Hospital and Surgical Caseload are Predictors of Comprehensive Surgical Treatment for Bladder Cancer: A Population Based Study

PurposeIn patients with nonmetastatic muscle invasive bladder cancer, radical cystectomy and pelvic lymph node dissection represent a comprehensive surgical treatment. We tested the hypothesis that radical cystectomy performed at a high caseload hospital and/or by a high caseload surgeon is more likely to include pelvic lymph node dissection.Materials and MethodsWe identified 12,274 patients with bladder cancer treated with radical cystectomy between 1998 and 2007 within the Nationwide Inpatient Sample. Univariable and multivariable analyses tested the relationship between hospital and surgical caseload at radical cystectomy, and the pelvic lymph node dissection rate. Generalized estimating equation models were used to adjust for clustering among hospitals and surgeons.ResultsOverall 70% of patients received comprehensive surgical treatment defined as radical cystectomy and pelvic lymph node dissection. The pelvic lymph node dissection rate was 63% vs 67% vs 80% for low vs intermediate vs high annual hospital caseload tertiles, respectively (p <0.001). The pelvic lymph node dissection rate was 64% vs 68% vs 80% for low vs intermediate vs high annual surgical caseload tertiles, respectively (p <0.001). On multivariable analyses and after adjusting for clustering, annual hospital caseload and annual surgical caseload were independent predictors of the pelvic lymph node dissection rate.ConclusionsOur findings indicate that a potentially comprehensive surgical treatment, defined as radical cystectomy with pelvic lymph node dissection, is only offered to a subset of patients. Annual hospital caseload and annual surgical caseload represent important determinants of potentially comprehensive bladder cancer surgery. Efforts should be made to ensure that virtually all patients with bladder cancer receive comprehensive surgical treatment.