SUO 2017: Hospital Volume and Short-Term Outcomes after Cytoreductive Nephrectomy

Washington, DC ( Dr. Xia and colleagues presented results from their study assessing hospital volume and short-term outcomes after cytoreductive nephrectomy. Indeed, cytoreductive nephrectomy is considered a treatment option for selected patients with metastatic renal cell carcinoma (mRCC), although it can be complex with significant perioperative morbidities. To date, there have been no studies reporting on volume-outcome associations in the CN setting; the current study’s objective was to explore this potential relationship.

The authors identified mRCC patients who underwent cytoreductive nephrectomy from 2006 to 2013 in the National Cancer Database (NCDB). Hospital volume was categorized as high (upper 20th%ile by hospital volume) and low (lower 80%). Univariable analyses and multivariable logistic regression models adjusted for patient (age, sex, race, comorbidity, insurance, education, income, and residence location), tumor (grade, pathology, T stage, N stage, and metastasis location), and treatment (metastasectomy, neoadjuvant systematic therapy, and neoadjuvant radiation) characteristics were used to compare 30-day mortality, 90-day mortality, prolonged length of stay (≥7 days), and 30-day readmission rates between high-volume and low-volume hospitals. Sensitivity analyses were performed with hospital volume considered as a continuous variable in the regression models.

A total of 9,789 patients were included in the analysis, with high-volume (n=1,916) as ≥8 cases per year and low-volume (n=7,873) as 1-7 cases per year. Unadjusted comparisons showed consistently better outcomes in the high-volume group for all four main outcomes. Multivariable logistic regression showed that high-volume was associated with lower risks of 30-day mortality (OR=0.69, 95%CI 0.51-0.92, p=0.013), 90-day mortality (OR=0.65, 95%CI 0.55-0.77, p<0.001), prolonged length of stay (OR=0.82, 95%CI 0.73-0.93, p=0.002), and 30-day readmission (OR=0.78, 95%CI 0.63-0.97, p=0.028). Sensitivity analyses showed that increasing hospital volume (per case) was associated with decreased risks of 30-day mortality (OR=0.965, 95%CI 0.941-0.991, p=0.008), 90-day mortality (OR=0.966, 95%CI 0.953-0.980, p<0.001), prolonged length of stay (OR=0.982, 95%CI 0.972-0.993, p=0.001), and 30-day readmission (OR=0.975, 95%CI 0.957-0.994, p=0.012). 
Based on this analysis, higher hospital volume is overwhelmingly associated with substantially improved mortality and other short-term outcomes after cytoreductive nephrectomy. The concept of centralizing complex surgical procedures, which has been suggested for other procedures such as radical cystectomy and retroperitoneal lymph node dissection, may apply to cytoreductive nephrectomy.

Presented by: Leilei Xia MD¹

Co-Authors:  Jose Pulido MD¹, Benjamin Taylor MD² and Thomas Guzzo MD, MPH¹

Affiliation:  ¹Division of Urology, Department of Surgery University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Department of Urology, Weill Cornell Medical College, New York, NY

Written by: Zachary Klaassen, MD, Society of Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC