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Improved outcomes following radical cystectomy for bladder cancer PowerPoint Presentation

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Slide 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
Slide 2 - Am I presenting the same old data again? “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? 1) Chahal R et al. European Urology 2003. 43:246-257. YES - 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.
Slide 3 - 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 Low-volume vs High-volume centres
Slide 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
Slide 5 - Pathological stage Median follow-up (survivors): Low-volume 63.2 months (range 44-90) High-volume 68.5 months (range 7-113) Follow-up
Slide 6 - 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
Slide 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.
Slide 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
 

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