Introduction: The gold standard for the treatment of upper tract urothelial carcinoma (UTUC) is radical nephroureterectomy (RNUx). While the surgeon/hospital volume-outcome relationship has been well established for resection of multiple other cancer types both within and outside of urology, it has never been examined for RNUx.
Methods: The National Cancer Database (NCDB) was queried for all cases of UTUC from 2004-2016. Average annual hospital volume for radical nephroureterectomy was calculated per hospital and subsequently stratified into tertiles. We considered high-volume to be the upper tertile, which was six or more RNUx per year and low-volume to be the lower two tertiles which was < 6 RNUx per year. Kaplan-Meier and Cox proportional hazards regression were used to identify independent predictors of overall survival, and logistic regression was used to identify predictors of perioperative outcomes.
Results: We identified 37,479 RNUx performed across 1,290 hospitals. There were no differences in baseline health or cancer staging between patients who presents at low vs high volume centers. For short-term perioperative outcomes, treatment at a high-volume center was associated with lower odds of both 30-day (OR 0.73, p = 0.015) and 90-day (OR 0.80, p = 0.016) mortality. In addition, there was lower odds of positive margin (OR 0.82, p = 0.036) and higher use of perioperative chemotherapy (OR 1.29, p <0.001). Median survival at a high-volume center was 66.2 months (95% CI 63.6 – 68.8) vs 63.6 months (95% CI 61.9 – 65.3) low volume center (p = 0.002). On multivariable survival analysis, treatment at a high-volume center was associated with improved hazards of survival (HR HR 0.914, 95% CI 0.859-0.972). This relationship for long-term survival remained consistent on sensitivity analysis where patients who died within 90 days of surgery were removed.
Conclusions: Treatment at a high-volume hospital was associated not only with improved short-term perioperative outcomes such as 30- and 90-day mortality but also with improved hazards of survival long-term. The mechanism behind this is likely multifactorial with surgeon volume, facility experience, and ancillary support services all playing critical roles. Source of