In this manuscript, the authors evaluated the influence of surgeon and hospital volume on outcomes after radical nephrectomy with inferior vena cava thrombectomy. The overall in-hospital mortality rate was 7%. Most deaths (75%) were noted in the surgeon's first 2 cases in the registry. Complications were noted in 78% of patients. Increasing surgeon volume, but not hospital volume, was associated with lower in-hospital mortality. They also found that patient's age, comorbidity, and need for cardiac bypass were the strongest predictors of in-hospital mortality. Although previous studies established improved results with increasing surgeon's volume in radical cystectomy and prostatectomy, it is important to recognize that complex vena caval tumor thrombectomy requires a multidisciplinary approach involving experienced anesthesiologists, cardiac, liver, and possibly vascular surgeons. Perioperative evaluation and preparation has been shown to be a critical factor in determining outcomes. High volume surgeons become seasoned enough with patient selection and predicting when other surgical disciplines are needed. It may be an underestimation to conclude that surgeons but not hospital volume may impact patient outcomes. The perioperative care typically involves ICU admission with need of experienced intensivists and skilled nursing. These challenging surgeries are typically performed at high volume tertiary care centers. Mentoring junior surgeons early in their career should be an effective way of improving patient outcomes. The author's suggestion of regionalization of these complex surgeries should be a priority.
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