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. 2021 Sep 20:33:1-10.
doi: 10.1016/j.euros.2021.08.005. eCollection 2021 Nov.

Defining Factors Associated with High-quality Surgery Following Radical Cystectomy: Analysis of the British Association of Urological Surgeons Cystectomy Audit

Wei Shen Tan  1   2 , Jeffrey J Leow  3   4 , Maya Marchese  5 , Ashwin Sridhar  1   6 , Giles Hellawell  7 , Matthew Mossanen  8 , Jeremy Y C Teoh  9 , Sarah Fowler  10 , Alexandra J Colquhoun  11 , Jo Cresswell  12 , James W F Catto  13 , Quoc-Dien Trinh  8 , John D Kelly  1   6 ; BAUS Section of Oncology
Affiliations

Defining Factors Associated with High-quality Surgery Following Radical Cystectomy: Analysis of the British Association of Urological Surgeons Cystectomy Audit

Wei Shen Tan et al. Eur Urol Open Sci. .

Abstract

Background: Radical cystectomy (RC) is associated with high morbidity.

Objective: To evaluate healthcare and surgical factors associated with high-quality RC surgery.

Design setting and participants: Patients within the prospective British Association of Urological Surgeons (BAUS) registry between 2014 and 2017 were included in this study.

Outcome measurements and statistical analysis: High-quality surgery was defined using pathological (absence of positive surgical margins and a minimum of a level I lymph node dissection template with a minimum yield of ten or more lymph nodes), recovery (length of stay ≤10 d), and technical (intraoperative blood loss <500 ml for open and <300 ml for minimally invasive RC) variables. A multilevel hierarchical mixed-effect logistic regression model was utilised to determine the factors associated with the receipt of high-quality surgery and index admission mortality.

Results and limitations: A total of 4654 patients with a median age of 70.0 yr underwent RC by 152 surgeons at 78 UK hospitals. The median surgeon and hospital operating volumes were 23.0 and 47.0 cases, respectively. A total of 914 patients (19.6%) received high-quality surgery. The minimum annual surgeon volume and hospital volume of ≥20 RCs/surgeon/yr and ≥68 RCs/hospital/yr, respectively, were the thresholds determined to achieve better rates of high-quality RC. The mixed-effect logistic regression model found that recent surgery (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.11-1.34, p < 0.001), laparoscopic/robotic RC (OR: 1.85, 95% CI: 1.45-2.37, p < 0.001), and higher annual surgeon operating volume (23.1-33.0 cases [OR: 1.54, 95% CI: 1.16-2.05, p = 0.003]; ≥33.1 cases [OR: 1.64, 95% CI: 1.18-2.29, p = 0.003]) were independently associated with high-quality surgery. High-quality surgery was an independent predictor of lower index admission mortality (OR: 0.38, 95% CI: 0.16-0.87, p = 0.021).

Conclusions: We report that annual surgeon operating volume and use of minimally invasive RC were predictors of high-quality surgery. Patients receiving high-quality surgery were independently associated with lower index admission mortality. Our results support the role of centralisation of complex oncology and implementation of a quality assurance programme to improve the delivery of care.

Patient summary: In this registry study of patients treated with surgical excision of the urinary bladder for bladder cancer, we report that patients treated by a surgeon with a higher annual operative volume and a minimally invasive approach were associated with the receipt of high-quality surgery. Patients treated with high-quality surgery were more likely to be discharged alive following surgery.

Keywords: Bladder cancer; British Association of Urological Surgeons audit; Centralisation; Outcomes; Quality surgery; Radical cystectomy.

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Figures

Fig. 1
Fig. 1
Inclusion and exclusion criteria used to determine study cohort.
Fig. 2
Fig. 2
Caterpillar graph of adjusted probability of individual surgeons achieving high-quality surgery ranked from the least to the greatest. CI = confidence interval.
See this image and copyright information in PMC

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