HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS REGISTER		Author Keyword(s) Vol Page [Advanced]

This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this link to a friend Similar articles in this journal Similar articles in PubMed Add article to my folders Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by McCabe, J. E Articles by Javle, P. M Search for Related Content PubMed PubMed Citation Articles by McCabe, J. E Articles by Javle, P. M

Radical cystectomy: defining the threshold for a surgeon to achieve optimum outcomes

Michael Heal Department of Urology, Leighton Hospital, Crewe, Cheshire, UK

Correspondence to:
Correspondence to:
MrJohn McCabe
3 Rimsdale Close, Liverpool L17 6EX, UK; johnemccabe{at}lineone.net

Background: The reorganisation of cancer services in England will result in the creation of specialist high volume cancer surgery centres. Studies have suggested a relationship between increasing surgical volume and improved outcomes in urological pelvic cancer surgery, although to date, they have pre-defined the definition of "high" and "low" volume surgeons.

Aim: To derive the minimum caseload a surgeon requires to achieve optimum outcomes and to examine the effect of the operating centre size upon individual surgeon’s outcomes.

Methods: All cystectomies performed for bladder cancer in England over 5 years were analysed from Hospital Episode Statistics (HES) data. Statistical analysis was undertaken to describe the relationship between each surgeon’s annual case volume and two outcome measures: in-hospital mortality rate, and hospital stay. The surgeon’s outcomes were then analysed with respect to the overall level of activity in their operating centre.

Results: A total of 6308 cystectomies were performed; the mean number of surgeons performing them annually was 327 with an overall mortality rate of 5.53%. A significant inverse correlation (–0.968, p<0.01) was found between case volume and mortality rate. Applying 95% confidence interval estimation, the minimum caseload required to achieve the lowest mortality rate was eight procedures per year. Increasing caseload beyond eight operations per year did not produce a significant reduction in mortality rate.

Conclusion: Analysis of HES data confirms an inverse relationship between surgeon’s caseload and mortality for radical cystectomy. A caseload of eight operations per year is associated with the lowest mortality rate.

Abbreviations: CI, confidence interval; HES, Hospital Episode Statistics; ICD-10, International classification of disease, 10th revision; NICE, National Institute for Health and Clinical Excellence; OPCS4, Office of Population, Census and Surveys – classification of surgical operations and procedures, 4th revision; RRP, radical retropubic prostatectomy