1
|
Edison E, Mazzon G, Arumuham V, Choong S. Prevention of complications in endourological management of stones: What are the basic measures needed before, during, and after interventions? Asian J Urol 2024; 11:180-190. [PMID: 38680580 PMCID: PMC11053336 DOI: 10.1016/j.ajur.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/17/2023] [Indexed: 05/01/2024] Open
Abstract
Objective This narrative review aims to describe measures to minimise the risk of complications during percutaneous nephrolithotomy (PCNL), ureteroscopy, and retrograde intrarenal surgery. Methods A literature search was conducted from the PubMed/PMC database for papers published within the last 10 years (January 2012 to December 2022). Search terms included "ureteroscopy", "retrograde intrarenal surgery", "PCNL", "percutaneous nephrolithotomy", "complications", "sepsis", "infection", "bleed", "haemorrhage", and "hemorrhage". Key papers were identified and included meta-analyses, systematic reviews, guidelines, and primary research. The references of these papers were searched to identify any further relevant papers not included above. Results The evidence is assimilated with the opinions of the authors to provide recommendations. Best practice pathways for patient care in the pre-operative, intra-operative, and post-operative periods are described, including the identification and management of residual stones. Key complications (sepsis and stent issues) that are relevant for any endourological procedure are then be discussed. Operation-specific considerations are then explored. Key measures for PCNL include optimising access to minimise the chance of bleeding or visceral injury. The role of endoscopic combined intrarenal surgery in this regard is discussed. Key measures for ureteroscopy and retrograde intrarenal surgery include planning and technique to minimise the risk of ureteric injury. The role of anaesthetic assessment is discussed. The importance of specific comorbidities on each step of the pathway is highlighted as examples. Conclusion This review demonstrates that the principles of meticulous planning, interdisciplinary teamworking, and good operative technique can minimise the risk of complications in endourology.
Collapse
Affiliation(s)
- Eric Edison
- Department of Urology, University College Hospital London, London, UK
| | - Giorgio Mazzon
- Department of Urology, San Bassiano Hospital, Vicenza, Italy
| | - Vimoshan Arumuham
- Department of Urology, University College Hospital London, London, UK
| | - Simon Choong
- Department of Urology, University College Hospital London, London, UK
| |
Collapse
|
2
|
Ambrosini F, Mantica G, Marchi G, Vecchio E, Col B, Gaia Genova L, Trani G, Ferrari A, Terrone C. Impact of Assistant Experience on Perioperative Outcomes of Simple and Radical Laparoscopic Nephrectomy: Does It Really Matter? MEDICINA (KAUNAS, LITHUANIA) 2023; 60:45. [PMID: 38256306 PMCID: PMC10820043 DOI: 10.3390/medicina60010045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/14/2023] [Accepted: 12/25/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: While systematic reviews highlight the advantages of laparoscopic nephrectomy over traditional open surgery, the impact of an assistant's experience on surgical outcomes remains unclear. This study aims to evaluate whether the level of assistant expertise influences laparoscopic nephrectomy outcomes. Materials and Methods: Retrospective data from our institutional database were analyzed for patients who underwent laparoscopic nephrectomy between January 2018 and December 2022. Procedures were performed by a highly experienced surgeon, including postgraduate year (PGY)-3 to PGY-5 residents as assistants. Senior-level assistants had completed at least 10 procedures. Patient characteristics, surgical outcomes, and postoperative details were collected. Multivariable linear and logistic regression models were performed to test the effect of assistant experience (low vs. high) on estimated blood loss (EBL), length of stay (LOS), operative time (OT), and postoperative complications. Results: 105 patients were included, where 53% had highly experienced assistants and 47% had less experienced ones. Low assistant experience and higher BMI predicted longer operative time (OT), confirmed by multivariable regression (β = 40.5, confidence interval [CI] 18.7-62.3, p < 0.001). Assistant experience did not significantly affect EBL or LOS after adjusting for covariates (β = -14.2, CI -91.8-63.3, p = 0.7 and β = -0.83, CI -2.7-1.02, p = 0.4, respectively). There was no correlation between assistant experience and postoperative complications. Conclusions: Assistant experience does not significantly impact complications, EBL, and LOS in laparoscopic nephrectomy. Surgeries with less experienced assistants had longer OT, but the overall clinical impact seems limited. Trainee involvement remains safe, guided by experienced surgeons.
Collapse
Affiliation(s)
- Francesca Ambrosini
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.A.); (G.M.); (E.V.); (B.C.); (L.G.G.); (G.T.); (A.F.); (C.T.)
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy
| | - Guglielmo Mantica
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.A.); (G.M.); (E.V.); (B.C.); (L.G.G.); (G.T.); (A.F.); (C.T.)
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy
| | - Giovanni Marchi
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.A.); (G.M.); (E.V.); (B.C.); (L.G.G.); (G.T.); (A.F.); (C.T.)
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy
| | - Enrico Vecchio
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.A.); (G.M.); (E.V.); (B.C.); (L.G.G.); (G.T.); (A.F.); (C.T.)
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy
| | - Benedetta Col
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.A.); (G.M.); (E.V.); (B.C.); (L.G.G.); (G.T.); (A.F.); (C.T.)
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy
| | - Luca Gaia Genova
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.A.); (G.M.); (E.V.); (B.C.); (L.G.G.); (G.T.); (A.F.); (C.T.)
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy
| | - Giorgia Trani
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.A.); (G.M.); (E.V.); (B.C.); (L.G.G.); (G.T.); (A.F.); (C.T.)
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy
| | - Arianna Ferrari
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.A.); (G.M.); (E.V.); (B.C.); (L.G.G.); (G.T.); (A.F.); (C.T.)
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy
| | - Carlo Terrone
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (F.A.); (G.M.); (E.V.); (B.C.); (L.G.G.); (G.T.); (A.F.); (C.T.)
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy
| |
Collapse
|
3
|
Pyrgidis N, Schulz GB, Stief C, Blajan I, Ivanova T, Graser A, Staehler M. Surgical Trends and Complications in Partial and Radical Nephrectomy: Results from the GRAND Study. Cancers (Basel) 2023; 16:97. [PMID: 38201523 PMCID: PMC10778168 DOI: 10.3390/cancers16010097] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND We aimed to evaluate the current trends in renal cancer surgery, as well as to compare the perioperative outcomes of partial versus radical nephrectomy. METHODS We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2005-2021). We report the largest study in the field, with 317,843 patients and multiple patient-level analyses. RESULTS Overall, 123,924 (39%) patients underwent partial and 193,919 (61%) underwent radical nephrectomy in Germany from 2005 to 2021. Of them, 57,308 (18%) were operated on in low-, 142,702 (45%) in intermediate-, and 117,833 (37%) in high-volume centers. A total of 249,333 (78%) patients underwent open, 44,994 (14%) laparoscopic, and 23,516 (8%) robotic nephrectomy. The number of patients undergoing renal surgery remained relatively stable from 2005 to 2021. Over the study period, the utilization of partial nephrectomy increased threefold, while radical nephrectomy decreased by about 40%. After adjusting for major risk factors in the multivariate regression analysis, radical nephrectomy was associated with 3.2-fold higher odds (95% CI: 3.2 to 3.9, p < 0.001) of 30-day mortality, longer hospitalization by 1.9 days (95% CI: 1.9 to 2, p < 0.001), and higher inpatient costs by EUR 1778 (95% CI: 1694 to 1862, p < 0.001) compared to partial nephrectomy. Furthermore, radical nephrectomy had a higher risk of in-hospital transfusion (p < 0.001), sepsis (p < 0.001), acute respiratory failure (p < 0.001), acute kidney disease (p < 0.001), acute thromboembolism (p < 0.001), surgical wound infection (p < 0.001), ileus (p < 0.001), intensive care unit admission (p < 0.001), and pancreatitis (p < 0.001). CONCLUSIONS More patients are offered partial nephrectomy in Germany. Patients undergoing radical nephrectomy present with a higher rate of concomitant risk factors and have increased perioperative morbidity and mortality, prolonged hospitalization, and increased in-hospital costs.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Michael Staehler
- Department of Urology, LMU University Hospital, LMU Munich, 81377 Munich, Germany; (N.P.); (G.B.S.); (C.S.); (I.B.); (T.I.); (A.G.)
| |
Collapse
|
4
|
Esdaille AR, Karam JA, Master VA, Spiess PE, Raman JD, Sharma P, Shapiro DD, Das A, Sexton WJ, Zemp L, Patil D, Allen GO, Matin SF, Wood CG, Abel EJ. Contemporary Patients Have Better Perioperative Outcomes Following Cytoreductive Nephrectomy: A Multi-institutional Analysis of 1272 Consecutive Patients. Urology 2023; 182:168-174. [PMID: 37690543 DOI: 10.1016/j.urology.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/12/2023] [Accepted: 08/23/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE To evaluate factors associated with perioperative outcomes in a multi-institutional cohort of patients treated with cytoreductive nephrectomy (CN). METHODS Data were analyzed for metastatic renal cell carcinoma patients treated with CN at 6 tertiary academic centers from 2005 to 2019. Outcomes included: Clavien-Dindo complications, mortality, length of hospitalization, 30-day readmission rate, and time to systemic therapy. Univariate and multivariable models evaluated associations between outcomes and prognostic variables including the year of surgery. RESULTS A total of 1272 consecutive patients were treated with CN. Patients treated in 2015-2019 vs 2005-2009 had better performance status (P<.001), higher pathologic N stage (P = .04), more frequent lymph node dissections (P<.001), and less frequent presurgical therapy (P = .02). Patients treated in 2015-2019 vs 2005-2009 had lower overall and major complications from surgery, 22% vs 39%, P<.001% and 10% vs 16%, P = .03. Mortality at 90days was higher for patients treated 2005-2009 vs 2015-2019; 10% vs 5%, P = .02. After multivariable analysis, surgical time period was an independent predictor of major complications and 90-day mortality following cytoreductive surgery. CONCLUSION Postoperative major complications and mortality rates following CN are significantly lower in patients treated within the most recent time period.
Collapse
Affiliation(s)
- Ashanda R Esdaille
- Department of Urology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Jose A Karam
- Department of Urology, MD Anderson Cancer Center, Houston, TX; Department of Translational and Molecular Pathology, MD Anderson Cancer Center, Houston, TX
| | - Viraj A Master
- Department of Urology, Emory University and Winship Cancer Institute, Atlanta, GA
| | | | - Jay D Raman
- Department of Urology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Pranav Sharma
- Department of Urology, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Daniel D Shapiro
- Department of Urology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Arighno Das
- Department of Urology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Wade J Sexton
- Department of Urology, Emory University and Winship Cancer Institute, Atlanta, GA
| | - Logan Zemp
- Department of Urology, Emory University and Winship Cancer Institute, Atlanta, GA
| | - Dattatraya Patil
- Department of Urology, Emory University and Winship Cancer Institute, Atlanta, GA
| | - Glenn O Allen
- Department of Urology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Surena F Matin
- Department of Urology, MD Anderson Cancer Center, Houston, TX
| | | | - Edwin Jason Abel
- Department of Urology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI.
| |
Collapse
|
5
|
Pandey A, Mandal S, Das MK, Nayak P. Laparoscopic Radical Nephrectomy in the Current Era: Technical Difficulties, Troubleshoots, a Guide to the Apprentice, and the Current Learning Curve. South Asian J Cancer 2023; 12:141-147. [PMID: 37969687 PMCID: PMC10635764 DOI: 10.1055/s-0042-1750185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abhishek Pandey, MSObjectives The main aim of this study is to present our experience with laparoscopic radical nephrectomy (LRN) and share practical solutions to various surgical challenges and the learning curve we realized. Materials and Methods We retrospectively analyzed our LRN database for relevant demographic, clinical, imaging, operative, and postoperative data, including operative videos. We described various complications, vascular anomalies, intraoperative difficulties, and our improvisations to improve safety and outcomes. Statistical Analysis We evaluated the learning curve, comparing the initial half cases (group 1) against the latter half (group 2), using the chi-squared test for categorical variables and Student's t -test for continuous variables. Results Of the 106 patients included, LRN was successful in 95% ( n = 101), and five cases converted to open surgical approach. The mean tumor size was 7.4 cm, 42% incidentally detected. The cumulative complication rate was 15%, including five main renal vein injuries. Intraoperative difficulties included ureter identification ( n = 6), venous bleed during hilar dissection ( n = 11), double renal arteries ( n = 23), and venous anomalies ( n = 20). Arterial anatomy had 95% concordance with the imaging findings. We describe various trade tricks to perform hilar dissection, identify and control anomalous vasculature, handle venous bleed, confirm arterial control, and improve decisions using imaging, technology, and guidance of a mentor. No statistically significant difference in the learning curve was observed between the study groups. Conclusion With LRN already established as the current standard of care, our description intends to share the trade tricks and inspire novice urologists, who can assimilate training and reproduce good results under proper guidance. The steep learning curve described in the past may not be apparent in the current era of training and technological advancement.
Collapse
Affiliation(s)
- Abhishek Pandey
- Department of Urology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Swarnendu Mandal
- Department of Urology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Manoj K. Das
- Department of Urology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Prasant Nayak
- Department of Urology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| |
Collapse
|
6
|
Pascoe J, John J, Fowler S, Narahari K, Challacombe B, Dickinson A, McGrath JS. Contemporary standards in UK nephrectomy practice: Analysis of the British Association of Urological Surgeons Complex Operations Reports, 2016–2018. JOURNAL OF CLINICAL UROLOGY 2021. [DOI: 10.1177/20514158211059633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To analyse the 2016–2018 British Association of Urological Surgeons (BAUS) Complex Operations Reports nephrectomy database, providing a comprehensive description of modern nephrectomy practice. Patients and Methods: Analysis of 2016–2018 data held on the BAUS Complex Operations Reports nephrectomy database was performed for 21,366 patients in England. Data are reported on patient, disease, operation and outcome variables. Results: Using Hospital Episode Statistics (HES) as a comparator, the database captured an estimated 88% of nephrectomies. Benign nephrectomies (BNs) accounted for 11%, 51% were radical nephrectomies (RNs), 14% were nephroureterectomies (NUs) and 22% were partial nephrectomies (PNs). Of the 2399 BNs, 10% were performed for stone disease, 9% for allograft donation and 9% for infective pathology. Aetiology was not specified further than non-functioning kidney in 51% of cases; 80% of cases adopted minimally invasive surgery (MIS). Histology was benign in 96% of cases. Of 10,843 RNs performed, 77% were performed using MIS. Final histology was renal cell carcinoma in 87% of cases and benign histology confirmed in 9% of cases. Of 3038 NUs performed, 88% were performed using MIS. Histology confirmed malignancy in 94% of cases with transitional cell carcinoma accounting for 82% of cases overall. Of 4708 PNs performed, 74% were performed using MIS; 85% of cases were performed for T1 disease; 16% of cases overall returned benign histology. Across the cohort, 30-day mortality was 0.36%. Transfusion rates were 3.3%, 6.1%, 3.3% and 2.0% for BNs, RNs, NUs and PNs, respectively. In malignant disease, positive surgical margins were present in 0.7% of RNs, 1.2% of NUs and 7.3% of PNs. Conclusions: The BAUS nephrectomy dataset provides a real-world description of nephrectomy practice across England, enabling surgeons to compare their practice against a national average. This dataset allows surgeons to share data with patients enhancing informed consent and facilitating shared-decision making. Overall, MIS is widespread, and early mortality after nephrectomy is low. Level of evidence: 2B
Collapse
Affiliation(s)
- John Pascoe
- The Royal Devon and Exeter NHS Foundation Trust, UK
| | - Joseph John
- The Royal Devon and Exeter NHS Foundation Trust, UK
| | | | | | | | | | | |
Collapse
|
7
|
Wainger JJ, Cheaib JG, Patel HD, Huang MM, Biles MJ, Metcalf MR, Canner JK, Singla N, Trock BJ, Allaf ME, Pierorazio P. Volume-outcome relationships for kidney cancer may be driven by disparities and patient risk. Urol Oncol 2021; 39:439.e1-439.e8. [PMID: 34078583 DOI: 10.1016/j.urolonc.2021.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 04/04/2021] [Accepted: 04/25/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Provider and hospital factors influence healthcare quality, but data are lacking to assess their impact on renal cancer surgery. We aimed to assess factors related to surgeon and hospital volume and study their impact on 30-day outcomes after radical nephrectomy. MATERIALS AND METHODS Renal surgery data were abstracted from Maryland's Health Service Cost Review Commission from 2000 to 2018. Patients ≤18 years old, without a diagnosis of renal cancer, and concurrently receiving another major surgery were excluded. Volume categories were derived from the mean annual cases distribution. Multivariable logistic and linear regression models assessed the association of volume on length of stay, intensive care days, cost, 30-day mortality, readmission, and complications. RESULTS 7,950 surgeries, completed by 573 surgeons at 48 hospitals, were included. Demographic, surgical, and admission characteristics differed between groups. Radical nephrectomies performed by low volume surgeons demonstrated increased post-operative complication frequency, mortality frequency, length of stay, and days spent in intensive care relative to other groups. However, after logistic regression adjusting for clinical risk and socioeconomic factors, only increased length of stay and ICU days remained associated with lower surgeon volume. Similarly, after adjusted logistic regression, hospital volume was not associated with the studied outcomes. CONCLUSIONS Surgeons and hospitals differ in regards to patient demographic and clinical factors. Barriers exist regarding access to high-volume care, and thus some volume-outcome trends may be driven predominantly by disparities and case mix.
Collapse
Affiliation(s)
- Julia J Wainger
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Joseph G Cheaib
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hiten D Patel
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mitchell M Huang
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael J Biles
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Meredith R Metcalf
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nirmish Singla
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bruce J Trock
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohamad E Allaf
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Phillip Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
8
|
Tsai SHL, Goyal A, Alvi MA, Kerezoudis P, Yolcu YU, Wahood W, Habermann EB, Burns TC, Bydon M. Hospital volume-outcome relationship in severe traumatic brain injury: stratified analysis by level of trauma center. J Neurosurg 2021; 134:1303-1315. [PMID: 32168482 DOI: 10.3171/2020.1.jns192115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The nature of the volume-outcome relationship in cases with severe traumatic brain injury (TBI) remains unclear, with considerable interhospital variation in patient outcomes. The objective of this study was to understand the state of the volume-outcome relationship at different levels of trauma centers in the United States. METHODS The authors queried the National Trauma Data Bank for the years 2007-2014 for patients with severe TBI. Case volumes for each level of trauma center organized into quintiles (Q1-Q5) served as the primary predictor. Analyzed outcomes included in-hospital mortality, total hospital length of stay (LOS), and intensive care unit (ICU) stay. Multivariable regression models were performed for in-hospital mortality, overall complications, and total hospital and ICU LOSs to adjust for possible confounders. The analysis was stratified by level designation of the trauma center. Statistical significance was established at p < 0.001 to avoid a type I error due to a large sample size. RESULTS A total of 122,445 patients were included. Adjusted analysis did not demonstrate a significant relationship between increasing hospital volume of severe TBI cases and in-hospital mortality, complications, and nonhome hospital discharge disposition among level I-IV trauma centers. However, among level II trauma centers, hospital LOS was longer for the highest volume quintile (adjusted mean difference [MD] for Q5: 2.83 days, 95% CI 1.40-4.26 days, p < 0.001, reference = Q1). For level III and IV trauma centers, both hospital LOS and ICU LOS were longer for the highest volume quintile (adjusted MD for Q5: LOS 4.6 days, 95% CI 2.3-7.0 days, p < 0.001; ICU LOS 3.2 days, 95% CI 1.6-4.8 days, p < 0.001). CONCLUSIONS Higher volumes of severe TBI cases at a lower level of trauma center may be associated with a longer LOS. These results may assist policymakers with target interventions for resource allocation and point to the need for careful prehospital decision-making in patients with severe TBI.
Collapse
Affiliation(s)
- Sung Huang Laurent Tsai
- 1Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic
- 3Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Anshit Goyal
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic
- Departments of4Neurologic Surgery and
| | - Mohammed Ali Alvi
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic
- Departments of4Neurologic Surgery and
| | - Panagiotis Kerezoudis
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic
- Departments of4Neurologic Surgery and
| | - Yagiz Ugur Yolcu
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic
- Departments of4Neurologic Surgery and
| | - Waseem Wahood
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic
- Departments of4Neurologic Surgery and
| | | | | | - Mohamad Bydon
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic
- Departments of4Neurologic Surgery and
| |
Collapse
|
9
|
Chandrasekar T, Boorjian SA, Capitanio U, Gershman B, Mir MC, Kutikov A. Collaborative Review: Factors Influencing Treatment Decisions for Patients with a Localized Solid Renal Mass. Eur Urol 2021; 80:575-588. [PMID: 33558091 DOI: 10.1016/j.eururo.2021.01.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
CONTEXT With the addition of active surveillance and thermal ablation (TA) to the urologist's established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced. OBJECTIVE To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process. EVIDENCE ACQUISITION A collaborative critical review of the medical literature was conducted. EVIDENCE SYNTHESIS We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making. CONCLUSIONS Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care. PATIENT SUMMARY With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.
Collapse
Affiliation(s)
- Thenappan Chandrasekar
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA.
| | | | - Umberto Capitanio
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Milan, Italy
| | - Boris Gershman
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Maria Carmen Mir
- Department of Urology, Fundación Instituto Valenciano Oncologia, Valencia, Spain
| | - Alexander Kutikov
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| |
Collapse
|
10
|
Nabi J, Tully KH, Cole AP, Marchese M, Cone EB, Melnitchouk N, Kibel AS, Trinh QD. Access denied: The relationship between patient insurance status and access to high-volume hospitals. Cancer 2020; 127:577-585. [PMID: 33084023 DOI: 10.1002/cncr.33237] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 07/27/2020] [Accepted: 08/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Underinsured patients face significant barriers in accessing high-quality care. Evidence of whether access to high-volume surgical care is mediated by disparities in health insurance coverage remains wanting. METHODS The authors used the National Cancer Data Base to identify all adult patients who had a confirmed diagnosis of breast, prostate, lung, or colorectal cancer during 2004 through 2016. The odds of receiving surgical care at a high-volume hospital were estimated according to the type of insurance using multivariable logistic regression analyses for each malignancy. Then, the interactions between study period and insurance status were assessed. RESULTS In total, 1,279,738 patients were included in the study. Of these, patients with breast cancer who were insured by Medicare (odds ratio [OR], 0.75; P < .001), Medicaid (OR, 0.55; P < .001), or uninsured (OR, 0.50; P < .001); patients with prostate cancer who were insured by Medicare (OR, 0.87; P = .003), Medicaid (OR, 0.58; P = .001), or uninsured (OR, 0.36; P < .001); and patients with lung cancer who were insured by Medicare (OR, 0.84; P = .020), Medicaid (OR, 0.74; P = .001), or uninsured (OR, 0.48; P < .001) were less likely to receive surgical care at high-volume hospitals compared with patients who had private insurance. For patients with colorectal cancer, the effect of insurance differed by study period, and improved since 2011. For those on Medicaid, the odds of receiving care at a high-volume hospital were 0.51 during 2004 through 2007 and 0.99 during 2014 through 2016 (P for interaction = .001); for uninsured patients, the odds were 0.45 during 2004 through 2007 and 1.19 during 2014 through 2016 (P for interaction < .001) compared with patients who had private insurance. CONCLUSIONS Uninsured, Medicare-insured, and Medicaid-insured patients are less likely to receive surgical care at high-volume hospitals. For uninsured and Medicaid-insured patients with colorectal cancer, the odds of receiving care at high-volume hospitals have improved since implementation of the Patient Protection and Affordable Care Act of 2010.
Collapse
Affiliation(s)
- Junaid Nabi
- Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Karl H Tully
- Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexander P Cole
- Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maya Marchese
- Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eugene B Cone
- Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nelya Melnitchouk
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Gastrointestinal and General Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adam S Kibel
- Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quoc-Dien Trinh
- Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
11
|
Payne SR, Fowler S, Mundy AR, Alhasso A, Almallah Y, Anderson P, Andrich D, Baird A, Biers S, Browning A, Chapple C, Cherian J, Clarke L, Conn I, Dickerson D, Doble A, Dorkin T, Duggan B, Eardley I, Garaffa G, Greenwell T, Hadway P, Harding C, Hilmy M, Inman R, Kayes O, Kirchin V, Krishnan R, Kumar V, Lemberger J, Malone P, Moore J, Moore K, Mundy A, Noble J, Nurse D, Palmer M, Payne S, Pickard R, Rai J, Rees R, Roux J, Seipp C, Shabbir M, Saxby M, Sharma D, Sinclair A, Summerton D, Tatarov O, Thiruchelvam N, Venn S, Watkin N, Zacherakis E. The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery. JOURNAL OF CLINICAL UROLOGY 2020. [DOI: 10.1177/2051415819894182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons. Methods: Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups. Results: More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures. Conclusion: Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology. Level of evidence: Level IV
Collapse
Affiliation(s)
| | - Sarah Fowler
- British Association of Urological Surgeons, London, UK
| | - Anthony R Mundy
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Ölçücüoğlu E. Comparing the complications of laparoscopically performed simple, radical and donor nephrectomy. Turk J Med Sci 2020; 50:922-929. [PMID: 32490652 PMCID: PMC7379416 DOI: 10.3906/sag-1910-120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 05/31/2020] [Indexed: 11/03/2022] Open
Abstract
Bacground/aim The aim of this study was to compare the complications of laparoscopic simple, radical and donor nephrectomies
performed in a single center. Materials and methods The study was conducted on 392 patients who underwent laparoscopic nephrectomy in University of Health Sciences, Ankara Türkiye Yüksek İhtisas Training and Research Hospital between January 1, 2008 and January 30, 2019. Clinical and laboratory parameters were recorded. Postoperative complications were recorded and graded as per Clavien-Dindo classification (CDC). All analyses were performed on SPSS v21.0 (IBM Corp., Armonk, NY, USA). Results The mean age of the patients was 49.13 ± 15.45 years. The frequency of comorbidities and ASA scores were significantly higher in the laparoscopic radical nephrectomy (LRN) group than in the other groups (P < 0.001). Amount of bleeding was significantly lower in the laparoscopic donor nephrectomy (LDN) group compared to the other groups (P < 0.001). Classification of complications according to CDC showed that complications occurred in 17.01% (n = 25) of the LRN group, 7.02% (n = 12) of the laparoscopic simple nephrectomy (LSN) group, and 2.70% (n = 2) of the LDN group. Length of stay in hospital was significantly higher in the LRN group than in the LSN group (P < 0.001). Conclusion In this study, the frequency of complications in LRN procedures was found to be higher than the LSN and LDN procedures. Patients with LRN may have more adverse health conditions before the operation. Considering the results of this study, variables such as patient and hospital characteristics, surgeon experience and skills should be evaluated in future studies. In addition, it is important to determine the frequency of complications using a standardized classification in order to enable correct interpretation of results.
Collapse
Affiliation(s)
- Erkan Ölçücüoğlu
- Department of Urology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| |
Collapse
|
13
|
Berg S, Tully KH, Sahraoui A, Tan WS, Krimphove MJ, Marchese M, Lipsitz SR, Noldus J, Trinh QD. Inequity in selective referral to high-volume hospitals for genitourinary malignancies. Urol Oncol 2020; 38:582-589. [PMID: 32217041 DOI: 10.1016/j.urolonc.2020.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/02/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Compared to low-volume hospitals, high-volume hospitals are associated with lower rates of perioperative morbidity and mortality. However, access to high-volume hospitals is unequal. We investigated racial and socioeconomic disparities among patients undergoing surgery for genitourinary malignancies at high-volume hospitals. MATERIAL AND METHODS We queried the National Cancer Database from 2004-2015 to identify patients who underwent radical prostatectomy, radical cystectomy, and nephrectomy for nonmetastatic prostate cancer, muscle-invasive urothelial bladder cancer, and kidney cancer, respectively. Hospitals were ranked based on their annual volume for the given procedure. The endpoint of our study was receipt of treatment at a high-volume hospital. Multivariable logistic regression models were used to identify predictors of treatment at a high-volume hospital. RESULTS Our final cohort consisted of 397,242 prostate cancer patients, 39,480 bladder cancer patients, and 292,095 kidney cancer patients. For prostate and bladder cancer, Black race was associated with lower odds of treatment at a high-volume hospital (Odds Ratio [OR] 0.83, 95% confidence interval [CI] 0.79-0.87 and 0.71, 95%CI 0.58-0.87; reference: White). Higher education level and private insurance status were associated with greater odds of treatment across all 3 procedures (strongest effect for prostate cancer; higher education level: OR 1.63 [1.58-1.68]; private insurance 1.86 [1.77-1.97]). Moreover, an interaction was found between race and study period for all cancers examined (P < 0.001). Subgroup analyses revealed that Black patients were more likely to undergo radical prostatectomy at high-volume hospitals in 2013-2015 (OR 0.98, 95%CI 0.94-1.02) compared to 2004-2006 (OR 0.83, 95%CI 0.79-0.87). CONCLUSION Across all procedures, patients with lower education status and lack of insurance were less likely to be treated at high-volume hospitals. For prostate cancer and bladder cancer, Black race was a negative predictor of treatment at high-volume hospitals. Further studies are needed to understand the root causes for this inequity.
Collapse
Affiliation(s)
- Sebastian Berg
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Karl H Tully
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Aliya Sahraoui
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Wei Shen Tan
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Surgery and Interventional Science, Department of Urology, University College London, London, United Kingdom
| | - Marieke J Krimphove
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Maya Marchese
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joachim Noldus
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Quoc-Dien Trinh
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
14
|
Kim LHC, Patel MI. Increased utilization of partial nephrectomy in the robotic surgery era. ANZ J Surg 2020; 90:9-10. [PMID: 32067306 DOI: 10.1111/ans.15644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/04/2019] [Accepted: 12/11/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Lawrence H C Kim
- Department of Urology, Westmead Hospital, Sydney, New South Wales, Australia.,Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Manish I Patel
- Department of Urology, Westmead Hospital, Sydney, New South Wales, Australia.,Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
15
|
Finelli A, Coakley N, Chin J, Flood TA, Loblaw A, Morash C, Shayegan B, Siemens R. Complex surgery and perioperative systemic therapy for genitourinary cancer of the retroperitoneum. Curr Oncol 2020; 27:e34-e42. [PMID: 32218666 PMCID: PMC7096201 DOI: 10.3747/co.27.5713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective The purpose of the present guideline is to recommend surgical or systemic treatment for metastatic testicular cancer; T3b or T4, or node-positive, and metastatic renal cell cancer (rcc); and T3, T4, or node-positive upper tract urothelial (utuc) cancer. Methods Draft recommendations were formulated based on evidence obtained through a systematic review of randomized controlled trials, comparative retrospective studies, and guideline endorsement. The draft recommendations underwent an internal review by clinical and methodology experts, and an external review by clinical practitioners. Results The primary literature search yielded eight guidelines, five systematic reviews, and twenty-seven primary studies that met the eligibility criteria. Conclusions Cytoreductive nephrectomy should no longer be considered the standard of care in patients with T3b or T4, or node-positive, and metastatic rcc. Eligible patients should be treated with systemic therapy and have their primary tumour removed only after review at a multidisciplinary case conference (mcc). Adjuvant sunitinib after surgery is not recommended. Patients with venous tumour thrombus should be considered for surgical intervention. Patients with T3, T4, or node-positive utuc should have their tumour removed without delay. Decisions concerning lymph node dissection should be done at a mcc and be based on stage, expertise, and imaging. Adjuvant systemic treatment is recommended for resected high-risk utuc. Patients with metastasis-positive testicular cancer with residual tumour after systemic treatment should be treated at specialized centres. For all complex retroperitoneal surgeries, the evidence shows that higher-volume centres are associated with lower rates of procedure-related mortality, and patients should be referred to higher-volume centres for surgical resection.
Collapse
Affiliation(s)
- A Finelli
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, and Ontario Health (Cancer Care Ontario), Toronto, ON
| | - N Coakley
- Department of Oncology, McMaster University, and Ontario Health (Cancer Care Ontario), Program in Evidence-Based Care, Hamilton, ON
| | - J Chin
- London Health Sciences Centre, and University of Western Ontario, London, ON
| | - T A Flood
- Department of Anatomic Pathology, The Ottawa Hospital, Ottawa, ON
| | - A Loblaw
- Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON
| | - C Morash
- Department of Surgery, University of Ottawa, Ottawa, ON
| | - B Shayegan
- McMaster University and St. Joseph's Healthcare, Hamilton, ON
| | - R Siemens
- Department of Urology, Queen's University, and Kingston General Hospital, Kingston, ON
| |
Collapse
|
16
|
Hsu RCJ, Barclay M, Loughran MA, Lyratzopoulos G, Gnanapragasam VJ, Armitage JN. Impact of hospital nephrectomy volume on intermediate- to long-term survival in renal cell carcinoma. BJU Int 2020; 125:56-63. [PMID: 31206987 PMCID: PMC6973244 DOI: 10.1111/bju.14848] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the relationship between hospital volume and intermediate- and long-term patient survival for patients undergoing nephrectomy for renal cell carcinoma (RCC). PATIENTS AND METHODS Adult patients with RCC treated with nephrectomy between 2000 and 2010 were identified from the English Hospital Episode Statistics database and National Cancer Data Repository. Patients with nodal or metastatic disease were excluded. Hospitals were categorised into low- (LV; <20 cases/year), medium- (20-39 cases/year) and high-volume (HV; ≥40 cases/year), based on annual cases of RCC nephrectomy. Multivariable Cox regression analyses were used to calculate hazard ratios (HRs) for all-cause mortality by hospital volume, adjusting for patient, tumour and surgical characteristics. We assessed conditional survival over three follow-up periods: short (30 days to 1 year), intermediate (1-3 years) and long (3-5 years). We additionally explored whether associations between volume and outcomes varied by tumour stage. RESULTS A total of 12 912 patients were included. Patients in HV hospitals had a 34% reduction in mortality risks up to 1 year compared to those in LV hospitals (HR 0.66, 95% confidence interval 0.53-0.83; P < 0.01). Assuming causality, treatment in HV hospitals was associated with one fewer death in every 71 patients treated. Benefit of nephrectomy centralisation did not change with higher T stage (P = 0.17). No significant association between hospital volume and survival was observed beyond the first year. CONCLUSIONS Nephrectomy for RCC in HV hospitals was associated with improved survival for up to 1 year after treatment. Our results contribute new insights regarding the value of nephrectomy centralisation.
Collapse
Affiliation(s)
- Ray C. J. Hsu
- Academic Urology GroupDepartment of SurgeryCambridge Biomedical CampusUniversity of CambridgeCambridgeUK
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Matthew Barclay
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
| | - Molly A. Loughran
- Transforming Cancer Services TeamNational Health ServiceLondonUK
- National Cancer Registration and Analysis ServicePublic Health EnglandLondonUK
| | - Georgios Lyratzopoulos
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) GroupDepartment of Behavioural Science and HealthUniversity College LondonLondonUK
| | - Vincent J. Gnanapragasam
- Academic Urology GroupDepartment of SurgeryCambridge Biomedical CampusUniversity of CambridgeCambridgeUK
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - James N. Armitage
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| |
Collapse
|
17
|
Ismail A, Oquendo F, Allard-Ihala E, Elmansy H, Shahrour W, Prowse O, Kotb A. Transverse Lumbotomy for Open Partial/Radical Nephrectomy: How I Do It. Urol Int 2019; 104:131-134. [PMID: 31825948 DOI: 10.1159/000504787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 11/13/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Conventional open surgical techniques allow proper surgical management for renal malignancies but have their intrinsic drawbacks. The aim of this paper is to present our technique in minimal renal exposure while avoiding the intrinsic complications of conventional techniques. METHODS We described our technique, which can be easily understood and replicated by urologists performing open kidney surgery. RESULTS Ninety-five patients had this technique done safely over the last 4 years, and 3 patients had this exposure changed into intraperitoneal extended wound for very large upper pole tumours. The median operating time was 70 min. No single patient required intraoperative blood transfusion. Median warm ischemic time was 9 min. CONCLUSION Transverse lumbotomy is a safe reproducible technique that allows proper kidney exposure through a relatively smaller wound and avoiding unnecessary auxiliary techniques as rib resection, pleural tear management, and intraperitoneal exposure.
Collapse
Affiliation(s)
- Asmaa Ismail
- Department of Urology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Fabiola Oquendo
- Department of Urology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Erika Allard-Ihala
- Department of Urology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Hazem Elmansy
- Department of Urology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Walid Shahrour
- Department of Urology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Owen Prowse
- Department of Urology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Ahmed Kotb
- Department of Urology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada,
| |
Collapse
|
18
|
Lyon M, Cost NG, Meacham R, Saltzman AF. Extirpative renal surgery volume in training: different roads to the (same?) destination. World J Urol 2019; 38:2221-2226. [PMID: 31781895 DOI: 10.1007/s00345-019-03021-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/10/2019] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To describe the overall extirpative renal surgery (ERS) training volume reported by PU and PS. METHODS Case log data from the Accreditation Council for Graduate Medical Education (ACGME) was examined from 2013-2016 for surgery residents (Sres), urology residents (Ures), pediatric surgery fellows (PSfel) and pediatric urology fellows (PUfel). Case log information for all levels of participation over all case categories that could potentially offer ERS volume were recorded. Volume was estimated using the mean number of included cases during residency and fellowship and the sum was used to estimate total training volume. Volume between groups was compared using the student's t test. RESULTS Case logs were included for 4447 residents (4259 Sres, 840 Ures) and fellows (188 PSfel, 71 PUfel). Mean PU volume was 113.1, which was higher than the mean PS volume of 10.3 (p < 0.001). For PU, more ERS were performed during residency than fellowship (p < 0.001). For PS the opposite was true (p < 0.001). When examining fellow training only, PUfel performed more ERS than PSfel (11.7 vs. 7.0 p < 0.001). CONCLUSION While previous publications note similar short-term outcomes for ERS for malignancy for PU and PS, ERS case volume during training is significantly different. Review of recent ACGME data indicate that PU have more overall experience with ERS, with most gained during residency. Additionally, PUfel performed significantly more ERS than PSfel. Further study into how these training differences affect long-term outcomes is necessary.
Collapse
Affiliation(s)
- Madison Lyon
- Division of Urology, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Nicholas G Cost
- Division of Urology, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Randall Meacham
- Division of Urology, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Amanda F Saltzman
- Department of Urology, University of Kentucky, 800 Rose Street, MS 237, Lexington, KY, 40536, USA.
| |
Collapse
|
19
|
Gray WK, Day J, Briggs TWR, Harrison S. Understanding volume-outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme. BJU Int 2019; 125:234-243. [PMID: 31674131 DOI: 10.1111/bju.14939] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To investigate volume-outcome relationships in nephrectomy and cystectomy for cancer. MATERIALS AND METHODS Data were extracted from the UK Hospital Episodes Statistics database, which records data on all National Health Service (NHS) hospital admissions in the England. Data were included for a 5-year period (April 2013-March 2018 inclusive) and data on emergency and paediatric admissions were excluded. Data were extracted on the NHS trust and surgeon undertaking the procedure, the surgical technique used (open, laparoscopic or robot-assisted) and length of hospital stay during the procedure. This dataset was supplemented by data on mortality from the UK Office for National Statistics. A number of volume thresholds and volume measures were investigated. Multilevel modelling was used to adjust for hierarchy and confounding factors. RESULTS Data were available for 18 107 nephrectomy and 6762 cystectomy procedures for cancer. There was little evidence of trust or surgeon volume influencing readmission rates or mortality. There was some evidence of shorter length of hospital stay for high-volume surgeons, although the volume measure and threshold used were important. CONCLUSIONS We found little evidence that further centralization of nephrectomy or cystectomy for cancer surgery will improve the patient outcomes investigated. It may be that length of stay can be optimized though training and support for lower-volume centres, rather than further centralization.
Collapse
Affiliation(s)
- William K Gray
- Getting it Right First Time Programme, NHS England and NHS Improvement, London, UK
| | - Jamie Day
- Getting it Right First Time Programme, NHS England and NHS Improvement, London, UK
| | - Tim W R Briggs
- Getting it Right First Time Programme, NHS England and NHS Improvement, London, UK
| | - Simon Harrison
- Getting it Right First Time Programme, NHS England and NHS Improvement, London, UK.,Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| |
Collapse
|
20
|
Herbst KW, Tomlinson P, Lockwood G, Mosha MH, Wang Z, D'Alessandri-Silva C. Survival and Kidney Outcomes of Children with an Early Diagnosis of Posterior Urethral Valves. Clin J Am Soc Nephrol 2019; 14:1572-1580. [PMID: 31582461 PMCID: PMC6832049 DOI: 10.2215/cjn.04350419] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/14/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Posterior urethral valve is the most common cause of bladder outlet obstruction in infants. We aimed to describe the rate and timing of kidney-related and survival outcomes for children diagnosed with posterior urethral valves in United States children's hospitals using the Pediatric Health Information System database. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective cohort study included children hospitalized between January 1, 1992 and December 31, 2006, who were in their first year of life, had a diagnosis of congenital urethral stenosis, and underwent endoscopic valve ablation or urinary drainage intervention, or died. Records were searched up to December 31, 2018 for kidney-related mortality, placement of a dialysis catheter, and kidney transplantation. Cox regression analysis was used to identify risk factors, and Kaplan-Meier survival analysis used to determine time-to-event probability. Subgroup survival analysis was performed with outcomes stratified by the strongest identified risk factor. RESULTS Included were 685 children hospitalized at a median age of 7 (interquartile range, 1-37) days. Thirty four children (5%) died, over half during their initial hospitalization. Pulmonary hypoplasia was the strongest risk factor for death (hazard ratio, 7.5; 95% confidence interval [95% CI], 3.3 to 17.0). Ten-year survival probability was 94%. Fifty-nine children (9%) underwent one or more dialysis catheter placements. Children with kidney dysplasia had over four-fold risk of dialysis catheter placement (hazard ratio, 4.6; 95% CI, 2.6 to 8.1). Thirty-six (7%) children underwent kidney transplant at a median age of 3 (interquartile range, 2-8) years. Kidney dysplasia had a nine-fold higher risk of kidney transplant (hazard ratio, 9.5; 95% CI, 4.1 to 22.2). CONCLUSIONS Patients in this multicenter cohort with posterior urethral valves had a 5% risk of death, and were most likely to die during their initial hospitalization. Risk of death was higher with a diagnosis of pulmonary hypoplasia. Kidney dysplasia was associated with a higher risk of need for dialysis/transplant. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_10_03_CJN04350419.mp3.
Collapse
Affiliation(s)
| | - Paul Tomlinson
- Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut.,Division of Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Gina Lockwood
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | | | - Zhu Wang
- Department of Epidemiology and Biostatistics, University of Texas Health San Antonio, San Antonio, Texas
| | - Cynthia D'Alessandri-Silva
- Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut.,Division of Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut
| |
Collapse
|
21
|
Coon C, Berger N, Eastwood D, Tsai S, Christians K, Mogal H, Clarke C, Gamblin TC. Primary Liver Cancer: An NCDB Analysis of Overall Survival and Margins After Hepatectomy. Ann Surg Oncol 2019; 27:1156-1163. [DOI: 10.1245/s10434-019-07843-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Indexed: 12/11/2022]
|
22
|
Hoshijima H, Wajima Z, Nagasaka H, Shiga T. Association of hospital and surgeon volume with mortality following major surgical procedures: Meta-analysis of meta-analyses of observational studies. Medicine (Baltimore) 2019; 98:e17712. [PMID: 31689806 PMCID: PMC6946306 DOI: 10.1097/md.0000000000017712] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Accumulation of the literature has suggested an inverse association between healthcare provider volume and mortality for a wide variety of surgical procedures. This study aimed to perform meta-analysis of meta-analyses (umbrella review) of observational studies and to summarize existing evidence for associations of healthcare provider volume with mortality in major operations.We searched MEDLINE, SCOPUS, and Cochrane Library, and screening of references.Meta-analyses of observational studies examining the association of hospital and surgeon volume with mortality following major operations. The primary outcome is all-cause short-term morality after surgery. Meta-analyses of observational studies of hospital/surgeon volume and mortality were included. Overall level of evidence was classified as convincing (class I), highly suggestive (class II), suggestive (class III), weak (class IV), and non-significant (class V) based on the significance of the random-effects summary odds ratio (OR), number of cases, small-study effects, excess significance bias, prediction intervals, and heterogeneity.Twenty meta-analyses including 4,520,720 patients were included, with 19 types of surgical procedures for hospital volume and 11 types of surgical procedures for surgeon volume. Nominally significant reductions were found in odds ratio in 82% to 84% of surgical procedures in both hospital and surgeon volume-mortality associations. To summarize the overall level of evidence, however, only one surgical procedure (pancreaticoduodenectomy) fulfilled the criteria of class I and II for both hospital and surgeon volume and mortality relationships, with a decrease in OR for hospital (0.42, 95% confidence interval[CI] [0.35-0.51]) and for surgeon (0.38, 95% CI [0.30-0.49]), respectively. In contrast, most of the procedures appeared to be weak or "non-significant."Only a very few surgical procedures such as pancreaticoduodenectomy appeared to have convincing evidence on the inverse surgeon volume-mortality associations, and yet most surgical procedures resulted in having weak or "non-significant" evidence. Therefore, healthcare professionals and policy makers might be required to steer their centralization policy more carefully unless more robust, higher-quality evidence emerges, particularly for procedures considered as having a weak or non-significant evidence level including total knee replacement, thyroidectomy, bariatric surgery, radical cystectomy, and rectal and colorectal cancer resections.
Collapse
Affiliation(s)
- Hiroshi Hoshijima
- Department of Anesthesiology, Saitama Medical University Hospital, Saitama
| | - Zen’ichiro Wajima
- Department of Anesthesiology, Tokyo Medical University Hachioji Medical Center, Tokyo
| | - Hiroshi Nagasaka
- Department of Anesthesiology, Saitama Medical University Hospital, Saitama
| | - Toshiya Shiga
- Department of Anesthesiology and Intensive Care Medicine, International University of Health and Welfare Ichikawa Hospital, Ichikawa, Chiba, Japan
| |
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW Hospital and surgical volumes, as well as complications, are considered to influence intra and postoperative results in most surgical operations. This trend is also seen in uro-oncologic surgery. The objective of this review is to critically analyze the most recent literature to give a comprehensive overview on whether surgical and hospital volumes have an impact, and whether regionalization of the procedure should be advised. RECENT FINDINGS Uro-oncologic surgery has recently become more regionalized, and data coming from different population-based analyses appear to support this trend. Recent data suggest that the most beneficial procedures could be radical cystectomy, radical prostatectomy, and partial nephrectomy. For radical cystectomy, even considering different cut-off values, saw better results for postoperative complications, mortality and long-term oncological and functional outcomes in patients treated in high-volume institutions. Centralization of radical prostatectomy seems to affect short-term outcomes and costs related to prostate cancer treatment, with high-volume institutions providing more affordable treatments reducing cancer recurrence and progression. Partial nephrectomy is more frequently performed in cT1-b cancer in high-volume than low-volume institutions. Additionally, in this setting it has a higher success rate and lower complications, shorter operative time, and fewer prolonged hospital stays. SUMMARY Regionalization of the procedure in high-volume centers seems to have impact on postoperative morbidity and mortality for the most frequent major uro-oncological procedures: radical prostatectomy, radical cystectomy, and partial nephrectomy; but there are insufficient data available on other procedures.
Collapse
|
24
|
Williams SB, Ray-Zack MD, Hudgins HK, Oldenburg J, Trinh QD, Nguyen PL, Shore ND, Wirth MP, O'Brien T, Catto JWF. Impact of Centralizing Care for Genitourinary Malignancies to High-volume Providers: A Systematic Review. Eur Urol Oncol 2019; 2:265-273. [PMID: 31200840 PMCID: PMC10007401 DOI: 10.1016/j.euo.2018.10.006] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 12/20/2022]
Abstract
CONTEXT The centralization of cancer care is associated with better clinical outcomes and may be a method for optimizing value-based health care systems. OBJECTIVE To systematically review the literature regarding the impact of centralization of care on clinical outcomes for genitourinary malignancies. EVIDENCE ACQUISITION A systematic review was conducted using Ovid and MEDLINE to identify studies between 1970 and 2018 reporting on the centralization of care for genitourinary malignancies. Prospective and retrospective studies were screened. EVIDENCE SYNTHESIS There were no published randomized control trials (RCTs) on the centralization of care for genitourinary malignancies. Twenty-two retrospective studies met inclusion criteria. Centralization of radical cystectomy was the most studied. Care for bladder cancer, prostate cancer, penile cancer, testicular cancer, and renal cancer was reportedly associated with better morbidity and survival outcomes for patients treated at high-volume centers. However, evidence of better outcomes for centralization of care remains limited for penile, renal, and testicular cancers owing to the paucity of data and/or the lower incidence of these genitourinary malignancies. CONCLUSIONS Care for genitourinary malignancies by high-volume providers was associated with greater utilization of cancer surgery, lower morbidity, and better survival outcomes. Centralization of care was most appropriate for complex procedures such as radical cystectomy when interpreted in the context of survival outcomes. Further research is needed to address the impact of centralizing care for all urologic malignancies with consideration of the associated costs and patient-reported measures, including quality of life and patient experience. PATIENT SUMMARY We explored the evidence for moving major operations into larger centers. We focused on surgery for cancers of the bladder, prostate, testicle, penis, and kidney, and found that larger-volume hospitals had better survival outcomes and fewer complications when compared to smaller hospitals. The difference may be greatest for complex major surgeries such as radical cystectomy.
Collapse
Affiliation(s)
- Stephen B Williams
- Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA.
| | - Mohamed D Ray-Zack
- Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hogan K Hudgins
- Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Jan Oldenburg
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Neal D Shore
- Department of Urology, Carolina Urologic Research Center, Myrtle Beach, SC, USA
| | - Manfred P Wirth
- Department of Urology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| |
Collapse
|
25
|
Who is dying after nephrectomy for cancer? Study of risk factors and causes of death after analyzing morbidity and mortality reviews (UroCCR-33 study). Prog Urol 2019; 29:282-287. [PMID: 30962141 DOI: 10.1016/j.purol.2019.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/03/2018] [Accepted: 02/01/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND METHODS Nephrectomy is the treatment for renal cell cancer from T1-4 tumors but remains at risk. To determine the thirty-day mortality rate after nephrectomy for cancer and to identify causes and risk factors of death in order to find clinical applications. From 2014 to 2017, we performed a retrospective multicentric analysis of prospectively collected data study involving the French network for research on kidney cancer (UroCCR). All patients who died after nephrectomy for cancer during the first thirty days were identified. Patients' characteristics, causes of death and morbidity and mortality reviews reports were analyzed for each death. RESULTS AND LIMITATIONS In total, 2578 patients underwent nephrectomy and 35 deaths occurred. The thirty-day mortality rate was 1.4%. In univariate analysis, symptoms at diagnosis (P=0.006, OR=2.56 IC (1.3-5.03)), c stage superior to cT1 (P<0.0001, OR=6.13 IC (2.8-13.2)), cT stage superior to cT2 (P<0.0001, OR=8.8 IC (4.39-17.8)), nodal invasion (P<0.0001, OR=4.6 IC (1.9-10.7)), distant metastasis (P=0.001, OR=4.01 IC (1.7-8.9)), open surgery (P<0.0001, OR=0.272 IC (0.13-0.54)) and radical nephrectomy (P=0.007, OR=2.737 IC (1.3-5.7)) were risk factors of thirty-day mortality. In a multivariable model, only cT stage superior to T2 (P=0.015, OR=3.55 IC (1.27-10.01)) was a risk factor of thirty-day mortality. The main cause of postoperative death was pulmonary (n=15; 43%). The second cause was postoperative digestive sepsis for 7 patients (20%). Only 2 morbidity and mortality reviews had been done for the 35 deaths. Limitations are related to the thirty-day mortality criteria and descriptive study design. CONCLUSIONS Symptomatic patients, stage cTNM and type and techniques of surgery are determinants of thirty-day mortality after nephrectomy for cancer. The first cause of postoperative death is pulmonary. Morbidity and mortality reviews should be considered to better understand causes of death and to reduce early mortality after nephrectomy for cancer. LEVEL OF EVIDENCE 4.
Collapse
|
26
|
Bodempudi S, Dombrovskiy V, Olweny EO. Contemporary Analysis of Calculous Nephrectomy Utilization and Outcomes in the United States. J Endourol 2019; 33:674-679. [PMID: 30834781 DOI: 10.1089/end.2019.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Calculous nephrectomy was a mainstay of treatment of complex upper tract stone disease up until the 1970s, but data on its contemporary utilization in the current era of rising rates of stone disease are lacking. We characterized the nationwide utilization and outcomes for calculous nephrectomy in the United States. Patients and Methods: The National/Nationwide Inpatient Sample databases for 2001 to 2014 were queried for adults with a principal diagnosis of upper urinary tract calculi (UUTCs), who underwent nephrectomy as well as other inpatient surgeries for UUTCs. Per-population trend in utilization of calculous nephrectomy was analyzed using negative binomial regression. The proportion of calculous nephrectomy as a fraction of all inpatient surgical procedures for UUTCs was analyzed using the Cochran-Armitage test. Patient demographics, hospital characteristics, perioperative outcomes, and complications were analyzed using appropriate statistical tests. Results: Of almost 1.42 million inpatient UUTC procedures performed over the study period, 9232 (0.65%) were calculous nephrectomies. Per-population utilization rate for calculous nephrectomy decreased significantly over time (incidence rate ratio = 0.82; 95% confidence interval = 0.73-0.91, p < 0.001). The proportion of calculous nephrectomy as a fraction of all inpatient surgical procedures for UUTC also decreased significantly over time (p < 0.0001). Majority of the procedures were performed in females, in urban teaching hospitals, and in the Southern United States. The overall complication rate was 38.3%, most commonly hemorrhage requiring transfusion (15.6%). Older age, female gender, and nonprivate insurance or lack of insurance were significant predictors of increased risk of complications, whereas hospitalization in urban hospitals was a predictor of lower risk. Conclusions: Despite increasing prevalence of stone disease in the United States in the contemporary era, utilization of calculous nephrectomy is low and is declining. Inpatient complication rates are moderately high and influenced by patient sociodemographic and hospital characteristics.
Collapse
Affiliation(s)
| | - Viktor Dombrovskiy
- 2Division of Urology, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Ephrem O Olweny
- 2Division of Urology, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| |
Collapse
|
27
|
Berg S, Cole AP, Fletcher SA, Pucheril D, Nabi J, Lipsitz SR, Chang SL, Sun M, Noldus J, Harshman LC, Choueiri TK, Trinh QD. Investigating the effect of treatment at high-volume hospitals on overall survival following cytoreductive nephrectomy. Urol Oncol 2018; 36:400.e15-400.e22. [PMID: 30274640 DOI: 10.1016/j.urolonc.2018.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 05/17/2018] [Accepted: 06/09/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Data revealed the benefit of high-volume care in many complex disease processes. Among patients undergoing nephrectomy, those receiving cytoreductive nephrectomy (CN) for metastatic renal cell cancer (mRCC) constitute a unique subset. They often have a greater medical and surgical complexity. Against this backdrop, we sought to investigate the effect of hospital volume on overall survival among patients undergoing CN for mRCC. MATERIAL AND METHODS We identified 11,089 patients who received CN for mRCC in the National Cancer Database from 1998 to 2012. We ranked hospitals based on annual CN volume. Patients who received surgery in hospitals in the top vs. bottom deciles were compared. Inverse Probability of Treatment Weighting (IPTW)-adjusted Kaplan-Meier and Cox regression analyses were used to compare the primary endpoint of overall survival between balanced cohorts of patients. Secondary endpoints were 30-day mortality, 30-day readmissions, and receipt of subsequent systemic therapy. RESULTS Median follow-up was 60.39 months (interquartile range [IQR] 35.09-95.95). Median overall survival was 17.61 months (IQR 7.16-44.58). Following propensity score weighting, surgery at a high-volume hospital was associated with a decreased risk of mortality (IPTW-adjusted Cox proportional Hazard Ratio = 0.91; 95% confidence interval: 0.86-0.96). On our IPTW-adjusted Kaplan-Meier analysis, the median survival was 19.94 months (IQR 7.98-50.27) at high-volume hospitals vs. 15.97 months (IQR 6.6-41.56) at low-volume hospitals. With regard to secondary endpoints, the data did not reveal a significant advantage for treatment at a high-volume hospital. CONCLUSION We found a significant association between receipt of CN at high-volume hospitals and prolonged overall survival, demonstrated by a nearly 4 month survival benefit.
Collapse
Affiliation(s)
- Sebastian Berg
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Alexander P Cole
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sean A Fletcher
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Daniel Pucheril
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Junaid Nabi
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Bioethics, Harvard Medical School, Boston, MA
| | - Stuart R Lipsitz
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Steven L Chang
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Maxine Sun
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joachim Noldus
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Lauren C Harshman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Toni K Choueiri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Quoc-Dien Trinh
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
28
|
Hsu RCJ, Barclay M, Loughran MA, Lyratzopoulos G, Gnanapragasam VJ, Armitage JN. Time trends in service provision and survival outcomes for patients with renal cancer treated by nephrectomy in England 2000-2010. BJU Int 2018; 122:599-609. [PMID: 29603575 PMCID: PMC6175431 DOI: 10.1111/bju.14217] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To describe the temporal trends in nephrectomy practice and outcomes for English patients with renal cell carcinoma (RCC). PATIENTS AND METHODS Adult RCC nephrectomy patients treated between 2000 and 2010 were identified in the National Cancer Data Repository and Hospital Episode Statistics, and followed-up until date of death or 31 December 2015 (n = 30 763). We estimated the annual frequency for each nephrectomy type, the hospital and surgeon numbers and their case volumes. We analysed short-term surgical outcomes, as well as 1- and 5-year relative survivals. RESULTS Annual RCC nephrectomy number increased by 66% during the study period. Hospital number decreased by 24%, whilst the median annual hospital volume increased from 10 to 23 (P < 0.01). Surgeon number increased by 27% (P < 0.01), doubling the median consultant number per hospital. The proportion of minimally invasive surgery (MIS) nephrectomies rose from 1% to 46%, whilst the proportion of nephron-sparing surgeries (NSS) increased from 5% to 16%, with 29% of all T1 disease treated with partial nephrectomy in 2010 (P < 0.01). The 30-day mortality rate halved from 2.4% to 1.1% and 90-day mortality decreased from 4.9% to 2.6% (P < 0.01). The 1-year relative survival rate increased from 86.9% to 93.4%, whilst the 5-year relative survival rate rose from 68.2% to 81.2% (P < 0.01). Improvements were most notable in patients aged ≥65 years and those with T3 and T4 disease. CONCLUSIONS Surgical RCC management has changed considerably with nephrectomy centralisation and increased NSS and MIS. In parallel, we observed significant improvements in short- and long-term survival particularly for elderly patients and those with locally advanced disease.
Collapse
Affiliation(s)
- Ray C. J. Hsu
- Academic Urology GroupDepartment of SurgeryUniversity of CambridgeCambridgeUK
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Matthew Barclay
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
| | - Molly A. Loughran
- Transforming Cancer Services TeamNational Health ServiceLondonUK
- National Cancer Registration and Analysis ServicePublic Health EnglandLondonUK
| | - Georgios Lyratzopoulos
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) GroupDepartment of Behavioural Science and HealthUniversity College LondonLondonUK
| | - Vincent J. Gnanapragasam
- Academic Urology GroupDepartment of SurgeryUniversity of CambridgeCambridgeUK
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - James N. Armitage
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| |
Collapse
|
29
|
|
30
|
Xia L, Strother MC, Taylor BL, Chelluri RR, Pulido JE, Guzzo TJ. Hospital volume and short-term outcomes after cytoreductive nephrectomy. J Surg Oncol 2018; 117:1589-1596. [PMID: 29575038 DOI: 10.1002/jso.25047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/16/2018] [Indexed: 01/29/2023]
Abstract
PURPOSE To investigate the impact of hospital volume on short-term outcomes after cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC). METHODS We identified mRCC patients who underwent CN from 2006 to 2013 in the National Cancer Database. Annual hospital CN volume was categorized as high (top 20th percentile) and low. Multivariable logistic regressions were used to compare 30-day mortality, 90-day mortality, prolonged length of stay (PLOS, ≥7 days), and 30-day readmission rates. Sensitivity analyses were performed with hospital volume considered as a continuous variable. RESULTS A total of 9789 patients were included with high-volume (n = 1916) defined as ≥8 cases and low-volume (n = 7873) as 1-7 cases annually. Multivariable logistic regression showed that high-volume was associated with lower odds of 30-day mortality (OR = 0.69, P = 0.013), 90-day mortality (OR = 0.65, P < 0.001), PLOS (OR = 0.82, P = 0.002), and 30-day readmission (OR = 0.78, P = 0.028). Sensitivity analyses showed that increasing hospital volume (per case) was associated with lower odds of 30-day mortality (OR = 0.965, P = 0.008), 90-day mortality (OR = 0.966, P < 0.001), PLOS (OR = 0.982, P = 0.001), and 30-day readmission (OR = 0.975, P = 0.012). CONCLUSION Higher hospital volume was associated with better short-term outcomes after CN. Future studies are needed to validate our findings and explore the potential components leading to better outcomes in the higher volume hospitals.
Collapse
Affiliation(s)
- Leilei Xia
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Marshall C Strother
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Raju R Chelluri
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jose E Pulido
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Thomas J Guzzo
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|