Tag Archive for: cystectomy


Editorial: High hospital volume reduces mortality after cystectomy

In the current issue of BJUI, Nielsen et al. [1] assessed the role of hospital characteristics on the risk of short-term mortality in a contemporary cohort of patients with bladder cancer treated with radical cystectomy (RC) representing the USA population. In their investigation, the authors evaluated >35 000 undergoing RC included within the National Cancer Database. Interestingly, they showed that hospital volume represents an independent predictor of both 30- and 90-day mortality. Several studies already explored the association between hospital characteristics (i.e., hospital volume) and short- and long-term postoperative outcomes, e.g. complication, blood transfusion, readmission, and mortality rates after RC [2-5]. Although this topic has already been broadly investigated, the current study was able to determine the 90-day mortality rates conditional on survival to 30 days after RC.

From a clinical standpoint, the authors report several relevant findings. First, hospital volume represented an independent predictor of 90-day mortality after RC [1]. Particularly, patients treated in centres performing an average of >20 RC/year had significantly lower mortality rates compared with those undergoing RC in smaller volume hospitals. However, it should be noted that the magnitude of the effect was substantially greater when evaluating the 30-day period as compared with 90 days after RC. This observation leads to clinically relevant considerations. Indeed, it might be speculated that the better quality of care generally provided in high-volume tertiary referral centres has a substantial impact on perioperative outcomes and mortality. However, this effect manifests itself mainly in the immediate period after RC. This is consistent with previous studies evaluating the impact of hospital volume on perioperative outcomes in inpatient cohorts [4, 5]. For example, Trinh et al. [3] showed that this parameter was significantly associated with the risk of dying in the perioperative period when a complication occurred. In this context, tertiary referral centres might be better equipped to assist patients in the postoperative period and eventually treat them in a timely fashion [4]. Particularly, better processes of care, e.g. preoperative patient evaluation, invasive monitoring, and perioperative consultations with critical care and other units, might be at least in part responsible for this phenomenon [4]. These observations justify the referral to high-volume centres when a major surgical procedure is planned [3, 4]. On the other hand, the quality of the assistance received during hospitalisation might have a limited impact on postoperative outcomes after hospital discharge. Consequently, these findings might be used to advocate better home care in order to improve patient management after hospital discharge and, in turn, reduce the risk of perioperative morbidity and mortality.

Second, it should be noted that a substantial proportion of patients had died by the 3-month follow-up (7.2%). Moreover, up to 5% of patients who survived at 1 month after RC died in the following 2 months. These observations are consistent with previous studies and highlight the need for better perioperative patient management [1, 3, 5, 6]. Additionally, these sobering figures should be used to advocate better patient selection in order to spare the potential RC-related complications in frail patients, where alternative and less invasive treatment options might be considered.

Concluding, the study by Nielsen et al. [1] further demonstrates that patients with bladder cancer undergoing RC have a non-negligible risk of perioperative mortality at 30- and 90-days after RC. Patients treated at higher volume centres (≥20 procedures/year) experience better perioperative outcomes compared with their counterparts undergoing RC at lower volume institutions (<10 procedures/year). However, the effect of hospital volume on the risk of perioperative mortality is considerably greater in the early period after RC. Consequently, substantive efforts should be made to improve postoperative patient care even after hospital discharge.

Giorgio Gandaglia*, Pierre I. Karakiewicz, Quoc-Dien Trinh and Maxine Sun*

*Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Canada, Urological Research Institute, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy, and Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women’s Hospital, Boston, MA, USA


  1. Nielsen ME, Mallin K, Weaver MA et al. Association of hospital volume with conditional 90-day mortality after cystectomy: an analysis of the national cancer database. BJU Int 2014; 114: 46–55
  2. Kulkarni GS, Urbach DR, Austin PC, Fleshner NE, Laupacis A. Higher surgeon and hospital volume improves long-term survival after radical cystectomy. Cancer 2013; 119: 3546–3554
  3. Trinh VQ, Trinh QD, Tian Z et al. In-hospital mortality and failure-to-rescue rates after radical cystectomy. BJU Int 2013; 112: E20–27
  4. Sun M, Ravi P, Karakiewicz PI et al. Is there a relationship between leapfrog volume thresholds and perioperative outcomes after radical cystectomy? Urol Oncol 2014; 32: 27 e7–13
  5. Kim SP, Boorjian SA, Shah ND et al. Contemporary trends of in-hospital complications and mortality for radical cystectomy. BJU Int 2012; 110: 1163–1168
  6. Gandaglia G, Popa I, Abdollah F et al. The effect of neoadjuvant chemotherapy on perioperative outcomes in patients who have bladder cancer treated with radical cystectomy: a population-based study. Eur Urol 2014; (in press) doi: 10.1016/j.eururo.2014.01.014


Video: Hospital volume and conditional 90-day post-cystectomy mortality

Association of hospital volume with conditional 90-day mortality after cystectomy: an analysis of the National Cancer Data Base

Matthew E. Nielsen*†‡, Katherine Mallin§, Mark A. Weaver, Bryan Palis§, Andrew Stewart§, David P. Winchester§ and Matthew I. Milowsky*,**

*University of North Carolina Lineberger Comprehensive Cancer Center, Department of Urology, and Divisions of General Medicine and Clinical Epidemiology and **Hematology and Oncology, University of North Carolina School Something like this?of Medicine, Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, and §American College of Surgeons, National Cancer Data Base, Chicago, IL, USA

This research was presented at the Society of Urologic Oncology 2012 Annual Meeting, 29 November 2012, Bethesda, MD, USA


To examine the association of hospital volume and 90-day mortality after cystectomy, conditional on survival for 30 days.


The National Cancer Data Base was used to evaluate 30- and 90-day mortality for 35 055 patients who underwent cystectomy for bladder cancer at one of 1118 hospitals.

Patient data were aggregated into hospital volume categories based on the mean annual number of procedures (low-volume hospital: <10 procedures; intermediate-volume hospital: 10–19 procedures; high-volume hospital: ≥20 procedures).

Associations between mortality and clinical, demographic and hospital characteristics were analysed using hierarchical logistic regression models. To assess the association between hospital volume and 90-day mortality independently of shorter-term mortality, 90-day mortality conditional on 30-day survival was assessed in the multivariate modelling.


Unadjusted 30- and 90-day mortality rates were 2.7 and 7.2% overall, 1.9 and 5.7% among high-volume hospitals, and 3.2 and 8.0% among low-volume hospitals, respectively.

Compared with high-volume hospitals, the adjusted risks among low-volume hospitals (odds ratio [95% CI]) of 30- and 90-day mortality, conditional on having survived for 30 days, from the hierarchical models were 1.5 (1.3–1.9), and 1.2 (1.0–1.4), respectively.


A low hospital volume was associated with greater 30- and 90-day mortality. These data support the need for further research to better understand the relatively high mortality rates seen between 30 and 90 days, which are high and less variable across hospital volume strata.

The stronger association between volume and 30-day mortality suggests that quality-reporting efforts should focus on shorter-term outcomes.


Article of the week: Quality of life after robotic cystectomy

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC)

Michael A. Poch, Andrew P. Stegemann, Shabnam Rehman, Mohamed A. Sharif, Abid Hussain, Joseph D. Consiglio*, Gregory E. Wilding* and Khurshid A. Guru

Departments of Urology and *Biostatistics, Roswell Park Cancer Institute, Buffalo, NY, USA

Read the full article

• To determine short-term health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC) using the Bladder Cancer Index (BCI) and European Organisation for Research and Treatment of Cancer (EORTC) Body Image Scale (BIS).


• All patients undergoing RARC were enrolled in a quality assurance database.

• The patients completed two validated questionnaires, BCI and BIS, preoperatively and at standardised postoperative intervals.

• The primary outcome measure was difference in interval and baseline BCI and BIS scores.

• Complications were identified and classified by Clavien grade.


• In all, 43 patients completed pre- and postoperative questionnaires.

• There was a decline in the urinary domain at 0–1 month after RARC (P = 0.006), but this returned to baseline by 1–2 months.

• There was a decline in the bowel domain at 0–1 month (P < 0.001) and 1–2 months (P = 0.024) after RARC, but this returned to baseline by 2–4 months.

• The decline in BCI scores was greatest for the sexual function domain, but this returned to baseline by 16–24 months after RARC.

• Body image perception using BIS showed no significant change after RARC except at the 4–10 months period (P = 0.018).


• Based on BCI and BIS scores HRQL outcomes after RARC show recovery of urinary and bowel domains ≤6 months. Longer follow-up with a larger cohort of patients will help refine HRQL outcomes.


Editorial: The evolution of robotic cystectomy

A decade has passed since the publication of the first series of robot-assisted radical cystectomies in the BJUI by Menon et al. [1]. New technologies are fascinating, and many surgeons who aspire to leave a mark in history take the lead in pioneering new procedures. Others follow without waiting for any evidence to justify the adoption of new procedures. In this race, the opinion of the most important stakeholder, the patient, gets ignored.

Although their study has many methodological flaws, Guru et al. [2] have made the effort to collect data on patients’ health-related quality of life (HRQL) after robot-assisted radical cystectomy for bladder cancer. Radical cystectomy is a morbid procedure with a serious impact on patients’ HRQL, no matter how it is performed. Loosing an organ which is responsible for the storage and evacuation of urine several times a day and replacing it with alternatives of continent or incontinent diversion has a serious impact on quality of life, as is evident from this study.

Robotic cystectomy is still evolving. With more experience, a few experts have ventured to perform intracorporeal reconstruction of the urinary diversion. While we await the long-term functional outcomes of this switch over in surgical approach, Guru et al. report the short-term HQRL outcomes in a series of 43 patients undergoing robot-assisted radical cystectomy and intracorporeal urinary diversion at their institution. Most patients (n = 38) had ileal conduit urinary diversion. The authors went on to compare the postoperative outcomes of this cohort with another group of 70 patients who only completed the questionnaire after having undergone robot-assisted radical cystectomy and extracorporeal urinary diversion.

It is interesting to note that there was no significant difference in HRQL between those undergoing extracorporeal and those undergoing intracorporeal reconstruction. These outcomes reinforce the need to gather robust scientific evidence from properly conducted multi-centre, multinational randomized trials before the introduction of new procedures, instead of evaluation with retrospective studies. The urological community has embraced new technologies and patients have benefited a great deal from these innovative approaches; however, it is incumbent upon us to develop a culture of independent, unbiased data collection on outcomes. In this regard we must make the HQRL one of the most important quality indicators in assessment of the new procedures. Such an approach will enable us to justify the extra cost which society has to bear for our innovative trends in the management of old problems [3].

Read the full article

Muhammad Shamim Khan
Guy’s and St Thomas’s Hospital and King’s College London, London, UK


  1. Menon M, Hemal AK, Tewari A et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversionBJU Int 2003; 92: 232–236
  2. Poch MA, Stegemann AP, Rehman S et al. Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC)BJU Int 2014; 113: 260–265
  3. Wang TT, Ahmed KA, Khan MS et al. Quality-of-care framework in urological cancers: where do we stand? BJU Int 2011; 109: 1436–1443


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