With the introduction of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) in 2001, surgeons across all specialties have utilized NSQIP as a comprehensive representation of individual hospital systems and operational improvement. Urologists and particularly urologic oncologists have frequently relied on NSQIP to compare complication rates during the transition from open to primarily minimally invasive surgery (MIS). Despite its presence for the last 2 decades, its influence on clinical decision making, particularly genitourinary reconstruction, is uncertain. With rising numbers of fellowship-trained reconstructive urologists, both academic and private practice settings have seen compensatory increases in reconstructive case volume. Still, in the context of quality, the role of NSQIP in reconstructive urology is not clear.

Given the breadth of reconstructive urology, it is difficult to assess the influence of NSQIP without narrowing the scope to specific subsets of CPT codes. Studies such as Armstrong et al have attempted to utilize NSQIP to assess 30-day complications after urethroplasty.¹ Their study highlighted an overall complication rate of 8.6% among 1,136 patients over 10-year period. Predictors of complications were identified as age >55 years, preoperative sepsis and length of procedure. Despite statistical significance, the clinical implications were limited by the overall low number of complications associated with urethroplasty. Additionally, variables intrinsic to urethroplasty were either unavailable (perioperative hematoma) or not differentiated (patients who underwent EPA vs substitution urethroplasty). In urethroplasty, limited granularity of operative data within NSQIP proved to be a significant barrier for successful change within a clinical setting.

In contrast to urethroplasty, which will continue to rely on open technique, minimally invasive robotic ureteral reconstruction has been quickly adopted over the last decade. As such, discrete CPT codes within NSQIP may be able to identify differences between open and MIS interventions. This was demonstrated by Hebert et al, who compared outcomes in open and MIS patients undergoing upper and lower ureteral reconstruction.² Of the 3,042 patients identified over a 10-year period, patients undergoing an open approach had increased risk of minor and major complications, transfusion and hospital stay. Packiam et al similarly looked at open and MIS approaches for ureteral reimplantation in a NSQIP population.³ Their conclusions rang similar with increasing complications in those undergoing an open approach, particularly transfusions and urinary tract infections. Use of NSQIP in this setting provides a clear difference in complication rates and actionable data, but in terms of novelty this information falls on deaf ears.

Use of NSQIP appears to be most effective at modifying clinical decision making when the question asked is small or an event is rare. Shelton et al showed that there was no difference in risk of postoperative complications between early (<24 hr) and late (>24 hr) discharges after artificial urinary sphincter placement.⁴ Theofanides et al utilized the size of the NSQIP database to better understand a relatively rare complication in managing vesicovaginal fistula, showing greater complications with transabdominal compared to transvaginal approaches.⁵ Utilization of NSQIP in both of the abovementioned studies allowed for the investigation of a rare event that is not always possible with prospective or retrospective data collection.

Although databases such as NSQIP have the ability to answer an array of surgical hypotheses within reconstructive urology, the information contained within is highly variable, and conclusions dependent on the extent of the available data. With significant case diversity and varying patient pathology, the scope of reconstructive urology remains difficult to capture within a CPT code. However, NSQIP is widely believed to be the most precise and accurate database available for measuring patient outcomes after surgery given its operative data points. With improvements in CPT codes, more granular patient details may allow for more tailored and clinically valuable conclusions. With the rise of the Trauma and Urologic Reconstruction Network of Surgeons multi-institutional database, collaborators have looked to address these gaps in data with retrospective review of large volume centers. Future improvement in reconstructive outcomes will rely heavily on effective use of both databases to validate changes in practice in ways that both databases alone are not able.