Research Article: Hospital Surgical Volume, Utilization, Costs and Outcomes of Retroperitoneal Lymph Node Dissection for Testis Cancer

Date Published: April 9, 2012

Publisher: Hindawi Publishing Corporation

Author(s): Hua-yin Yu, Nathanael D. Hevelone, Sunil Patel, Stuart R. Lipsitz, Jim C. Hu.


Objectives. Retroperitoneal lymph node dissection (RPLND) outcomes for testis cancer originate mostly from single-center series. We characterized population-based utilization, costs, and outcomes and assessed whether higher volume affects outcomes. Methods and Materials. Using the US Nationwide Inpatient Sample from 2001–2008, we identified 993 RPLND and used propensity score methods to assess utilization, costs, and inpatient outcomes based on hospital surgical volume. Results. 51.6% of RPLND were performed at hospitals where there were two or fewer cases per year. RPLND was more commonly performed at large urban teaching hospitals, where men were younger, more likely to be white and earning incomes exceeding the 50th percentile (all P ≤ .05). Higher hospital volumes were associated with fewer complications and more routine home discharges (all P ≤ .047). However, higher volume hospitals had more transfusions (P = .004) and incurred $1,435 more in median costs (P < .001). Limitations include inability to adjust for tumor characteristics and absence of outpatient outcomes. Conclusions. Sociodemographic differences exist between high versus low volume RPLND hospitals. Although higher volume hospitals had more transfusions and higher costs, perhaps due to more complex cases, they experienced fewer complications. However, most RPLND are performed at hospitals where there were two or fewer cases per year.

Partial Text

Testis cancer is the most common malignancy among US men aged 18–34 years. The overall incidence of germ cell tumors has risen since 1973, and the annual increase in the incidence of nonseminomatous germ cell tumors (NSGCT-) has been 2% per year [1, 2]. Retroperitoneal lymph node dissection (RPLND) is used for the treatment of men with stage I NSGCT, low volume stage II disease, and in the postchemotherapy setting to eradicate residual mass. However, RPLND utilization has decreased since 1988 due to the increased use of surveillance and primary chemotherapy [3].

The relative low incidence of testis cancer (5.5 per 100,000 men) compared with more common genitourinary cancers such as prostate cancer (156 per 100,000 men) [11] contributes to the challenge of exploring RPLND population-based outcomes. While published RPLND outcomes come largely from experienced high volume hospitals [12–17], we found that more than half of all RPLND are performed at hospitals with volumes of less than three RPLND annually. Thus, with a more stringent definition for “high volume” of >40 cases per year, the vast majority of RPLND is performed at low volume centers. Therefore published RPLND series may not be representative of community outcomes. While higher provider volume is associated with improved outcomes for genitourinary oncologic conditions including radical prostatectomy, cystectomy, and nephrectomy [4], this effect has yet to be studied or demonstrated for RPLND. To our knowledge, this is the first population-based study to characterize RPLND patterns of care, outcomes, and costs, and to demonstrate volume outcomes effects.

This is the first population-based study of RPLND utilization, costs and outcomes that also characterizes hospital volume outcomes effects for RPLND. The majority of cases are performed at hospitals with two or fewer RPLNDs per year. Sociodemographic differences exist between high versus low RPLND volume hospitals, which suggests an inequity in access. Higher volume hospitals had higher transfusion rates and incurred higher costs, possibly related to higher degrees of surgical case complexity. Finally, high volume hospitals had fewer complications and greater likelihood of routine home discharge, despite likely greater case complexity.