AUA 2018: Adrenalectomy: Shouldn’t Urologists Be Doing More?
In this study, the authors assess whether there is a difference in outcomes depending on the specialty training of the surgeon – with the understanding that if no differences exist, urologists should begin to claim this operation back. They utilize the NSQIP database to address this question – though the database is limited to short-term outcomes. They extracted all adrenalectomy cases between 2011 and 2015 – both open and laparoscopic cases were assessed. Outcomes of interest included post-surgical complications, reoperations, 30-day readmission, mortality, and hospital length of stay.
A total of 3358 patients who underwent adrenalectomy were included, 3012 (90%) by a general surgeon and 334 (10%) by a urologist. On univariate analysis and on multivariate analysis accounting for potential confounders, there were no differences in post-surgical complication number, length of stay (LOS), rate of reoperation, 30-day readmission, and mortality between general surgeons and urologists performing adrenalectomies. Dr. Raman did note that there was a trend towards better outcomes in the hands of urologists (not clinically significant). While interesting and compelling that urologists should technically be able to do more of the adrenalectomies, there are a few limitations and points to consider:
1. By pure volume, there are more general surgeons than urologists. The referral pattern and distribution of cases may just reflect the ability to handle the volume!
2. The indication for the adrenalectomy is not assessed. True malignancy vs. adrenal endocrine pathology may account for some of the differences. Endocrine surgeons may be better versed in the evaluation and work-up of adrenal masses and pathology and may, therefore, draw more volume.
- However, the audience members noted that, if an effort is made to learn the endocrine evaluation, then urologists may be better technically suited to complete these retroperitoneal procedures.
3. The urology cohort was more likely to perform the surgery in an open fashion (though not statistically significant) – perhaps we are not as adept in minimally invasive techniques for adrenalectomy as our general surgery colleagues?
- Dr. Raman notes that the rates were actually very similar between the groups.
The Asian colleagues in the room note that upwards of 70-80% of the adrenalectomies in Japan are done by urologists – but they are all well versed in the endocrine management and work-up.
Take-home point: If urologists in North America want to draw back the volume, then an effort needs to be made to learn the endocrine evaluation and work with the endocrinologists and primary care physicians to increase referral.
Presented By: Jay Fuletra, MD
Co-Authors: Amber Schilling, Christopher Hollenbeak, Jay Raman
Author Affiliation: Pennsylvania State University, Pennsylvania
Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, | twitter: @tchandra_uromd at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA