Measuring quality for robot-assisted radical cystectomy worldwide: External validation of the quality cystectomy score utilizing the international robotic cystectomy consortium
Aly AAH, Ahmed Y, Kozlowski J, Wijburg C, Wiklund P, Hosseini A, Peabody JO, Menon M, Canda A, Richstone L, Wagner A, Kaouk J, Mottrie A, Rha KH, Kelly J, Tan WS, Redorta JP, Khan MS, Kawa O, Gaboradi F, Saar M, Hemal A, Stockle M, Maatman T, and Guru KA. Measuring quality for robot-assisted radical cystectomy worldwide: External validation of the quality cystectomy score utilizing the international robotic cystectomy consortium. Can Urol Assoc J 2017; 11(9):S315-S316.
Can Urol Assoc J
Introduction: Ensuring quality and comprehensive patient care is a duty of modern surgical practice. To optimize care for patients undergoing cystectomy, our group developed best practices for patients undergoing robot-assisted radical cystectomy (RARC) - Quality Cystectomy Score (QCS). In this study, we sought to validate the QCS and its effect on survival utilizing the International Robotic Cystectomy Consortium (IRCC) database. Methods: Retrospective review of IRCC database (23 institutions from 12 countries) was performed. QCS is a composite measure of surgical performance based on four sets of quality metrics (I- preoperative criteria [administration of neoadjuvant chemotherapy]; II-operative criteria [overall operative time (<6.5 hours) and estimated blood loss <500 ml]; III-pathological criteria [negative soft tissue surgical margins and lymph node yield of >20]; and IV-perioperative criteria [no Clavien- Dindo Grade III-IV complications, readmission, or mortality within 30-d]). QCS was used to evaluate surgical performance and Kaplan-Meier method was used to compute relationship to oncological outcomes (recurrence-free survival [RFS], diseasespecific survival [DSS], and overall survival [OS] rates]. Cox proportional hazards model was fit to evaluate predictors of survival Results: 1412 patients were included. Mean age was 67 years; 41% had extravesical and 22% were node-positive; 20% received NAC. Improvements in all the individual domains were observed except the perioperative domain, which was high and did not change. 86% received at least three stars and the proportion of patients receiving four stars increased from 8% in 2006 to 40% in 2016. Patients who had higher QCS star score showed better RFS, DSS, and OS (log rank p<0.001). On multivariable Cox proportional hazards analysis, patients who had lower QCS scores were more likely to have worse RFS (odds ratio [OR] 1.32; 95% confidence interval [CI] 1.01-1.92; p=0.04), DSS (OR 1.59; 95% CI 1.05-2.40; p=0.03), and OS (OR 1.69; 95% CI 1.27-2.25; p=0.004). Conclusions: QCS was a significant predictor of RFS, DSS, and OS and was able to measure the quality of surgical care worldwide. QCS can be measured to monitor programs and guide remediation.