Smith NJ, Douglas D, Sundaram SK, Weston PMT, Chahal R.

1. 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. • McCabe JE et al. Postgraduate medical journal. 83 (982):556-560. • Mayer EK et al. BMJ 2010. 340: c1128. • Douglas D et al. Paper presentation, YUAG 2008

2. 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.

3. 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 high- and low-volume centres. • Ileal conduit diversion (88% vs 86%) and other reconstructions similar between groups

4. 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

5. Pathological stage Follow-up • Median follow-up (survivors): • Low-volume 63.2 months (range 44-90) • High-volume 68.5 months (range 7-113)

6. Log rank p=0.011 • 5-year OS was significantly higher in the high-volume group (56% vs. 37%), as was the 5-year CSS (70% vs. 50%). Log rank p=0.009

7. 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.

8. 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