title: The importance of surgeon characteristics on impacting oncologic outcomes for patients undergoing radical cystectomy.
abstract: OBJECTIVE
  Given that the urologist has a major influence on outcomes of radical cystectomy, it is of interest to patients, trainees, urologists and administrators to understand the provider characteristics associated with favorable outcomes. Therefore, we assessed associations between various surgeon characteristics and long-term oncologic outcomes for patients undergoing radical cystectomy for bladder cancer.
  
  
  METHODS
  A retrospective cohort treated with radical cystectomy for muscle invasive or nonmuscle invasive bladder cancer at University Health Network (Toronto) was assembled. The characteristics studied included years of experience in independent practice, surgical radical cystectomy volume, subspecialized focus in bladder cancer and uro-oncology fellowship training. The outcomes were overall survival, bladder cancer specific survival and recurrence-free survival. Kaplan-Meier analyses and multivariate Cox proportional hazards models adjusting for patient, tumor and treatment related parameters were used.
  
  
  RESULTS
  The final cohort included 410 patients treated by 11 urologists (median followup 57 months). Bladder cancer focused and uro-oncology fellowship trained urologists performed more extensive lymphadenectomies and more often performed continent diversions, but there was no difference in the use of neoadjuvant chemotherapy. In Kaplan-Meier and univariate Cox analyses, subspecialized bladder cancer focus and uro-oncology fellowship were associated with improved survival outcomes. However, in multivariate Cox models only subspecialized bladder cancer focus was independently associated with improved overall survival (HR 0.68, 95% CI 0.55-0.85, p <0.001), bladder cancer specific survival (HR 0.63, 95% CI 0.41-0.96, p = 0.032) and recurrence-free survival (HR 0.63, 95% CI 0.42-0.95, p = 0.027).
  
  
  CONCLUSIONS
  While radical cystectomy volume, experience and uro-oncology fellowship are all likely important, we found that subspecialized focus in bladder cancer was independently associated with improved long-term oncologic outcomes. Our data support disease site differentiation among uro-oncologists at large institutions.
authors.affiliation: Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada. Electronic address: bimal.bhindi@mail.utoronto.ca.
authors.forename: Bimal
authors.initials: B
authors.lastname: Bhindi
authors.affiliation: Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Julie
authors.initials: J
authors.lastname: Yu
authors.affiliation: Division of Urology, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Kuk
authors.affiliation: Department of Medical Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Srikala S
authors.initials: SS
authors.lastname: Sridhar
authors.affiliation: Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Hamilton
authors.affiliation: Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Antonio
authors.initials: A
authors.lastname: Finelli
authors.affiliation: Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Michael A S
authors.initials: MA
authors.lastname: Jewett
authors.affiliation: Department of Pathology, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Evans
authors.affiliation: Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Neil E
authors.initials: NE
authors.lastname: Fleshner
authors.affiliation: Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Alexandre R
authors.initials: AR
authors.lastname: Zlotta
authors.affiliation: Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical and Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Girish S
authors.initials: GS
authors.lastname: Kulkarni
mesh_terms: D000368:Aged; D002983:Clinical Competence; D015331:Cohort Studies; D015653:Cystectomy / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008495:Medical Oncology; D012189:Retrospective Studies; D013038:Specialization; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000601:surgery*; D014572:Urology
keywords: cystectomy; mortality; patient outcome assessment; urinary bladder neoplasms