Defining factors associated with high-quality surgery following radical cystectomy : analysis of the British Association of Urological Surgeons cystectomy audit

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.