Association of hospital volume with perioperative and oncological outcomes of robot-assisted laparoscopic radical prostatectomy: a retrospective multicenter cohort study

BACKGROUND

This retrospective multicenter cohort study investigated the association of hospital volume with perioperative and oncological outcomes in patients treated with robot-assisted radical prostatectomy (RARP).

METHODS

We collected the clinical data of patients who underwent RARP at eight institutions in Japan between September 2012 and August 2021. The patients were divided into two groups based on the treatment site-high- and non-high-volume hospitals. We defined a high-volume hospital as one where RARP was performed for more than 100 cases per year.

RESULTS

After excluding patients who received neoadjuvant therapy, a total of 2753 patients were included in this study. In the high-volume hospital group, console time and estimated blood loss were significantly (p < 0.001) lower than that of the non-high-volume hospital group. However, the continence rate at 3 months after RARP, positive surgical margins, and prostate-specific antigen (PSA)-relapse-free survival showed no significant differences between the two groups. Furthermore, the console time was significantly shorter after 100 cases in the non-high-volume hospital group but not in the high-volume hospital group.

CONCLUSIONS

A higher hospital volume was significantly associated with shorter console time and less estimated blood loss. However, oncological outcomes and early continence recovery appear to be comparable regardless of the hospital volume in Japan.

Investigating the effect of treatment at high-volume hospitals on overall survival following cytoreductive nephrectomy

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.

Validation of an assessment tool: Estimation of Postoperative Overall Survival for Gastric Cancer

BACKGROUND

Benchmarking of long-term surgical outcomes has rarely been attempted. We previously devised a prediction model for assessing the outcome of late survival after surgery, termed the Estimation of Postoperative Overall Survival for Gastric Cancer (EPOS-GC). This study was undertaken to validate EPOS-GC in an external data set.

METHODS

A retrospective cohort study was conducted in 11 cancer care hospitals in Japan, analyzing a consecutive series of patients who underwent elective gastric cancer resection between April 2007 and March 2009. EPOS-GC consists of three tumor-related variables and three physiological variables. The primary endpoint was postoperative overall survival. The observed-to-expected (O/E) ratio of 5-year survival rates was defined as a metric of quality of care. The sample size for O/E was determined as 42.

RESULTS

We included 2045 patients for analysis. The median (95% confidence interval) follow-up time was 5.1 (1.2-6.8) years for censored patients. Although EPOS-GC demonstrated a good discriminative power (Harrell's C-index, 95% confidence interval: 0.80, 0.79-0.83), the calibration plot revealed that EPOS-GC underestimated 5-year survival rates in the high-risk group. Therefore, we recalibrated the model with Cox's regression analysis. The recalibrated EPOS-GC showed a good calibration, preserving the high discriminative power (C-index, 95% confidence interval: 0.80, 0.78-0.82). The O/E among hospitals according to the recalibrated EPOS-GC ranged between 0.87 and 1.27. The O/E correlated with hospital volumes (Spearman's correlation = 0.76, n = 11, p = .006).

CONCLUSION

EPOS-GC with recalibration can convey risk-adjusted quality assurance regarding late survival following gastric cancer resection.

Validation of the board certification system for expert surgeons (hepato-biliary-pancreatic field) using the data of the National Clinical Database of Japan: part 1 - Hepatectomy of more than one segment

BACKGROUND

The objective of this study was to validate the board certification system of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) using the data of hepatectomy cases from the National Clinical Database (NCD) of Japan.

METHODS

Minimal required annual numbers of high-level hepato-biliary-pancreatic (HBP) surgeries were 50 for a board-certified A training institution and 30 for a board-certified B training institution. Records of 14,970 patients who had undergone hepatectomy of more than one segment (MOS), excluding lateral segmentectomy, during 2011 and 2012 were analyzed according to the category of board-certified institution and with or without participation of board-certified instructors or expert surgeons.

RESULTS

Thirty-day mortality and operative mortality of 14,970 patients after MOS hepatectomy were 1.9% and 3.8%, respectively. Operative mortality rates after MOS hepatectomies performed at certified A institutions, certified B institutions, and non-certified institutions were 3.1%, 3.8%, and 4.5%, respectively (P < 0.001). The operative mortality rates after MOS hepatectomies performed with participation of certified instructors or expert surgeons were better than those without (3.5% vs. 4.3%, P = 0.012). A multiple logistic regression model showed that the cutoffs of high-level HBP surgeries performed per year at hospitals that predicted operative mortality after MOS hepatectomies were 10 and 50.

CONCLUSIONS

Competences and requirements for board-certified institutions, instructors, and expert surgeons to perform hepatectomy were found to be appropriate.

Volume matters in the systemic treatment of metastatic pancreatic cancer: a population-based study in the Netherlands

PURPOSE

In pancreatic surgery, a relation between surgical volume and postoperative mortality and overall survival (OS) has been recognized, with high-volume centers reporting significantly better survival rates. We aimed to explore the influence of hospital volume on administration of palliative chemotherapy and OS in the Netherlands.

METHODS

Patients diagnosed between 2007 and 2011 with metastatic pancreatic cancer were identified in the Netherlands Cancer Registry. Three types of high-volume centers were defined: high-volume (1) incidence center, based on the number of patients diagnosed with metastatic pancreatic cancer, (2) treatment center based on number of patients with metastatic pancreatic cancer who started treatment with palliative chemotherapy and (3) surgical center based on the number of resections with curative intent for pancreatic cancer. Independent predictors of administration of palliative chemotherapy were evaluated by means of logistic regression analysis. The multivariable Cox proportional hazard model was used to assess the impact of being diagnosed or treated in high-volume centers on survival.

RESULTS

A total of 5385 patients presented with metastatic pancreatic cancer of which 24 % received palliative chemotherapy. Being treated with chemotherapy in a high-volume chemotherapy treatment center was associated with improved survival (HR 0.76, 95 % CI 0.67-0.87). Also, in all patients with metastatic pancreatic cancer, being diagnosed in a high-volume surgical center was associated with improved survival (HR 0.74, 95 % CI 0.66-0.83).

CONCLUSIONS

Hospital volume of palliative chemotherapy for metastatic pancreatic cancer was associated with improved survival, demonstrating that a volume-outcome relationship, as described for pancreatic surgery, may also exist for pancreatic medical oncology.