The role of surgical margins as outcome metrics in a quality assurance program for robot-assisted radical prostatectomy.

BACKGROUND

Positive surgical margins (PSMs) serve as outcome metrics after robot-assisted radical prostatectomy (RARP) and are frequently used in quality assurance programs (QAPs). Despite their central role as a quality indicator, the prognostic significance of PSMs remains debated, and limited research examines how clinicians actually interpret and use this metric within QAPs. This qualitative study explores how urologists collectively interpret and use PSM metrics within a regional prostate cancer QAP and considers the implications for quality improvement and clinical collaboration.

METHODS

We conducted a qualitative study examining how urologists interpret and use PSMs within the Prostate Cancer Network Netherlands. We audio-recorded 12 monthly QAP meetings and completed structured fieldnotes. Semi-structured interviews were conducted with all six participating RARP urologists. Transcripts and fieldnotes were analyzed using the Gioia-method.

RESULTS

Positive surgical margins operated in three interconnected ways within QAPs. First, as quality improvement instruments: they shaped clinical interpretation by helping urologists balance oncological control and functional outcomes, while supporting peer learning, knowledge sharing, and alignment across hospitals. Second, as vehicles of professional legitimation: they helped justify QAP to administrators, patients, and peer institutions. Third, as instruments of power and positioning: they enabled professional differentiation and ranking but were contested in their definition, sometimes reinforcing hierarchy or competition. Across all three themes, PSMs were not neutral outcome metrics but active forces shaping quality assurance practices and professional relations.

CONCLUSION

Understanding how PSMs operate in practice reveals their multifaceted role beyond quality measurement, where they could simultaneously serve as tools for clinical interpretation, legitimation vehicles, and instruments of professional power.