Upper Urinary Tract
Nephroureterectomy surgery in the UK in 2012: British Association of Urological Surgeons (BAUS) Registry data Stephen S. Connolly and Mark A. Rochester* on behalf of BAUS Department of Surgical Oncology, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK, and *Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
Objective To report registry data obtained by the British Association of Urological Surgeons (BAUS) for nephroureterectomy (NU) surgery in the UK performed between 1 January and 31 December 2012.
Subjects/Patients and Methods Registry data entered by each individual surgeon’s team (self-reported) on all 6042 nephrectomy surgeries reported to BAUS during 2012 were analysed to identify all NU surgery. Parameters for analysis included demographics, indication, type of surgery, histopathology and complications (Clavien system) of surgery. Data did not include tumour location or multiplicity, preoperative diagnostic evaluation or details of minimally invasive surgery (MIS) undertaken. Before analysis for this report a central process of ‘datacleansing’ was undertaken by a BAUS group to address any discrepancy between the listed surgery and the preoperative indication.
Results In all, 863 NU surgeries were included, performed by 220 consultant surgeons in 119 centres, and the median (range) number of NU per surgeon and unit was 3 (1–20) and 6 (1–29), respectively. The most common age group was 71– 80 years (40%), most were male (64%), and haematuria
Introduction Although urothelial cancer (UC) of the bladder is common, upper tract UC (UTUC) accounts for only 5% of the disease and has an annual incidence in Western countries, including the UK, of about 1–2 per 100 000 population [1,2]. As a more aggressive variant of UC, the ‘gold-standard’ therapy is radical nephroureterectomy (NU); however, greater subspecialisation and increased use of minimally invasive surgery (MIS) may have reduced the numbers of NU performed by the general urologist [3]. Despite the clear lethality of UTUC,
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was the most common presentation (74%). The dominant pathology was upper tract urothelial cancer (89%, 735), with final stage ≥pT2 in 47% (367), and the grade was 1, 2 or 3 in 6% (38), 36% (228) and 58% (362) respectively. Operative technique included MIS in 85% (720) and total reported operative complication rate (any Clavien) was 15% (128), of which Clavien ≥3 was reported in 4% (36), and perioperative death was reported in nine patients (1%). Advantages in favour of MIS included reduced hospital stay (median 5 vs 8 days), reduced major blood loss (3% vs 14%) and reduced transfusion requirement (6% vs 24%). In all, 76 cases (8%) were excluded from analysis based on benign pathology leading to reassignment to the ‘simple nephrectomy’ category.
Conclusions NU is currently a low-volume operation (median 3 cases/ year) within the remit of the nephrectomy surgeon, but is a safe procedure with a relatively low complication rate. Most NU surgery in the UK is now performed with laparoscopic assistance, with advantages including reduced major blood loss, reduced transfusion requirement and shorter hospital stay.
Keywords upper tract urothelial cancer, nephroureterectomy, UK
the performance of NU seems now to be associated with considerable variability in technique, with many different combinations of laparoscopic, open and cystoscopic techniques possible, with an uncertain effect on both patient safety and oncological outcomes [4]. In 2012, as part of a government initiative for the compulsory reporting of surgeon-specific outcomes for surgery, the BAUS required urologists performing any nephrectomy surgery in England to enter their data for all such surgery performed between 1 January and 31 December 2012 on a centralised
© 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12827 Published by John Wiley & Sons Ltd. www.bjui.org
Nephroureterectomy surgery in the UK in 2012
national database registry. Entry of data to this database was also made available to all urologists within the UK. This summary report is specific to NU surgery information collected by that database. Offering a contemporary review of NU practice within the UK, this article was invited by the Board of Trustees of BAUS (Officers of the Association) and it is the intention of this report to make public an accurate description of the current state of NU surgery performed in the UK in 2012. International guidelines have been produced by the European Association of Urology (EAU), amongst others, in relation to UTUC and NU surgery since 2004, and a recent update provides a template for the current controversies that may be addressed by a national report of this scale [5]. Within the last few years numerous working groups have developed to examine the complexities that exist in relation to this surgery, such as the safety of laparoscopy, the optimum management of the distal ureter and bladder, as well as the role for lymphadenectomy [5]. Importantly, the purpose of the present survey was not to address these controversies, but to provide an accurate description of current practice to facilitate audit of individual surgeon and centre outcomes.
Subjects/Patients and Methods At the request of BAUS, data in relation to any nephrectomy surgery performed between 1 January and 31 December 2012 was requested from all surgeons performing this surgery in England, and data entry was invited from all urologists within the UK (Appendix 1 lists all contributing surgeons and centres). Data were entered by each individual surgeon’s team to a web-based database tool established by the BAUS Section of Oncology (audits.baus.org.uk) and commissioned from Nuvola. Access to this database was provided by the BAUS and was password privileged. The BAUS is a membership-based organisation to which qualified medical practitioners in the field of urological surgery are eligible to apply for membership. Although there is no requirement for urologists in England to have membership of BAUS, there is no other similar national organisation within the UK. This nephrectomy database was not specific to NU surgery, and in addition to basic demographic details, 59 patientspecific parameters were included. Whilst a few of these data items were mandatory, there was no obligation to provide complete data. A paper pro forma produced by the BAUS based on this database amounts to three A4 pages (http:// www.baus.org.uk/Resources/BAUS/Documents/PDF%20 documents/date%20and%20audit/NephrectomyProformas.pdf, 2012), and it is therefore considered beyond the ability of this report to provide this detail. Recorded parameters can be considered within the following surgical sub-headings:
(i) Presentation and indication; (ii) Diagnosis and comorbidity; (iii) Stage of malignancy; (iv) Surgeon; (v) Details of procedure; (vi) Outcome and complications; and (vii) Histopathology. For the purpose of the present report on NU surgery, all patients were identified though this dataset. At the outset of this report it was noted that data were very limited in relation to tumour location, preoperative diagnostic evaluation and precise details of the MIS undertaken. It is hoped that this will be addressed in future modifications of the database. Exclusion criteria for the present report included cases where the primary procedure was missing or listed as ‘other’. For the purpose of the present report the complications of NU surgery are presented with the Clavien system, and major blood loss was defined as an estimated volume of >1 L. Before any formal analysis of the data provided by this database, a process of ‘data cleansing’ was undertaken centrally by a BAUS committee to address what were felt to be inconsistencies between the listed surgery and the preoperative indication. As a result, some cases listed as NU but noted to have a preoperative benign indication were reassigned to the category of ‘simple nephrectomy’ and therefore excluded from this NU analysis. Other recategorisations performed centrally due to data inconsistencies included those listed as undergoing ‘radical nephrectomy’ with the indication ‘being performed as a donor’ being changed to ‘simple nephrectomy’, and those listed as undergoing ‘simple nephrectomy’ with the indication ‘being a renal malignancy’ being re-categorised as ‘radical nephrectomy’ (Fig. 1). Detailed comparative statistical sub-analysis of the data within this report was not undertaken due to the absence of randomisation, and the decision was taken to offer this report as pure descriptive data.
Results An overview of nephrectomy surgery performed in England in 2012 is presented in Figure 1. The ‘data cleansing’ can be considered to have little effect on the overall numbers, but did lead to the exclusion of 76 cases (8%) originally listed as NU by the operating surgeon, re-categorised by the committee due to benign pathology as simple nephrectomy, whether or not NU may have been undertaken. Cases were otherwise excluded from analysis based on missing (n = 43) or ‘other’ primary procedure (n = 45). The characteristics of the patient population are presented in Table 1. Most patients were aged >60 years (83%), frequently presented with haematuria (74%), and mostly had satisfactory renal function (serum creatinine 50% in bed, but not bedbound 4 – bedbound (5 – death) Not recorded Serum creatinine (lmol/L), n (%) Recorded Normal (200) Not recorded
Table 2 Disease parameters Value
72 (32–92, 64–75) 4 859 553 (64.4) 306 (35.6) 4 777 578 (74.4) 74 (9.5) 125 (16.1) 86 674 247 (36.6) 304 (45.1) 109 (16.2) 14 (2.1) 0 189 697 512 (73.5) 169 (24.2) 16 (2.3) 166
IQR, interquartile range.
Group [ECOG] score 0–1, 82%). Disease-specific parameters are presented in Table 2. All patients had a diagnosis of malignancy, unsurprisingly dominated by UTUC (89%). Diagnosis category is likely based on the final pathology report after surgery and does not necessarily relate to the working diagnosis preoperatively, which may have been UTUC in all cases. The listed TNM stage and grade is
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Parameter Diagnosis: Recorded UTUC (TCC) RCC (including clear cell, papillary, chromophobe and collecting duct carcinoma) Other cancer Not recorded T-stage of disease: Recorded 0 a/papillary (UC) 1 2 3 4 In situ (UC) Not recorded N-stage: Recorded 0, negative node 1–3, positive nodal disease X/unknown Not recorded M-stage: Recorded 0, negative for metastasis 1, positive Not recorded Grade of UTUC: Recorded G1 G2 G3 Not recorded
n (%)
822 735 (89.4) 71 (8.6) 16 (2) 41 781 8 (1) 193 (24.7) 210 (26.9) 102 (13.1) 226 (28.9) 39 (5) 3 (0.4) 82 794 438 (55.2) 78 (9.8) 278 (35) 69 485 453 (93.4) 32 (6.6) 378 628 38 (6.1) 228 (36.3) 362 (57.6) 235
thought likely to have been reported based on the best clinical information, which is considered to be histopathology data when available. Metastatic involvement of lymph nodes
Nephroureterectomy surgery in the UK in 2012
Table 3 Surgery overview Variable
Value
Surgery technique, n (%) Recorded Open surgery MIS technique Not recorded Grade of operating surgeon, n (%) Recorded Consultant Specialist registrar or other non-consultant grade Not recorded Surgery volume, median (IQR, total range) Cases by consultant Cases by centre
850 130 (15.3) 720 (84.7) 13 858 803 (93.6) 55 (6.4) 5 3 (1–5; 1–20) 6 (3–10; 1–29)
Discussion
Operating time, n (%) Type of surgery Recorded 6 h Not recorded
Open
11 65 22 5
103 (10.7) (63.1) (21.3) (4.9) 27
MIS
Total
614 59 (9.6) 399 (65) 143 (23.3) 13 (2.1) 106
718 71 (9.9) 464 (64.6) 165 (23) 18 (2.5) 145*
Length of stay in hospital Type of surgery Median (range) stay, days, Not recorded, n
The complications of surgery are presented in Tables 4 and 5 with subdivision between MIS and open surgery. An estimated blood loss of >0.5 L was reported in 37% of those undergoing open surgery vs 12% of the MIS group, and blood transfusion was administered to 24% of the open group and 6% of the MIS group. Complications are further presented according to the Clavien-Dindo system in Table 4, with subdivision in to intra- and postoperative complications in Table 5. MIS was associated with Clavien 3–5, intraoperative, and postoperative complications in 4%, 3% and 14% respectively, vs a corresponding 6%, 12% and 24% for open surgery.
Open
MIS
Total
8 (1–109) 14
5 (0–106) 62
5 (0–109) 77
*In 13 cases the type of surgery (open or MIS) was not recorded, and therefore the total numbers for open surgery and MIS do not add up to the total number. IQR, interquartile range.
or other organs was predictably unusual (80% of all such surgery performed in the UK in 2012, representing a substantial strength of the present publication. However, some cases performed within the private healthcare system may have eluded reporting in this dataset, but there is no reasonable evidence to suggest that this introduced significant bias. The data presented in the present report therefore presents an accurate picture of contemporary NU surgery in the UK in 2012, albeit with limitations. The dataset collected in the present report was generated by the BAUS for audit purposes and has been refined on an annual basis. It is likely that further data obtained in the coming years from this national database will address some of the questions posed elsewhere but left unanswered by the present report. Differences clearly exist between UC of the bladder and UTUC, which have been reported elsewhere and are further supported by the present report [3]. Although limited by the lack of clarity for the methodology regarding the grading system used (it seems likely that the 1973 WHO system was largely used in preference to the 2004 modification), it is important to note that in this series grade 1 UTUC was reported in only 6% of NU surgeries [10]. Furthermore, muscle-invasive and locally advanced disease (T stage ≥2) was reported in 47% of cases with a further ‘invasive’ group (T1) in 27%. Importantly this increased aggression by stage and grade may not reflect the entirety of UTUC in the UK with complete accuracy, as some cases may have been managed by a less radical strategy (such as endoscopic ablative therapy) that cannot be clearly transparent in the present report [11]. Controversies in the diagnostic pathway for UTUC continue to exist, but are not addressed by the present report as these data are not available. It is thought that with the establishment of CT urography, the performance of NU © 2014 The Authors BJU International © 2014 BJU International
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A
Fig. 2 Histogram presentations of the 863 NU
Total number by Centre
surgeries performed in UK in 2012. (A) Data
35
from 119 centres. The median (range) number per centre was 6 (1–29). (B) Data from 220
30
surgeons. The median (range) number per surgeon was 3 (1–20).
25 20 15 10
0
1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101 105 109 113 117
5
B
Total number by Consultant
25
20
15
10
5
1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106 113 120 127 134 141 148 155 162 169 176 183 190 197 204 211 218
0
without confirmed malignancy is appropriately declining [12]. But the need for diagnostic flexible uretero-pyeloscopy in all cases of UTUC has been questioned [13]. EAU guidelines state ‘if available, ureteroscopy and biopsy should be performed in . . . any UTUC patient’, but they allocate this a grade C recommendation indicative of the limited evidence [5]. Since the first laparoscopic nephrectomy, almost a quarter century ago, the ‘gold-standard’ technique for extirpative renal cancer surgery has evolved with the rapid displacement of open surgery due to the overt morbidity advantages of the MIS alternative [14,15]. The present series highlights the near-complete integration of MIS in to the practice of NU surgery in the UK, leaving only a minority (15%) of contemporary NU surgery performed by the traditional open technique in 2012. Interestingly, the most recent EAU guidelines fail to completely endorse laparoscopic NU, making specific mention of the fact that laparoscopic NU ‘has
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yet to achieve final proof of its safety’ [5]. But this report suggests that the belief in at least comparable oncological efficacy is sufficient to motivate most urologists in England to incorporate MIS in some way into their practice. The differences displayed between MIS and open surgery (most notable reduced blood loss and shorted length of hospitalisation) in the present report may not, however, reflect the technique of surgery but may be explained by a selection bias as no randomisation was used. The present report should therefore not be interpreted as displaying evidence of superiority for MIS over open surgery. Nor is it felt to display any message regarding volumes of surgery undertaken. Limitations of the present report have been touched upon in the methodology and above, but perhaps none more so than the self-reporting of data collected in this report. Ideally data for this surgery would be obtained from a centralised database recording validated outcomes in each
Nephroureterectomy surgery in the UK in 2012
Table 4 Complications of surgery overview Type of surgery, n (%)
Variable
Estimated blood loss: Recorded 2 L Not recorded Blood transfusion received: Recorded Transfusion received No transfusion Not recorded Perioperative Clavien-Dindo complication grade: Recorded no complications 1, any ‘deviation’ or minimal intervention 2, increased intervention (may include TPN, blood transfusion etc.) 3, endoscopic, radiological or surgical intervention 4, requiring intensive care 5, death Not recorded Subtotal for grade 3–5 complications Subtotal for ‘any’ complication (1–5)
Total*
Open
MIS
101 64 (63.3) 23 (22.8) 11 (10.9) 3 (3) 29
585 518 (88.5) 49 (8.4) 15 (2.6) 3 (0.5) 135
688 584 (84.9) 72 (10.5) 26 (3.8) 6 (0.9) 175
103 25 (24.3) 78 (75.7) 27
641 37 (5.8) 604 (94.2) 79
747 62 (8.3) 685 (91.7) 116
115 91 (79.1) 8 (7) 9 (7.8) 4 (3.5) 1 (0.9) 2 (1.7) 15 7 (6.1) 24 (20.9)
704 601 (85.4) 30 (4.3) 44 (6.2) 17 (2.4) 5 (0.7) 7 (1) 16 29 (4.1) 103 (14.6)
829 701 (84.6) 38 (4.6) 54 (6.5) 21 (2.5) 6 (0.7) 9 (1.1) 34 36 (4.3) 128 (15.4)
*In 13 cases the type of surgery (open or MIS) was not recorded, and therefore the total numbers for open surgery and MIS do not add up to the total number.
Table 5 Perioperative complication details: intra- and postoperative analysis† Type of surgery, n (%)
Complications
Intraoperative complications: Recorded No intraoperative complication(s) Bleeding Injury to adjacent organ (spleen, liver, pancreas or bowel) Pneumothorax Other Not recorded Subtotal for any intraoperative complication(s) Postoperative complications Recorded No postoperative complication(s) Bleeding Renal failure Wound problems Other Not recorded Subtotal for any postoperative complication(s)
Total*
Open
MIS
129 114 (88.4) 5 (3.9) 4 (3.1) 3 (2.3) 3 (2.3) 1 15 (11.6)
720 696 (96.6) 12 (1.7) 5 (0.7) 0 7 (1) 0 24 (3.3)
862 823 (95.5) 17 (2) 9 (1) 3 (0.3) 10 (1.2) 1 39 (4.5)
130 99 (76.2) 5 (3.8) 0 5 (3.8) 21 (16.2) 0 31 (23.8)
719 617 (85.8) 10 (1.4) 11 (1.5) 14 (1.9) 67 (9.3) 1 102 (14.2)
860 725 (84.3) 15 (1.7) 12 (1.4) 19 (2.2) 89 (10.4) 3 135 (15.7)
*In 13 cases the type of surgery (open or MIS) was not recorded, and therefore the total numbers for open surgery and MIS do not add up to the total number. †This data was entered separately to the Clavien classification in the previous table and this may explain some apparent inconsistencies between the two analyses. Furthermore, overlap may exist with some patients encountering both intra- and postoperative complications.
hospital and for each surgeon. No such validation exists for these data. In conclusion, the present report illuminates the current practice of NU surgery in the UK in 2012. This is a lowvolume operation (median 3 cases/year by surgeon and 6
cases/year by centre), but a safe procedure within the repertoire of the nephrectomy surgeon. Although this is not a comparative study, the data suggest that most patients are suitable for MIS and receive benefits in terms of reduced blood loss and shorter stay in hospital.
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Acknowledgement
9
We thank Sarah Fowler for data collection and analysis. 10
Conflict of Interest None declared.
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Correspondence: Stephen Connolly, Department of Urology, Addenbrooke’s Hospital, Box 43, Hills Road, Cambridge CB2 0QQ, UK. e-mail: [email protected] Abbreviations: EAU, European Association of Urology; ECOG, Eastern Cooperative Oncology Group; MIS, minimally invasive surgery; NU, nephroureterectomy; (UT)UC, (upper tract) urothelial cancer.
Nephroureterectomy surgery in the UK in 2012
Appendix 1 List of Contributing Surgeons and Centres Surgeon Abbasi, Z Adamson, A S Adeyoju, A A Adshead, J M Aho, T F Al-Akraa, M Allan, J Almond, D J Anderson, C J Andrews, S J Apakama, I Armitage, T Banerjee, G K Barber, N J Basu, S Bdesha, A S Beatty, J Bell, C R W Bhanot, S M Bhatt, R Biyani, C S Blake, C Boddy, J Bromage, S J Bromwich, E Browning, A J Bryan, N P Burgess, N A Burns-Cox, N Butterworth, P C Bycroft, J Campbell, I Cannon, A Carter, C J M Carter, P G Cartledge, J J Casey, R Chakravarti, A Chappell, B G Chen, T F Cherian, J Choi, W H Clavijo Eisele, J Cliff, A M Cohen, N P Cole, O J Collins, J Connolly, S Cooke, P W Cornaby, A J Corr, J G Coulthard, R Cresswell, J Crundwell, M C Cynk, M Daruwala, P D Datta, S N Davenport, K de Bolla, A R Devarajan, R Doherty, A P Donaldson, P J Dyer, J Eaton, J
Hospital Episode Statistics (HES) Trust/Centre THE ROTHERHAM NHS FOUNDATION TRUST WINCHESTER AND EASTLEIGH HEALTHCARE NHS TRUST STOCKPORT NHS FOUNDATION TRUST EAST AND NORTH HERTFORDSHIRE NHS TRUST CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST ROYAL FREE HAMPSTEAD NHS TRUST WEST SUFFOLK HOSPITALS NHS TRUST HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST ST GEORGE’S HEALTHCARE NHS TRUST DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST GEORGE ELIOT HOSPITAL NHS TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST IPSWICH HOSPITAL NHS TRUST FRIMLEY PARK HOSPITAL NHS FOUNDATION TRUST CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST BUCKINGHAMSHIRE HOSPITALS NHS TRUST NORTHAMPTON GENERAL HOSPITAL NHS TRUST NORTHAMPTON GENERAL HOSPITAL NHS TRUST PRIVATE PATIENTS UNIVERSITY HOSPITAL BIRMINGHAM NHS FOUNDATION TRUST MID YORKSHIRE HOSPITALS NHS TRUST ROYAL CORNWALL HOSPITALS NHS TRUST THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST STOCKPORT NHS FOUNDATION TRUST ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST MID YORKSHIRE HOSPITALS NHS TRUST CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST TAUNTON AND SOMERSET NHS FOUNDATION TRUST UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST EAST AND NORTH HERTFORDSHIRE NHS TRUST BLACKPOOL, FYLDE AND WYRE HOSPITALS NHS FOUNDATION TRUST TAUNTON AND SOMERSET NHS FOUNDATION TRUST THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST WESTERN SUSSEX HOSPITALS NHS TRUST LEEDS TEACHING HOSPITALS NHS TRUST COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST THE DUDLEY GROUP OF HOSPITALS NHS FOUNDATION TRUST WESTERN SUSSEX HOSPITALS NHS TRUST WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST PENNINE ACUTE HOSPITALS NHS TRUST EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST NORTHERN LINCOLNSHIRE AND GOOLE HOSPITALS NHS FOUNDATION TRUST WIRRAL UNIVERSITY TEACHING HOSPITAL NHS FOUNDATION TRUST ABERDEEN ROYAL INFIRMARY PRINCESS ELIZABETH HOSPITAL, GUERNSEY ASHFORD AND ST PETER’S HOSPITALS NHS TRUST CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST UNIVERSITY HOSPITAL OF WALES SOUTH TEES HOSPITALS NHS FOUNDATION TRUST ROYAL DEVON AND EXETER NHS FOUNDATION TRUST MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST UNITED LINCOLNSHIRE HOSPITALS NHS TRUST UNIVERSITY HOSPITAL OF WALES GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST WREXHAM MAELOR HOSPITAL SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST UNIVERSITY HOSPITAL BIRMINGHAM NHS FOUNDATION TRUST IPSWICH HOSPITAL NHS TRUST SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST
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Table 6 (continued) Appendix 1 Continued Surgeon Eddy, B Eden, C G Fiala, R Foster, M C Frymann, R J Gall, Z J Gana, H B Y Garnett, S Gibbons, N Gillatt, D A Godbole, H C Golash, A Gowardhan, B Gujral, S Gunendran, T Haldar, N Hanbury, D C Hawkyard, S J Haynes, M D Henderson, A Hicks, J A Hindley, R G Hodgson, D J Hotston, M Howell, G P Hrouda, D Ilie, C Jain, S Janjua, K S Javle, P Johnson, M I Johnson, P Joshi, H Joyce, A D Keeley, F X Kelkar, A Kelleher, J P Khattak, A Q Kimuli, M Kirollos, M M Kockelbergh, R C Kooiman, G Kumar, P Kynaston, H G Laniado, M E Larner, T Latif, Z Lau, M W le Roux, P J Leung, S Leveckis, J Lewis, G Lockyer, C R W Lodge, R N Lynch, M Lynn, N N K MacDermott, J P Madaan, S Maddineni, S B Maheshkumar, P Makar, A A Makunde, J T Manikandan, R Mann, G S
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Hospital Episode Statistics (HES) Trust/Centre EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST ROYAL SURREY COUNTY NHS FOUNDATION TRUST CAUSEWAY HOSPITAL HEART OF ENGLAND NHS FOUNDATION TRUST JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST ST HELENS AND KNOWSLEY HOSPITALS NHS TRUST EAST SUSSEX HOSPITALS NHS TRUST IMPERIAL COLLEGE HEALTHCARE NHS TRUST NORTH BRISTOL NHS TRUST NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE NHS TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST BUCKINGHAMSHIRE HOSPITALS NHS TRUST EAST AND NORTH HERTFORDSHIRE NHS TRUST SCARBOROUGH AND NORTH EAST YORKSHIRE HEALTH CARE NHS TRUST SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST WESTERN SUSSEX HOSPITALS NHS TRUST BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST PORTSMOUTH HOSPITALS NHS TRUST ROYAL CORNWALL HOSPITALS NHS TRUST ROYAL UNITED HOSPITAL BATH NHS TRUST IMPERIAL COLLEGE HEALTHCARE NHS TRUST THE QUEEN ELIZABETH HOSPITAL KING’S LYNN NHS TRUST LEEDS TEACHING HOSPITALS NHS TRUST VICTORIA HOSPITAL, KIRKCALDY LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST UNIVERSITY HOSPITAL OF WALES LEEDS TEACHING HOSPITALS NHS TRUST GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST and NORTH BRISTOL NHS TRUST BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST BUCKINGHAMSHIRE HOSPITALS NHS TRUST ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST and ST HELENS AND KNOWSLEY HOSPITALS NHS TRUST SHREWSBURY AND TELFORD HOSPITAL NHS TRUST SOUTH DEVON HEALTHCARE NHS FOUNDATION TRUST UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST KING’S COLLEGE HOSPITAL NHS FOUNDATION TRUST THE ROYAL MARSDEN NHS FOUNDATION TRUST UNIVERSITY HOSPITAL OF WALES HEATHERWOOD AND WEXHAM PARK HOSPITALS NHS FOUNDATION TRUST BRIGHTON AND SUSSEX UNIVERSITY HOSPITALS NHS TRUST ROYAL ALEXANDRA HOSPITAL (PAISLEY) SALFORD ROYAL NHS FOUNDATION TRUST EPSOM AND ST HELIER UNIVERSITY HOSPITALS NHS TRUST and ST GEORGE’S HEALTHCARE NHS TRUST VICTORIA HOSPITAL, KIRKCALDY DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST ASHFORD AND ST PETER’S HOSPITALS NHS TRUST SHREWSBURY AND TELFORD HOSPITAL NHS TRUST SOUTH DEVON HEALTHCARE NHS FOUNDATION TRUST DARTFORD AND GRAVESHAM NHS TRUST SALFORD ROYAL NHS FOUNDATION TRUST THE QUEEN ELIZABETH HOSPITAL KING’S LYNN NHS TRUST WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST ISLE OF WIGHT NHS PRIMARY CARE TRUST WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
Nephroureterectomy surgery in the UK in 2012
Table 6 (continued) Appendix 1 Continued Surgeon Mantle, M Mark, I R Matanhelia, S S McClinton, S McInerney, P D McIntyre, I G McLarty, E McLoughlin, J McNeill, S A Mehta, S Mellon, J K Menezes, P Mills, R D Mokete, M Montague, R Motiwala, H G Mulholland, C K Mumtaz, F H Munro, N Myatt, A Nathan, S Neilson, D Nicol, D L Oades, G Oakley, N O’Brien, T S O’Kane, H F Okeke, A A O’Riordan, A Paez, E Page, T Parkin, J Patel, N Patel, P Pathak, S Patil, K Payne, D Phillips, J T Phillips, S M A Phipps, S Pillai, M K Potter, J M Rajan, T N Rajjayabun, P Rane, A Ravi, R Ravichandran, S Richmond, P J M Riddick, A C P Rimington, P D Rix, D Rix, G H Rochester, M Rowe, E Sahadevan, K Sandhu, S Sangar, V K Sells, H Shackley, D C Shah, Z Shaikh, N N A Sharma, H Sherwood, B Singh, S Solomon, L
Hospital Episode Statistics (HES) Trust/Centre ROYAL CORNWALL HOSPITALS NHS TRUST UNITED LINCOLNSHIRE HOSPITALS NHS TRUST LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST ABERDEEN ROYAL INFIRMARY PLYMOUTH HOSPITALS NHS TRUST CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST PLYMOUTH HOSPITALS NHS TRUST PRIVATE PATIENTS WESTERN GENERAL HOSPITAL, EDINBURGH SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST HEATHERWOOD AND WEXHAM PARK HOSPITALS NHS FOUNDATION TRUST ALTNAGELVIN AREA HOSPITAL BARNET AND CHASE FARM HOSPITALS NHS TRUST ROYAL CORNWALL HOSPITALS NHS TRUST HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST PRIVATE PATIENTS EAST LANCASHIRE HOSPITALS NHS TRUST UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST SOUTHERN GENERAL HOSPITAL SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST and STOCKPORT NHS FOUNDATION TRUST GUY’S AND ST THOMAS’ NHS FOUNDATION TRUST BELFAST CITY HOSPITAL GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST OXFORD RADCLIFFE HOSPITALS NHS TRUST UNIVERSITY HOSPITAL BIRMINGHAM NHS FOUNDATION TRUST DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST ASHFORD AND ST PETER’S HOSPITALS NHS TRUST KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUST ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST HEART OF ENGLAND NHS FOUNDATION TRUST WESTERN GENERAL HOSPITAL, EDINBURGH EAST LANCASHIRE HOSPITALS NHS TRUST NORTHAMPTON GENERAL HOSPITAL NHS TRUST BELFAST CITY HOSPITAL WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST SURREY AND SUSSEX HEALTHCARE NHS TRUST BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST WARRINGTON AND HALTON HOSPITALS NHS FOUNDATION TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST WESTERN GENERAL HOSPITAL, EDINBURGH EAST SUSSEX HOSPITALS NHS TRUST THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST NORTH BRISTOL NHS TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST KINGSTON HOSPITAL NHS TRUST UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST PLYMOUTH HOSPITALS NHS TRUST SALFORD ROYAL NHS FOUNDATION TRUST ROYAL BERKSHIRE NHS FOUNDATION TRUST AIREDALE NHS FOUNDATION TRUST BEDFORD HOSPITAL NHS TRUST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST SHERWOOD FOREST HOSPITALS NHS FOUNDATION TRUST PORTSMOUTH HOSPITALS NHS TRUST
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Table 6 (continued) Appendix 1 Continued Surgeon Sriprasad, S I Stubington, S R Taneja, S Thilagarajah, R Thomas, B Thomas, D J Thurston, A V Turner, K J Umez-Eronini, O N Vale, J A Varadaraj, H Vesey, S G Viney, R Walton, T Waymont, B Webster, J J Wedderburn, A Wemyss-Holden, G D Weston, R Whittlestone, T Wilkinson, B Wilkinson, S Williams, S Wills, M I Wilson, J R Woodhouse, C R J Yates, D R
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Hospital Episode Statistics (HES) Trust/Centre DARTFORD AND GRAVESHAM NHS TRUST MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST LUTON AND DUNSTABLE HOSPITAL NHS FOUNDATION TRUST MID ESSEX HOSPITAL SERVICES NHS TRUST WESTERN GENERAL HOSPITAL, EDINBURGH THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST WEST HERTFORDSHIRE HOSPITALS NHS TRUST THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST NORTH CUMBRIA UNIVERSITY HOSPITALS NHS TRUST IMPERIAL COLLEGE HEALTHCARE NHS TRUST UNITED LINCOLNSHIRE HOSPITALS NHS TRUST SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST UNIVERSITY HOSPITAL BIRMINGHAM NHS FOUNDATION TRUST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST NORTH WEST LONDON HOSPITALS NHS TRUST ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST EAST LANCASHIRE HOSPITALS NHS TRUST ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST NORTH BRISTOL NHS TRUST THE ROTHERHAM NHS FOUNDATION TRUST PORTSMOUTH HOSPITALS NHS TRUST DERBY HOSPITALS NHS FOUNDATION TRUST UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST YORK HOSPITALS NHS FOUNDATION TRUST THE ROYAL MARSDEN NHS FOUNDATION TRUST SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST
Nephroureterectomy surgery in the UK in 2012: British Association of Urological Surgeons (BAUS) Registry data Stephen S. Connolly and Mark A. Rochester* on behalf of BAUS Department of Surgical Oncology, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK, and *Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
Objective To report registry data obtained by the British Association of Urological Surgeons (BAUS) for nephroureterectomy (NU) surgery in the UK performed between 1 January and 31 December 2012.
Subjects/Patients and Methods Registry data entered by each individual surgeon’s team (self-reported) on all 6042 nephrectomy surgeries reported to BAUS during 2012 were analysed to identify all NU surgery. Parameters for analysis included demographics, indication, type of surgery, histopathology and complications (Clavien system) of surgery. Data did not include tumour location or multiplicity, preoperative diagnostic evaluation or details of minimally invasive surgery (MIS) undertaken. Before analysis for this report a central process of ‘datacleansing’ was undertaken by a BAUS group to address any discrepancy between the listed surgery and the preoperative indication.
Results In all, 863 NU surgeries were included, performed by 220 consultant surgeons in 119 centres, and the median (range) number of NU per surgeon and unit was 3 (1–20) and 6 (1–29), respectively. The most common age group was 71– 80 years (40%), most were male (64%), and haematuria
Introduction Although urothelial cancer (UC) of the bladder is common, upper tract UC (UTUC) accounts for only 5% of the disease and has an annual incidence in Western countries, including the UK, of about 1–2 per 100 000 population [1,2]. As a more aggressive variant of UC, the ‘gold-standard’ therapy is radical nephroureterectomy (NU); however, greater subspecialisation and increased use of minimally invasive surgery (MIS) may have reduced the numbers of NU performed by the general urologist [3]. Despite the clear lethality of UTUC,
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was the most common presentation (74%). The dominant pathology was upper tract urothelial cancer (89%, 735), with final stage ≥pT2 in 47% (367), and the grade was 1, 2 or 3 in 6% (38), 36% (228) and 58% (362) respectively. Operative technique included MIS in 85% (720) and total reported operative complication rate (any Clavien) was 15% (128), of which Clavien ≥3 was reported in 4% (36), and perioperative death was reported in nine patients (1%). Advantages in favour of MIS included reduced hospital stay (median 5 vs 8 days), reduced major blood loss (3% vs 14%) and reduced transfusion requirement (6% vs 24%). In all, 76 cases (8%) were excluded from analysis based on benign pathology leading to reassignment to the ‘simple nephrectomy’ category.
Conclusions NU is currently a low-volume operation (median 3 cases/ year) within the remit of the nephrectomy surgeon, but is a safe procedure with a relatively low complication rate. Most NU surgery in the UK is now performed with laparoscopic assistance, with advantages including reduced major blood loss, reduced transfusion requirement and shorter hospital stay.
Keywords upper tract urothelial cancer, nephroureterectomy, UK
the performance of NU seems now to be associated with considerable variability in technique, with many different combinations of laparoscopic, open and cystoscopic techniques possible, with an uncertain effect on both patient safety and oncological outcomes [4]. In 2012, as part of a government initiative for the compulsory reporting of surgeon-specific outcomes for surgery, the BAUS required urologists performing any nephrectomy surgery in England to enter their data for all such surgery performed between 1 January and 31 December 2012 on a centralised
© 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12827 Published by John Wiley & Sons Ltd. www.bjui.org
Nephroureterectomy surgery in the UK in 2012
national database registry. Entry of data to this database was also made available to all urologists within the UK. This summary report is specific to NU surgery information collected by that database. Offering a contemporary review of NU practice within the UK, this article was invited by the Board of Trustees of BAUS (Officers of the Association) and it is the intention of this report to make public an accurate description of the current state of NU surgery performed in the UK in 2012. International guidelines have been produced by the European Association of Urology (EAU), amongst others, in relation to UTUC and NU surgery since 2004, and a recent update provides a template for the current controversies that may be addressed by a national report of this scale [5]. Within the last few years numerous working groups have developed to examine the complexities that exist in relation to this surgery, such as the safety of laparoscopy, the optimum management of the distal ureter and bladder, as well as the role for lymphadenectomy [5]. Importantly, the purpose of the present survey was not to address these controversies, but to provide an accurate description of current practice to facilitate audit of individual surgeon and centre outcomes.
Subjects/Patients and Methods At the request of BAUS, data in relation to any nephrectomy surgery performed between 1 January and 31 December 2012 was requested from all surgeons performing this surgery in England, and data entry was invited from all urologists within the UK (Appendix 1 lists all contributing surgeons and centres). Data were entered by each individual surgeon’s team to a web-based database tool established by the BAUS Section of Oncology (audits.baus.org.uk) and commissioned from Nuvola. Access to this database was provided by the BAUS and was password privileged. The BAUS is a membership-based organisation to which qualified medical practitioners in the field of urological surgery are eligible to apply for membership. Although there is no requirement for urologists in England to have membership of BAUS, there is no other similar national organisation within the UK. This nephrectomy database was not specific to NU surgery, and in addition to basic demographic details, 59 patientspecific parameters were included. Whilst a few of these data items were mandatory, there was no obligation to provide complete data. A paper pro forma produced by the BAUS based on this database amounts to three A4 pages (http:// www.baus.org.uk/Resources/BAUS/Documents/PDF%20 documents/date%20and%20audit/NephrectomyProformas.pdf, 2012), and it is therefore considered beyond the ability of this report to provide this detail. Recorded parameters can be considered within the following surgical sub-headings:
(i) Presentation and indication; (ii) Diagnosis and comorbidity; (iii) Stage of malignancy; (iv) Surgeon; (v) Details of procedure; (vi) Outcome and complications; and (vii) Histopathology. For the purpose of the present report on NU surgery, all patients were identified though this dataset. At the outset of this report it was noted that data were very limited in relation to tumour location, preoperative diagnostic evaluation and precise details of the MIS undertaken. It is hoped that this will be addressed in future modifications of the database. Exclusion criteria for the present report included cases where the primary procedure was missing or listed as ‘other’. For the purpose of the present report the complications of NU surgery are presented with the Clavien system, and major blood loss was defined as an estimated volume of >1 L. Before any formal analysis of the data provided by this database, a process of ‘data cleansing’ was undertaken centrally by a BAUS committee to address what were felt to be inconsistencies between the listed surgery and the preoperative indication. As a result, some cases listed as NU but noted to have a preoperative benign indication were reassigned to the category of ‘simple nephrectomy’ and therefore excluded from this NU analysis. Other recategorisations performed centrally due to data inconsistencies included those listed as undergoing ‘radical nephrectomy’ with the indication ‘being performed as a donor’ being changed to ‘simple nephrectomy’, and those listed as undergoing ‘simple nephrectomy’ with the indication ‘being a renal malignancy’ being re-categorised as ‘radical nephrectomy’ (Fig. 1). Detailed comparative statistical sub-analysis of the data within this report was not undertaken due to the absence of randomisation, and the decision was taken to offer this report as pure descriptive data.
Results An overview of nephrectomy surgery performed in England in 2012 is presented in Figure 1. The ‘data cleansing’ can be considered to have little effect on the overall numbers, but did lead to the exclusion of 76 cases (8%) originally listed as NU by the operating surgeon, re-categorised by the committee due to benign pathology as simple nephrectomy, whether or not NU may have been undertaken. Cases were otherwise excluded from analysis based on missing (n = 43) or ‘other’ primary procedure (n = 45). The characteristics of the patient population are presented in Table 1. Most patients were aged >60 years (83%), frequently presented with haematuria (74%), and mostly had satisfactory renal function (serum creatinine 50% in bed, but not bedbound 4 – bedbound (5 – death) Not recorded Serum creatinine (lmol/L), n (%) Recorded Normal (200) Not recorded
Table 2 Disease parameters Value
72 (32–92, 64–75) 4 859 553 (64.4) 306 (35.6) 4 777 578 (74.4) 74 (9.5) 125 (16.1) 86 674 247 (36.6) 304 (45.1) 109 (16.2) 14 (2.1) 0 189 697 512 (73.5) 169 (24.2) 16 (2.3) 166
IQR, interquartile range.
Group [ECOG] score 0–1, 82%). Disease-specific parameters are presented in Table 2. All patients had a diagnosis of malignancy, unsurprisingly dominated by UTUC (89%). Diagnosis category is likely based on the final pathology report after surgery and does not necessarily relate to the working diagnosis preoperatively, which may have been UTUC in all cases. The listed TNM stage and grade is
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Parameter Diagnosis: Recorded UTUC (TCC) RCC (including clear cell, papillary, chromophobe and collecting duct carcinoma) Other cancer Not recorded T-stage of disease: Recorded 0 a/papillary (UC) 1 2 3 4 In situ (UC) Not recorded N-stage: Recorded 0, negative node 1–3, positive nodal disease X/unknown Not recorded M-stage: Recorded 0, negative for metastasis 1, positive Not recorded Grade of UTUC: Recorded G1 G2 G3 Not recorded
n (%)
822 735 (89.4) 71 (8.6) 16 (2) 41 781 8 (1) 193 (24.7) 210 (26.9) 102 (13.1) 226 (28.9) 39 (5) 3 (0.4) 82 794 438 (55.2) 78 (9.8) 278 (35) 69 485 453 (93.4) 32 (6.6) 378 628 38 (6.1) 228 (36.3) 362 (57.6) 235
thought likely to have been reported based on the best clinical information, which is considered to be histopathology data when available. Metastatic involvement of lymph nodes
Nephroureterectomy surgery in the UK in 2012
Table 3 Surgery overview Variable
Value
Surgery technique, n (%) Recorded Open surgery MIS technique Not recorded Grade of operating surgeon, n (%) Recorded Consultant Specialist registrar or other non-consultant grade Not recorded Surgery volume, median (IQR, total range) Cases by consultant Cases by centre
850 130 (15.3) 720 (84.7) 13 858 803 (93.6) 55 (6.4) 5 3 (1–5; 1–20) 6 (3–10; 1–29)
Discussion
Operating time, n (%) Type of surgery Recorded 6 h Not recorded
Open
11 65 22 5
103 (10.7) (63.1) (21.3) (4.9) 27
MIS
Total
614 59 (9.6) 399 (65) 143 (23.3) 13 (2.1) 106
718 71 (9.9) 464 (64.6) 165 (23) 18 (2.5) 145*
Length of stay in hospital Type of surgery Median (range) stay, days, Not recorded, n
The complications of surgery are presented in Tables 4 and 5 with subdivision between MIS and open surgery. An estimated blood loss of >0.5 L was reported in 37% of those undergoing open surgery vs 12% of the MIS group, and blood transfusion was administered to 24% of the open group and 6% of the MIS group. Complications are further presented according to the Clavien-Dindo system in Table 4, with subdivision in to intra- and postoperative complications in Table 5. MIS was associated with Clavien 3–5, intraoperative, and postoperative complications in 4%, 3% and 14% respectively, vs a corresponding 6%, 12% and 24% for open surgery.
Open
MIS
Total
8 (1–109) 14
5 (0–106) 62
5 (0–109) 77
*In 13 cases the type of surgery (open or MIS) was not recorded, and therefore the total numbers for open surgery and MIS do not add up to the total number. IQR, interquartile range.
or other organs was predictably unusual (80% of all such surgery performed in the UK in 2012, representing a substantial strength of the present publication. However, some cases performed within the private healthcare system may have eluded reporting in this dataset, but there is no reasonable evidence to suggest that this introduced significant bias. The data presented in the present report therefore presents an accurate picture of contemporary NU surgery in the UK in 2012, albeit with limitations. The dataset collected in the present report was generated by the BAUS for audit purposes and has been refined on an annual basis. It is likely that further data obtained in the coming years from this national database will address some of the questions posed elsewhere but left unanswered by the present report. Differences clearly exist between UC of the bladder and UTUC, which have been reported elsewhere and are further supported by the present report [3]. Although limited by the lack of clarity for the methodology regarding the grading system used (it seems likely that the 1973 WHO system was largely used in preference to the 2004 modification), it is important to note that in this series grade 1 UTUC was reported in only 6% of NU surgeries [10]. Furthermore, muscle-invasive and locally advanced disease (T stage ≥2) was reported in 47% of cases with a further ‘invasive’ group (T1) in 27%. Importantly this increased aggression by stage and grade may not reflect the entirety of UTUC in the UK with complete accuracy, as some cases may have been managed by a less radical strategy (such as endoscopic ablative therapy) that cannot be clearly transparent in the present report [11]. Controversies in the diagnostic pathway for UTUC continue to exist, but are not addressed by the present report as these data are not available. It is thought that with the establishment of CT urography, the performance of NU © 2014 The Authors BJU International © 2014 BJU International
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A
Fig. 2 Histogram presentations of the 863 NU
Total number by Centre
surgeries performed in UK in 2012. (A) Data
35
from 119 centres. The median (range) number per centre was 6 (1–29). (B) Data from 220
30
surgeons. The median (range) number per surgeon was 3 (1–20).
25 20 15 10
0
1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101 105 109 113 117
5
B
Total number by Consultant
25
20
15
10
5
1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106 113 120 127 134 141 148 155 162 169 176 183 190 197 204 211 218
0
without confirmed malignancy is appropriately declining [12]. But the need for diagnostic flexible uretero-pyeloscopy in all cases of UTUC has been questioned [13]. EAU guidelines state ‘if available, ureteroscopy and biopsy should be performed in . . . any UTUC patient’, but they allocate this a grade C recommendation indicative of the limited evidence [5]. Since the first laparoscopic nephrectomy, almost a quarter century ago, the ‘gold-standard’ technique for extirpative renal cancer surgery has evolved with the rapid displacement of open surgery due to the overt morbidity advantages of the MIS alternative [14,15]. The present series highlights the near-complete integration of MIS in to the practice of NU surgery in the UK, leaving only a minority (15%) of contemporary NU surgery performed by the traditional open technique in 2012. Interestingly, the most recent EAU guidelines fail to completely endorse laparoscopic NU, making specific mention of the fact that laparoscopic NU ‘has
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yet to achieve final proof of its safety’ [5]. But this report suggests that the belief in at least comparable oncological efficacy is sufficient to motivate most urologists in England to incorporate MIS in some way into their practice. The differences displayed between MIS and open surgery (most notable reduced blood loss and shorted length of hospitalisation) in the present report may not, however, reflect the technique of surgery but may be explained by a selection bias as no randomisation was used. The present report should therefore not be interpreted as displaying evidence of superiority for MIS over open surgery. Nor is it felt to display any message regarding volumes of surgery undertaken. Limitations of the present report have been touched upon in the methodology and above, but perhaps none more so than the self-reporting of data collected in this report. Ideally data for this surgery would be obtained from a centralised database recording validated outcomes in each
Nephroureterectomy surgery in the UK in 2012
Table 4 Complications of surgery overview Type of surgery, n (%)
Variable
Estimated blood loss: Recorded 2 L Not recorded Blood transfusion received: Recorded Transfusion received No transfusion Not recorded Perioperative Clavien-Dindo complication grade: Recorded no complications 1, any ‘deviation’ or minimal intervention 2, increased intervention (may include TPN, blood transfusion etc.) 3, endoscopic, radiological or surgical intervention 4, requiring intensive care 5, death Not recorded Subtotal for grade 3–5 complications Subtotal for ‘any’ complication (1–5)
Total*
Open
MIS
101 64 (63.3) 23 (22.8) 11 (10.9) 3 (3) 29
585 518 (88.5) 49 (8.4) 15 (2.6) 3 (0.5) 135
688 584 (84.9) 72 (10.5) 26 (3.8) 6 (0.9) 175
103 25 (24.3) 78 (75.7) 27
641 37 (5.8) 604 (94.2) 79
747 62 (8.3) 685 (91.7) 116
115 91 (79.1) 8 (7) 9 (7.8) 4 (3.5) 1 (0.9) 2 (1.7) 15 7 (6.1) 24 (20.9)
704 601 (85.4) 30 (4.3) 44 (6.2) 17 (2.4) 5 (0.7) 7 (1) 16 29 (4.1) 103 (14.6)
829 701 (84.6) 38 (4.6) 54 (6.5) 21 (2.5) 6 (0.7) 9 (1.1) 34 36 (4.3) 128 (15.4)
*In 13 cases the type of surgery (open or MIS) was not recorded, and therefore the total numbers for open surgery and MIS do not add up to the total number.
Table 5 Perioperative complication details: intra- and postoperative analysis† Type of surgery, n (%)
Complications
Intraoperative complications: Recorded No intraoperative complication(s) Bleeding Injury to adjacent organ (spleen, liver, pancreas or bowel) Pneumothorax Other Not recorded Subtotal for any intraoperative complication(s) Postoperative complications Recorded No postoperative complication(s) Bleeding Renal failure Wound problems Other Not recorded Subtotal for any postoperative complication(s)
Total*
Open
MIS
129 114 (88.4) 5 (3.9) 4 (3.1) 3 (2.3) 3 (2.3) 1 15 (11.6)
720 696 (96.6) 12 (1.7) 5 (0.7) 0 7 (1) 0 24 (3.3)
862 823 (95.5) 17 (2) 9 (1) 3 (0.3) 10 (1.2) 1 39 (4.5)
130 99 (76.2) 5 (3.8) 0 5 (3.8) 21 (16.2) 0 31 (23.8)
719 617 (85.8) 10 (1.4) 11 (1.5) 14 (1.9) 67 (9.3) 1 102 (14.2)
860 725 (84.3) 15 (1.7) 12 (1.4) 19 (2.2) 89 (10.4) 3 135 (15.7)
*In 13 cases the type of surgery (open or MIS) was not recorded, and therefore the total numbers for open surgery and MIS do not add up to the total number. †This data was entered separately to the Clavien classification in the previous table and this may explain some apparent inconsistencies between the two analyses. Furthermore, overlap may exist with some patients encountering both intra- and postoperative complications.
hospital and for each surgeon. No such validation exists for these data. In conclusion, the present report illuminates the current practice of NU surgery in the UK in 2012. This is a lowvolume operation (median 3 cases/year by surgeon and 6
cases/year by centre), but a safe procedure within the repertoire of the nephrectomy surgeon. Although this is not a comparative study, the data suggest that most patients are suitable for MIS and receive benefits in terms of reduced blood loss and shorter stay in hospital.
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Acknowledgement
9
We thank Sarah Fowler for data collection and analysis. 10
Conflict of Interest None declared.
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Correspondence: Stephen Connolly, Department of Urology, Addenbrooke’s Hospital, Box 43, Hills Road, Cambridge CB2 0QQ, UK. e-mail: [email protected] Abbreviations: EAU, European Association of Urology; ECOG, Eastern Cooperative Oncology Group; MIS, minimally invasive surgery; NU, nephroureterectomy; (UT)UC, (upper tract) urothelial cancer.
Nephroureterectomy surgery in the UK in 2012
Appendix 1 List of Contributing Surgeons and Centres Surgeon Abbasi, Z Adamson, A S Adeyoju, A A Adshead, J M Aho, T F Al-Akraa, M Allan, J Almond, D J Anderson, C J Andrews, S J Apakama, I Armitage, T Banerjee, G K Barber, N J Basu, S Bdesha, A S Beatty, J Bell, C R W Bhanot, S M Bhatt, R Biyani, C S Blake, C Boddy, J Bromage, S J Bromwich, E Browning, A J Bryan, N P Burgess, N A Burns-Cox, N Butterworth, P C Bycroft, J Campbell, I Cannon, A Carter, C J M Carter, P G Cartledge, J J Casey, R Chakravarti, A Chappell, B G Chen, T F Cherian, J Choi, W H Clavijo Eisele, J Cliff, A M Cohen, N P Cole, O J Collins, J Connolly, S Cooke, P W Cornaby, A J Corr, J G Coulthard, R Cresswell, J Crundwell, M C Cynk, M Daruwala, P D Datta, S N Davenport, K de Bolla, A R Devarajan, R Doherty, A P Donaldson, P J Dyer, J Eaton, J
Hospital Episode Statistics (HES) Trust/Centre THE ROTHERHAM NHS FOUNDATION TRUST WINCHESTER AND EASTLEIGH HEALTHCARE NHS TRUST STOCKPORT NHS FOUNDATION TRUST EAST AND NORTH HERTFORDSHIRE NHS TRUST CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST ROYAL FREE HAMPSTEAD NHS TRUST WEST SUFFOLK HOSPITALS NHS TRUST HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST ST GEORGE’S HEALTHCARE NHS TRUST DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST GEORGE ELIOT HOSPITAL NHS TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST IPSWICH HOSPITAL NHS TRUST FRIMLEY PARK HOSPITAL NHS FOUNDATION TRUST CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST BUCKINGHAMSHIRE HOSPITALS NHS TRUST NORTHAMPTON GENERAL HOSPITAL NHS TRUST NORTHAMPTON GENERAL HOSPITAL NHS TRUST PRIVATE PATIENTS UNIVERSITY HOSPITAL BIRMINGHAM NHS FOUNDATION TRUST MID YORKSHIRE HOSPITALS NHS TRUST ROYAL CORNWALL HOSPITALS NHS TRUST THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST STOCKPORT NHS FOUNDATION TRUST ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST MID YORKSHIRE HOSPITALS NHS TRUST CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST TAUNTON AND SOMERSET NHS FOUNDATION TRUST UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST EAST AND NORTH HERTFORDSHIRE NHS TRUST BLACKPOOL, FYLDE AND WYRE HOSPITALS NHS FOUNDATION TRUST TAUNTON AND SOMERSET NHS FOUNDATION TRUST THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST WESTERN SUSSEX HOSPITALS NHS TRUST LEEDS TEACHING HOSPITALS NHS TRUST COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST THE DUDLEY GROUP OF HOSPITALS NHS FOUNDATION TRUST WESTERN SUSSEX HOSPITALS NHS TRUST WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST PENNINE ACUTE HOSPITALS NHS TRUST EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST NORTHERN LINCOLNSHIRE AND GOOLE HOSPITALS NHS FOUNDATION TRUST WIRRAL UNIVERSITY TEACHING HOSPITAL NHS FOUNDATION TRUST ABERDEEN ROYAL INFIRMARY PRINCESS ELIZABETH HOSPITAL, GUERNSEY ASHFORD AND ST PETER’S HOSPITALS NHS TRUST CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST UNIVERSITY HOSPITAL OF WALES SOUTH TEES HOSPITALS NHS FOUNDATION TRUST ROYAL DEVON AND EXETER NHS FOUNDATION TRUST MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST UNITED LINCOLNSHIRE HOSPITALS NHS TRUST UNIVERSITY HOSPITAL OF WALES GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST WREXHAM MAELOR HOSPITAL SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST UNIVERSITY HOSPITAL BIRMINGHAM NHS FOUNDATION TRUST IPSWICH HOSPITAL NHS TRUST SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST
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Table 6 (continued) Appendix 1 Continued Surgeon Eddy, B Eden, C G Fiala, R Foster, M C Frymann, R J Gall, Z J Gana, H B Y Garnett, S Gibbons, N Gillatt, D A Godbole, H C Golash, A Gowardhan, B Gujral, S Gunendran, T Haldar, N Hanbury, D C Hawkyard, S J Haynes, M D Henderson, A Hicks, J A Hindley, R G Hodgson, D J Hotston, M Howell, G P Hrouda, D Ilie, C Jain, S Janjua, K S Javle, P Johnson, M I Johnson, P Joshi, H Joyce, A D Keeley, F X Kelkar, A Kelleher, J P Khattak, A Q Kimuli, M Kirollos, M M Kockelbergh, R C Kooiman, G Kumar, P Kynaston, H G Laniado, M E Larner, T Latif, Z Lau, M W le Roux, P J Leung, S Leveckis, J Lewis, G Lockyer, C R W Lodge, R N Lynch, M Lynn, N N K MacDermott, J P Madaan, S Maddineni, S B Maheshkumar, P Makar, A A Makunde, J T Manikandan, R Mann, G S
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Hospital Episode Statistics (HES) Trust/Centre EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST ROYAL SURREY COUNTY NHS FOUNDATION TRUST CAUSEWAY HOSPITAL HEART OF ENGLAND NHS FOUNDATION TRUST JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST ST HELENS AND KNOWSLEY HOSPITALS NHS TRUST EAST SUSSEX HOSPITALS NHS TRUST IMPERIAL COLLEGE HEALTHCARE NHS TRUST NORTH BRISTOL NHS TRUST NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE NHS TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST BUCKINGHAMSHIRE HOSPITALS NHS TRUST EAST AND NORTH HERTFORDSHIRE NHS TRUST SCARBOROUGH AND NORTH EAST YORKSHIRE HEALTH CARE NHS TRUST SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST WESTERN SUSSEX HOSPITALS NHS TRUST BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST PORTSMOUTH HOSPITALS NHS TRUST ROYAL CORNWALL HOSPITALS NHS TRUST ROYAL UNITED HOSPITAL BATH NHS TRUST IMPERIAL COLLEGE HEALTHCARE NHS TRUST THE QUEEN ELIZABETH HOSPITAL KING’S LYNN NHS TRUST LEEDS TEACHING HOSPITALS NHS TRUST VICTORIA HOSPITAL, KIRKCALDY LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST UNIVERSITY HOSPITAL OF WALES LEEDS TEACHING HOSPITALS NHS TRUST GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST and NORTH BRISTOL NHS TRUST BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST BUCKINGHAMSHIRE HOSPITALS NHS TRUST ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST and ST HELENS AND KNOWSLEY HOSPITALS NHS TRUST SHREWSBURY AND TELFORD HOSPITAL NHS TRUST SOUTH DEVON HEALTHCARE NHS FOUNDATION TRUST UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST KING’S COLLEGE HOSPITAL NHS FOUNDATION TRUST THE ROYAL MARSDEN NHS FOUNDATION TRUST UNIVERSITY HOSPITAL OF WALES HEATHERWOOD AND WEXHAM PARK HOSPITALS NHS FOUNDATION TRUST BRIGHTON AND SUSSEX UNIVERSITY HOSPITALS NHS TRUST ROYAL ALEXANDRA HOSPITAL (PAISLEY) SALFORD ROYAL NHS FOUNDATION TRUST EPSOM AND ST HELIER UNIVERSITY HOSPITALS NHS TRUST and ST GEORGE’S HEALTHCARE NHS TRUST VICTORIA HOSPITAL, KIRKCALDY DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST ASHFORD AND ST PETER’S HOSPITALS NHS TRUST SHREWSBURY AND TELFORD HOSPITAL NHS TRUST SOUTH DEVON HEALTHCARE NHS FOUNDATION TRUST DARTFORD AND GRAVESHAM NHS TRUST SALFORD ROYAL NHS FOUNDATION TRUST THE QUEEN ELIZABETH HOSPITAL KING’S LYNN NHS TRUST WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST ISLE OF WIGHT NHS PRIMARY CARE TRUST WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
Nephroureterectomy surgery in the UK in 2012
Table 6 (continued) Appendix 1 Continued Surgeon Mantle, M Mark, I R Matanhelia, S S McClinton, S McInerney, P D McIntyre, I G McLarty, E McLoughlin, J McNeill, S A Mehta, S Mellon, J K Menezes, P Mills, R D Mokete, M Montague, R Motiwala, H G Mulholland, C K Mumtaz, F H Munro, N Myatt, A Nathan, S Neilson, D Nicol, D L Oades, G Oakley, N O’Brien, T S O’Kane, H F Okeke, A A O’Riordan, A Paez, E Page, T Parkin, J Patel, N Patel, P Pathak, S Patil, K Payne, D Phillips, J T Phillips, S M A Phipps, S Pillai, M K Potter, J M Rajan, T N Rajjayabun, P Rane, A Ravi, R Ravichandran, S Richmond, P J M Riddick, A C P Rimington, P D Rix, D Rix, G H Rochester, M Rowe, E Sahadevan, K Sandhu, S Sangar, V K Sells, H Shackley, D C Shah, Z Shaikh, N N A Sharma, H Sherwood, B Singh, S Solomon, L
Hospital Episode Statistics (HES) Trust/Centre ROYAL CORNWALL HOSPITALS NHS TRUST UNITED LINCOLNSHIRE HOSPITALS NHS TRUST LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST ABERDEEN ROYAL INFIRMARY PLYMOUTH HOSPITALS NHS TRUST CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST PLYMOUTH HOSPITALS NHS TRUST PRIVATE PATIENTS WESTERN GENERAL HOSPITAL, EDINBURGH SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST HEATHERWOOD AND WEXHAM PARK HOSPITALS NHS FOUNDATION TRUST ALTNAGELVIN AREA HOSPITAL BARNET AND CHASE FARM HOSPITALS NHS TRUST ROYAL CORNWALL HOSPITALS NHS TRUST HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST PRIVATE PATIENTS EAST LANCASHIRE HOSPITALS NHS TRUST UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST SOUTHERN GENERAL HOSPITAL SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST and STOCKPORT NHS FOUNDATION TRUST GUY’S AND ST THOMAS’ NHS FOUNDATION TRUST BELFAST CITY HOSPITAL GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST OXFORD RADCLIFFE HOSPITALS NHS TRUST UNIVERSITY HOSPITAL BIRMINGHAM NHS FOUNDATION TRUST DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST ASHFORD AND ST PETER’S HOSPITALS NHS TRUST KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUST ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST HEART OF ENGLAND NHS FOUNDATION TRUST WESTERN GENERAL HOSPITAL, EDINBURGH EAST LANCASHIRE HOSPITALS NHS TRUST NORTHAMPTON GENERAL HOSPITAL NHS TRUST BELFAST CITY HOSPITAL WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST SURREY AND SUSSEX HEALTHCARE NHS TRUST BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST WARRINGTON AND HALTON HOSPITALS NHS FOUNDATION TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST WESTERN GENERAL HOSPITAL, EDINBURGH EAST SUSSEX HOSPITALS NHS TRUST THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST NORTH BRISTOL NHS TRUST CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST KINGSTON HOSPITAL NHS TRUST UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST PLYMOUTH HOSPITALS NHS TRUST SALFORD ROYAL NHS FOUNDATION TRUST ROYAL BERKSHIRE NHS FOUNDATION TRUST AIREDALE NHS FOUNDATION TRUST BEDFORD HOSPITAL NHS TRUST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST SHERWOOD FOREST HOSPITALS NHS FOUNDATION TRUST PORTSMOUTH HOSPITALS NHS TRUST
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Table 6 (continued) Appendix 1 Continued Surgeon Sriprasad, S I Stubington, S R Taneja, S Thilagarajah, R Thomas, B Thomas, D J Thurston, A V Turner, K J Umez-Eronini, O N Vale, J A Varadaraj, H Vesey, S G Viney, R Walton, T Waymont, B Webster, J J Wedderburn, A Wemyss-Holden, G D Weston, R Whittlestone, T Wilkinson, B Wilkinson, S Williams, S Wills, M I Wilson, J R Woodhouse, C R J Yates, D R
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Hospital Episode Statistics (HES) Trust/Centre DARTFORD AND GRAVESHAM NHS TRUST MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST LUTON AND DUNSTABLE HOSPITAL NHS FOUNDATION TRUST MID ESSEX HOSPITAL SERVICES NHS TRUST WESTERN GENERAL HOSPITAL, EDINBURGH THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST WEST HERTFORDSHIRE HOSPITALS NHS TRUST THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST NORTH CUMBRIA UNIVERSITY HOSPITALS NHS TRUST IMPERIAL COLLEGE HEALTHCARE NHS TRUST UNITED LINCOLNSHIRE HOSPITALS NHS TRUST SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST UNIVERSITY HOSPITAL BIRMINGHAM NHS FOUNDATION TRUST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST NORTH WEST LONDON HOSPITALS NHS TRUST ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST EAST LANCASHIRE HOSPITALS NHS TRUST ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST NORTH BRISTOL NHS TRUST THE ROTHERHAM NHS FOUNDATION TRUST PORTSMOUTH HOSPITALS NHS TRUST DERBY HOSPITALS NHS FOUNDATION TRUST UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST YORK HOSPITALS NHS FOUNDATION TRUST THE ROYAL MARSDEN NHS FOUNDATION TRUST SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST
