Improved outcomes following radical
cystectomy for bladder cancer at a higher
volume centre: Is increased cystectomy
workload not the determining factor?
Smith NJ, Douglas D, Sundaram SK, Weston PMT, Chahal R.
Background:
• HES data (>6000 pts) suggests an inverse correlation between
case volume and mortality rate following cystectomy. The minimum
number of cases/yr for a surgeon to achieve low mortality rates
being 81.
• In a separate HES study (>8000 pts), significant differences in 30
day mortality have not been seen in comparing low volume (<10
cases) and high-volume (>15 cases) centres in England2.
• We previously reported that increasing cystectomy volume from 5
to 24 per annum results in improved bladder cancer survival, but no
difference in 30-day mortality3.
1) McCabe JE et al. Postgraduate medical journal. 83 (982):556-560.
2) Mayer EK et al. BMJ 2010. 340: c1128.
3) Douglas D et al. Paper presentation, YUAG 2008
Am I presenting the same old
data again?
• YES
• “low-volume” cystectomy cohort (95 patients) from the
Yorkshire radical cystectomy/radiotherapy study 1993-19961
• Compared to 102 cystectomies performed at our centre
(2002-2005) forming the “high-volume” cohort.
• So what’s new?
- 29 patients from 2005
- Longer-term follow-up of all the high-volume cohort
- Clavien-Dindo classification of complications
- Estimation of overall (OS) and cancer-specific
survival (CSS).
- Multivariate analysis for confounding factors.
• To determine whether higher caseload volume improves
survival.
1) Chahal R et al. European Urology 2003. 43:246-257.
Low-volume vs High-volume centres
• Mean no. of cases per year/centre:
Low-volume (10 centres) = 2.0 cases/yr/centre vs High-volume = 25.3
cases/yr . (p=0.03)
• No difference in co-morbidities and high ASA grades between highand low-volume centres.
• Ileal conduit diversion (88% vs 86%) and other reconstructions
similar between groups
Low-volume (range)
High-volume (range)
p value
Number of patients
Mean age
Median length of procedure
95
63yrs (35-76)
5 hrs (1.5-8)
102
66yrs (41-87)
6 hrs (3.5-10)
p=0.005
p<0.0001
Mean blood loss
Transfusion rate
Median hospital stay
2332ml (500-7000)
N/R
14 days (8-75)
2358ml (500-10000)
86%
19 days (6-120)
Median delay from TURBT to cystectomy
30 day mortality
60 day mortality
90 day mortality
90 day non-cancer mortality
48 days (2-440)
3 (3%)
7 (7%)
14 (15%)
8 (8%)
81 days (14-187)
3 (3%)
3 (3%)
5 (5%)
4 (4%)
p = 0.72
p<0.0001
p<0.0001
1.0
0.03
ns
Clavian-Dindo grade
No complications
Grade I
Grade II
Grade IIIA
Grade IIIB
Grade IVA
Grade IVB
Grade V
Total
Low volume
66 (69%)
11
11
4
9
3
0
3
41
High volume
37 (36%)
46
45
4
3
9
1
3
110
All
complications
• 30-day re-operation rate = 6% low-volume vs 3%
high-volume
• Difficulty in comparing minor complication rates
(ileus, minor wound problems etc. not recorded in
low-volume data).
• No difference in major complication rates at 30
days (19%)
• Long-term morbidity similar between groups
T0N0
pTcis
pTa
T1
T2
T3
T4
T2 or less
Low-volume
5 (5%)
5 (5%)
1 (1%)
5 (5%)
20 (21%)
42 (44%)
16 (17%)
38%
High volume
11 (11%)
20 (20%)
7 (7%)
13 (13%)
18 (18%)
25 (25%)
9 (9%)
67%
Node +ve
Nx
CIS present
Non-TCC
23 (24%)
18 (19%)
25 (26%)
10 (10%)
18 (18%)
9 (9%)
42 (41%)
7 (7%)
P value
Pathological
stage
p<0.0001
p=0.29
p=0.06
p=0.04
Follow-up
•
Median follow-up (survivors):
Low-volume 63.2 months (range 44-90)
High-volume 68.5 months (range 7-113)
• 5-year OS was significantly higher in the highvolume group (56% vs. 37%), as was the 5-year
CSS (70% vs. 50%).
Overall Survival
1
Cancer-specific Survival
1
High-volume
Low-volume
Censored data
0.8
0.8
0.6
0.6
0.4
0.4
0.2
0.2
Log rank p=0.009
Log rank p=0.011
0
0
0
24
48
72
96
Follow-up (months)
120
0
24
48
72
96
Follow-up (months)
120
Other univariate analysis
• pT3 or more (vs pT2 or less) significantly associated with
poorer OS and CSS (log rank, p<0.0001)
• pN+ (vs pN-) significantly associated with poorer OS and CSS
(log rank, p<0.0001)
• Not significant on univariate analysis:
- Age >70 vs <70 yrs
- Nodal dissection vs No dissection
- TCC vs non-TCC
- Neoadjuvant vs no neoadjuvant.
Multivariate analysis:
• High-volume vs. Low-volume not an independent risk factor
for OS (p=0.8) or CSS (p=0.6)
• Advanced pT-stage and lymph node-positivity independent
risk factors (p=0.002, p=0.04 for OS and p=0.0002, p=0.008 for
CSS) and therefore are confounding factors.
Conclusions
• Improved long-term OS and CSS survival has occurred over
the past decade following increased cystectomy workload.
• Improved survival doesn’t appear to be due to surgical
advances and may reflect changes in patient case selection.
• To enable comparisons of complications of major surgical
procedures, a standardised reporting system is required.
• Complication rates of 64% (13% grade 3 or more) have been
reported in a large cystectomy series using a strict reporting
system1 . The rate of complications in this present study is
comparable.
1) Shabsigh A. European urology 2009. 55:164-176