing, he believes.
“I think that’s where you would see some really interesting things. For example, if all the big prostates are done on a certain weekday, that could explain it.”
Dr. Gill plans to publish the results this year.
“It really is a thought-provoking study. For us it serves as a motivator to dive into our outcomes to find out what drives the variability and learn how we can raise the bar to make sure that we have excellent outcomes across every day of the week.”