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


OBJECTIVE
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


METHODS
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.


CONCLUSIONS
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.
Michael Heal Department of Urology, Leighton Hospital, Crewe, Cheshire, UK. johnemccabe@lineone.net
John E
JE
McCabe
Abdullah
A
Jibawi
Pradip M
PM
Javle
D000368:Aged; D002983:Clinical Competence / Q000592:standards; D015653:Cystectomy / Q000379:methods* / Q000592:standards; D004739:England; D005260:Female; D006276:Health Facility Size; D006801:Humans; D008297:Male; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000601:surgery*; D014572:Urology / Q000592:standards* / Q000706:statistics & numerical data; D016526:Workload