title: Regional, institutional and individual factors affecting selection of minimally invasive nephroureterectomy in Japan: a national database analysis.
abstract: OBJECTIVE
  To reveal individual, institutional and regional factors affecting selection of minimally invasive nephroureterectomy in Japan.
  
  
  METHODS
  The Japanese Diagnosis Procedure Combination database was queried to retrieve cases of nephroureterectomy for pelvic or ureter malignancies carried out between 2007 and 2010. A multivariate logistic regression analysis with variables including age, sex, pre-existing comorbidities, tumor location, tumor-nodes-metastasis classification, academic status of hospitals, hospital volume, geographic region and year of surgery was modeled to evaluate predictors of carrying out a minimally invasive (including laparoscopic and minimum incision endoscopic) nephroureterectomy.
  
  
  RESULTS
  Overall, 3863 open (58.2%), 2635 laparoscopic (39.7%) and 139 minimum incision endoscopic nephroureterectomy (2.1%) cases from 713 hospitals were identified. The proportion of minimally invasive procedures increased from 35.7% to 48.6%. Minimally invasive nephroureterectomy was the most frequently carried out in the Kinki and Chugoku regions (50.9% and 50.4%, respectively) compared with the least in the Kanto region (31.3%). Multivariate analysis showed that lower Charlson Comorbidity Index, lower tumor-nodes-metastasis stage, academic hospitals, higher operative volume centers, western regions of Japan and later year were independently associated with the use of minimally invasive nephroureterectomy. Age, sex and tumor location were not significant factors.
  
  
  CONCLUSIONS
  Despite regional and institutional variations, the proportion of minimally invasive nephroureterectomy has gradually increased in Japan. Minimally invasive nephroureterectomy is more likely to be carried out in patients with low tumor stage and low risk at higher volume academic hospitals. Our findings provide fundamental data for future health policies to foster nationwide healthcare uniformity.
authors.affiliation: Department of Urology, Shintoshi Hospital, Iwata, Japan; Department of Urology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan. ezy04707@nifty.com
authors.forename: Toru
authors.initials: T
authors.lastname: Sugihara
authors.forename: Hideo
authors.initials: H
authors.lastname: Yasunaga
authors.forename: Hiromasa
authors.initials: H
authors.lastname: Horiguchi
authors.forename: Tetsuya
authors.initials: T
authors.lastname: Fujimura
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Nishimatsu
authors.forename: Nobuo
authors.initials: N
authors.lastname: Tsuru
authors.forename: Kazuo
authors.initials: K
authors.lastname: Suzuki
authors.forename: Suzuki
authors.initials: S
authors.lastname: Kazuo
authors.forename: Kazuhiko
authors.initials: K
authors.lastname: Ohe
authors.forename: Kiyohide
authors.initials: K
authors.lastname: Fushimi
authors.forename: Yukio
authors.initials: Y
authors.lastname: Homma
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000208:ethnology* / Q000601:surgery; D015897:Comorbidity; D016208:Databases, Factual / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007564:Japan / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000706:statistics & numerical data*; D009392:Nephrectomy / Q000706:statistics & numerical data*; D018579:Patient Selection; D010386:Pelvic Neoplasms / Q000208:ethnology* / Q000601:surgery; D012189:Retrospective Studies; D012307:Risk Factors; D014513:Ureter / Q000601:surgery; D014516:Ureteral Neoplasms / Q000208:ethnology* / Q000601:surgery