Influence of hospital volume on nephrectomy mortality and complications: a systematic review and meta-analysis stratified by surgical type

Abstract

ObjectivesThe provision of complex surgery is increasingly centralised to high-volume (HV) specialist hospitals. Evidence to support nephrectomy centralisation however has been inconsistent. We conducted a systematic review and meta-analysis to determine the association between hospital case volumes and perioperative outcomes in radical nephrectomy, partial nephrectomy and nephrectomy with venous thrombectomy.MethodsMedline, Embase and the Cochrane Library were searched for relevant studies published between 1990 and 2016. Pooled effect estimates for nephrectomy mortality and complications were calculated for each nephrectomy type using the DerSimonian and Laird random-effects model. Sensitivity analyses were performed to examine the effects of heterogeneity on the pooled effect estimates by excluding studies with the heaviest weighting, lowest methodological score and most likely to introduce bias from misclassification of standardised hospital volume.ResultsSome 226 372 patients from 16 publications were included in our review and meta-analysis. Considerable between-study heterogeneity was noted and only a few reported volume–outcome relationships specifically in partial nephrectomy or nephrectomy with venous thrombectomy.HV hospitals were correlated with a 26% and 52% reduction in mortality for radical nephrectomy (OR 0.74, 95% CI 0.61 to 0.90, p<0.01) and nephrectomy with venous thrombectomy (OR 0.48, 95% CI 0.29 to 0.81, p<0.01), respectively. In addition, radical nephrectomy in HV hospitals was associated with an 18% reduction in complications (OR 0.82, 95% CI 0.73 to 0.92, p<0.01). No significant volume–outcome relationship in mortality (OR 0.84, 95% CI 0.31 to 2.26, p=0.73) or complications (OR 0.85, 95% CI 0.55 to 1.30, p=0.44) was observed for partial nephrectomy.ConclusionsOur findings suggest that patients undergoing radical nephrectomy have improved outcomes when treated by HV hospitals. Evidence of this in partial nephrectomy and nephrectomy with venous thrombectomy is however not yet clear and could be secondary to the low number of studies included and the small patient number in our analyses. Further investigation is warranted to establish the full potential of nephrectomy centralisation particularly as existing evidence is of low quality with significant heterogeneity.

Hospital volume and short‐term outcomes after cytoreductive nephrectomy

“…When it comes to nephrectomy, there is also a need to account for different nephrectomy types (RN vs PN vs CN) considering the differences in technical complexity and rates of adverse outcomes. One recent systemic review with stratified meta‐analyses included 16 studies, the majority of which focused on RN (10 studies on RN, two studies on nephrectomy with thrombectomy, and four studies on PN) . Our study adds to the literature with novel findings showing the volume‐outcome association in the setting of CN.…”

“…In the field of urology, numerous studies focused on radical cystectomy and radical prostatectomy . However, there is a paucity of data on the association between surgical volume and outcomes after nephrectomy . When it comes to nephrectomy, there is also a need to account for different nephrectomy types (RN vs PN vs CN) considering the differences in technical complexity and rates of adverse outcomes.…”

“…[10][11][12][13][14] When it comes to the volume-outcome association in nephrectomy, studies in the literature almost exclusively focus on radical nephrectomy (RN) or partial nephrectomy (PN) for nonmetastatic RCC. 15 It is well documented that RN, PN, and CN have different surgical complexities and perioperative safety profiles. 7,8,15,16 The population of patients undergoing CN is also generally at higher risk with poorer baseline health than patients undergoing RN or PN.…”

“…15 It is well documented that RN, PN, and CN have different surgical complexities and perioperative safety profiles. 7,8,15,16 The population of patients undergoing CN is also generally at higher risk with poorer baseline health than patients undergoing RN or PN. 4,7,16 Herein, we hypothesized that volume-outcome associations might also exist for CN and there have been no studies reported on this topic in the literature.…”

Increased utilization of partial nephrectomy in the robotic surgery era

“…Hospital volume and surgeon volume were independent predictors of perioperative outcomes of patients undergoing RAPN, with hospital volume playing a greater impact than surgeon volume . A systematic review and meta‐analysis confirmed improved outcomes in the UK following the centralization of care …”