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Radical cystectomy: defining the threshold for a surgeon to achieve optimum outcomes
  1. John E McCabe,
  2. Abdullah Jibawi,
  3. Pradip M Javle
  1. Michael Heal Department of Urology, Leighton Hospital, Crewe, Cheshire, UK
  1. Correspondence to:
 MrJohn McCabe
 3 Rimsdale Close, Liverpool L17 6EX, UK; johnemccabe{at}


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.

  • 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

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  • Competing interests: None declared