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Objectives : To determine the rate of benign pathology in cT1 tumors following partial nephrectomy in the Netherlands, thereby evaluating the rate of overtreatment. Methods: Data were collected from a nationwide database containing histopathology of resected renal tissue from 2014 to 2022. Patients who underwent partial nephrectomy for suspected RCC staged T1a-b were extracted for analysis. Data are shown in percentages, and multivariable logistic regression was performed to determine predictive factors for benign pathology. Results : 3409 cases were analyzed, of which 403 (12%) were benign and 3006 (88%) malignant. Subtype analysis showed 2126 (62%) cases of clear-cell RCC, followed by 604 (18%) of papillary RCC and 344 (10%) oncocytomas. Mean age was 63 years among patients with malignant pathology versus 65 years for patients with benign lesions ( p < 0.001). Mean tumor size was 3.2 cm for malignant pathology and 2.9 cm for benign ( p < 0.001). The rates of benign and malignant pathology did not change between 2014 and 2022 ( p = 0.377). Multivariable regression showed age ≥ 65 years (65-79 years [OR 1.881, p = 0.002], ≥ 80 years [OR 3.642, p < 0.001]) and tumor size (OR 0.793, p < 0.001) as predictors for benign pathology. The main limitation of this study is that we do not know the biopsy rate of our cohort. Conclusion: This study reports a low rate of 12% benign pathology after partial nephrectomy in the Netherlands. It remains debatable whether these rates are acceptable, or if renal tumor biopsies should be utilized more frequently to reduce overtreatment.

Background: Comparing outcomes across hospitals to learn from best performing hospitals can be valuable. However, reliably identifying best performance is challenging. This study assesses the possibility to distinguish best performing hospitals on single outcomes and consistency of performance on different outcomes., Methods: Data were derived from the Dutch ColoRectal Audit 2013-2015. Outcomes considered were textbook outcome (colon), (circumferential) resection margins, (serious) complications, mortality, and 'failure to rescue'. To include uncertainty in rankings, random effect logistic regression models were used to calculate expected ranks (ERs), for each hospital and outcome. Rankability was calculated for each outcome, as a measure of reliability of ranking. Furthermore, correlation between ERs on different outcomes was assessed. Correlation was considered weak <0.40, moderate between 0.40 - 0.59 and strong >0.60., Results: The study included 32 143 patients; of whom 11 373 were treated in 2015 across 84 hospitals, 8181 colon and 3192 rectal cancer patients. In this one-year period 'Postoperative complications' had the highest rankability for colon (57%) and rectal (41%) surgery. No (group of) hospital(s) had the highest ER(s) on all outcomes. Correlation between ERs of outcomes was moderate in 2 (of 25) and strong in 4 (of 25) combinations. Rankability of colorectal mortality increased from 14% in 2015 to 35% when data over 2013-2015 were used., Conclusion: The highest reliability of identifying best performance based on an outcome was 57%. However, the balance between reliability and relevance of outcomes is vulnerable. No (group of) hospital(s) could be identified as best performer on all outcomes. Performance was not consistent on outcomes., Competing Interests: Declaration of competing interest None of the authors have anything to disclose., (Copyright © 2020. Published by Elsevier Ltd.)

Background: The goal of this study was to evaluate current clinical practice and treatment outcomes regarding locally advanced colon cancer (LACC) at the population level. Methods: Data were used from the Dutch Surgical Colorectal Audit from 2009 to 2014. A total of 34,527 patients underwent resection for non-LACC and 6,918 for LACC, which was defined as cT4 and/or pT4 stage. LACC was divided into those with multivisceral resection (LACC-MV; n=3,385) and without (LACC-noMV; n=1,595). Guideline adherence, treatment strategy, and short-term outcomes were evaluated. Results: Guideline adherence was >90% regarding preoperative imaging and ≥80% regarding preoperative multidisciplinary team (MDT) discussion. In the elective setting, neoadjuvant chemoradiotherapy (chemoRT) was applied in 6.2% of the cT4 cases, and neoadjuvant chemotherapy in 4.0%. R0 resection rates were 99%, 91%, and 87% in patients with non-LACC, LACC-noMV, and LACC-MV, respectively ( P <.001). A postoperative complicated course occurred in 17%, 25%, and 29% of patients ( P <.001), and the 30-day/in-hospital mortality rate was 3.6%, 6.0%, and 5.4% ( P <.001) in the non-LACC, LACC-noMV, and LACC-MV groups, respectively. Discussion/Conclusions: This population-based study suggests that there is room for improvement in the treatment of LACC, with regard to short-term surgical outcomes and oncologic outcomes (ie, radicality of resection). Improvement might be expected from optimized preoperative imaging, routine MDT discussions, and further specialization and centralization of care. Optimized use of neoadjuvant treatment strategies based on already available and upcoming evidence is likely to result in a better margin status and thereby a better long-term prognosis. Furthermore, lower R0 resection rates in an emergency setting suggest a potential role for bridging strategies in order to enable optimal staging, neoadjuvant treatment, and elective surgery by a surgical team most optimally qualified for the procedure., (Copyright © 2017 by the National Comprehensive Cancer Network.)

Unlabelled: This population-based study evaluates the association between hospital volume and CRM (circumferential resection margin) involvement, adjusted for other confounders, in rectal cancer surgery. A low hospital volume (<20 cases/year) was independently associated with a higher risk of CRM involvement (odds ratio=1.54; 95% CI: 1.12-2.11)., Objective: To evaluate the association between hospital volume and CRM (circumferential resection margin) involvement in rectal cancer surgery., Background: To guarantee the quality of surgical treatment of rectal cancer, the Association of Surgeons of the Netherlands has stated a minimal annual volume standard of 20 procedures per hospital. The influence of hospital volume has been examined for different outcome variables in rectal cancer surgery. Its influence on the pathological outcome (CRM) however remains unclear. As long-term outcomes are best predicted by the CRM status, this parameter is of essential importance in the debate on the justification of minimal volume standards in rectal cancer surgery., Methods: Data from the Dutch Surgical Colorectal Audit (2011-2012) were used. Hospital volume was divided into 3 groups, and baseline characteristics were described. The influence of hospital volume on CRM involvement was analyzed, in a multivariate model, between low- and high-volume hospitals, according to the minimal volume standards., Results: This study included 5161 patients. CRM was recorded in 86% of patients. CRM involvement was 11% in low-volume group versus 7.7% and 7.9% in the medium- and high-volume group (P≤0.001). After adjustment for relevant confounders, the influence of hospital volume on CRM involvement was still significant odds ratio (OR) = 1.54; 95% CI: 1.12-2.11)., Conclusions: The outcomes of this pooled analysis support minimal volume standards in rectal cancer surgery. Low hospital volume was independently associated with a higher risk of CRM involvement (OR = 1.54; 95% CI: 1.12-2.11).

Background: Recent literature suggests that focus in health care should shift from reducing costs to improving quality; where quality of health care improves, cost reduction will follow. Our primary aim was to investigate whether improving the quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs., Study Design: This was a retrospective analysis of clinical and financial outcomes after colorectal cancer surgery in 29 Dutch hospitals (9,913 patients). Detailed clinical data were obtained from the 2010 to 2012 population-based Dutch Surgical Colorectal Audit. Patient-level costs were measured uniformly in all participating hospitals and based on time-driven, activity-based costing. Odds ratios (OR) and relative differences (RD) were risk adjusted for hospitals and differences in patient characteristics., Results: Over 3 consecutive years, severe complications and mortality declined by 20% (risk-adjusted OR 0.739, 95% CI 0.653 to 0.836, p < 0.001), and 29% (risk-adjusted OR 0.757, 95% CI 0.571 to 1.003, p = 0.05), respectively. Simultaneously, costs during primary admission decreased 9% (risk-adjusted RD -7%, 95% CI -10% to -5%, p < 0.001) without an increase in costs within the first 90 days after discharge (RD -2%, 95% CI -10% to 6%, p = 0.65). An inverse relationship (at hospital level) between severe complication rate and hospital costs was identified (R = 0.64). Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs; hospitals with declining severe complication rates were associated with cost reduction., Conclusions: This report presents evidence for simultaneous quality improvement and cost reduction. Participation in a nationwide quality improvement initiative with continuous quality measurement and benchmarked feedback reveals opportunities for targeted improvements, bringing the medical field forward in improving value of health care delivery. The focus of health care should shift to improving quality, which will catalyze costs savings as well., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The circumferential resection margin (CRM) is a significant prognostic factor for local recurrence, distant metastasis, and survival after rectal cancer surgery. Therefore, availability of this parameter is essential. Although the Dutch total mesorectal excision trial raised awareness about CRM in the late 1990s, quality assurance on pathologic reporting was not available until the Dutch Surgical Colorectal Audit (DSCA) started in 2009. The present study describes the rates of CRM reporting and involvement since the start of the DSCA and analyzes whether improvement of these parameters can be attributed to the audit., Methods: Data from the DSCA (2009-2013) were analyzed. Reporting of CRM and CRM involvement was plotted for successive years, and variations of these parameters were analyzed in a funnelplot. Predictors of CRM involvement were determined in univariable analysis and the independent influence of year of registration on CRM involvement was analyzed in multivariable analysis., Results: A total of 12,669 patients were included for analysis. The mean percentage of patients with a reported CRM increased from 52.7% to 94.2% (2009-2013) and interhospital variation decreased. The percentage of patients with CRM involvement decreased from 14.2% to 5.6%. In multivariable analysis, the year of DSCA registration remained a significant predictor of CRM involvement., Conclusions: After the introduction of the DSCA, a dramatic improvement in CRM reporting and a major decrease of CRM involvement after rectal cancer surgery have occurred. This study suggests that a national quality assurance program has been the driving force behind these achievements., (Copyright © 2015 by the National Comprehensive Cancer Network.)

Introduction and Hypothesis: The objective of this study was to evaluate the degree and reliability of evidence used by manufacturers before the introduction of mid-urethral slings (MUS) onto the commercial market. Furthermore, minimum standards for marketed slings are recommended by evaluating recent suggestions for the introduction of gynecological meshes., Methods: A systematic literature search was conducted using PubMed and commercial internet search engines in order to identify slings introduced by the industry over the last decade. Moreover, manufacturers were contacted by email, mail, and phone to provide data from before the introduction of the slings onto the commercial market. Once contact had been initiated, a 6-month deadline was set for data collection., Results: Forty-one slings introduced between 1996 and 2012 were identified. Ten slings were described in a total of 20 studies with sample sizes varying from 10 to 368. The 41 MUS were produced by a total of 19 different companies. Seven companies never responded to recurrent emails, phone calls or other means of attempted contact. Thirty-one slings (76%) remained without any comparative pre-launch data., Conclusions: Mid-urethral slings were often introduced without any scientifically proven basis or pre-launch research. The US Food and Drug Administration and the European authorities should undertake immediate action by imposing strict rules before the launch of new MUS comparable with those recently suggested for meshes used in vaginal prolapse surgery.

Background: Hydronephrosis can be a side effect of radical hysterectomy for cervical cancer. The incidence of clinically relevant hydronephrosis has not been studied in a large sample and the benefit of early detection of hydronephrosis is not clear., Objective: To assess the incidence of hydronephrosis, following radical hysterectomy and evaluate the usefulness of routine renal ultrasound (RH)., Methods: Retrospective study, January 1998 and December 2008. Cervical cancer patients (FIGO stage IBI-IIA), treated with radical hysterectomy and pelvic lymph node dissection with or without adjuvant radiotherapy, without surgical lesion of the ureter, followed-up 6 months in the Academic Medical Center Amsterdam. Routine renal ultrasound was performed four weeks after RH, and in some on indication before or after the routine ultrasound. We documented which interventions for hydronephrosis were performed and evaluated the profile of patients at risk for hydronephrosis., Results: 281 patients were included: 252 (90%) underwent routine renal ultrasound and 29 (10%) underwent imaging on indication before routine ultrasound. The overall incidence of hydronephrosis was 12%. In symptomatic patients, the incidence was 21% and 9% in asymptomatic women undergoing routine ultrasound. Four patients were invasively treated for hydronephrosis (1% of the total group) after imaging for clinical suspicion of hydronephrosis. Patients with hydronephrosis were significantly more often treated with radiotherapy than patients without (43% versus 25% (p=0.03)., Conclusion: There is no place for routine renal ultrasound following radical hysterectomy. Patients should be instructed about the symptoms that may be related to hydronephrosis, to allow for renal ultrasound on indication., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: The surgical management of multi-compartment prolapse is challenging and often requires a combination of techniques. This study evaluates anterior vaginal mesh repair, sacrospinous hysteropexy and posterior fascial plication in women with anterior compartment dominated uterovaginal prolapse., Methods: Consecutive women who underwent the aforementioned surgery were prospectively evaluated. Main outcome measures included objective (pelvic organ prolapse quantification stage <2) and subjective success rates, patient satisfaction, functional outcomes and complications., Results: One hundred and seventeen women were eligible, and 100 agreed to participate. At 12 months, objective success rate at the anterior compartment was 87% and at all compartments, 75%. Subjective success was 84%, and mean patient satisfaction was 8.5/10. There were no stage 3 or 4 recurrences at any site., Conclusions: The combination of anterior vaginal mesh, sacrospinous hysteropexy and posterior fascial plication is reasonably effective in restoring the anatomy and achieving favourable bladder, bowel and sexual function.