Worse Survival After Robotic Cystectomy Seen at Low-Volume Centers

BOSTON — Muscle-invasive bladder cancer (MIBC) patients undergoing robot-assisted radical cystectomy (RARC) at hospitals with a low volume of cases have worse survival, researchers reported at the American Urological Association meeting.

Of 2773 patients undergoing RARC during 2010 to 2012 according to the National Cancer Data Base, 948 attended low-volume centers and 1825 high-volume centers. Low-volume hospitals performed 10 or fewer robotic cystectomies within the period and high-volume hospitals more than 10, according to study definitions.

Over a median of 25 months follow-up, a third of patients died. Those who had RARC at facilities with high surgical volume had 26% lower overall mortality. The researchers adjusted for common clinical and pathologic disease characteristics and hospital features, including patient age, disease stage, length of stay after surgery, and type of surgical facility (i.e., community center, comprehensive community center, or academic center).

“This suggests that adequate center volume may be important for conferring surgical quality and ultimately survival outcomes,” lead investigator Patrick Lewicki, MD, of New York-Presbyterian/Weill Cornell Medical Center in New York City, told Renal & Urology News. “Our study does not distinguish between the individual surgeon and the experience of the hospital in caring for RARC patients. It’s likely that both factors contribute to the findings of our brief study. RARC represents a technically demanding procedure with involved perioperative care, and — as has been demonstrated in open cystectomy — adequate volume from both a surgeon’s and a hospital’s perspective seem important for optimizing survival outcomes.”

Senior author Douglas Scherr, MD, Professor of Urology at Weill Cornell, added: “The impact of a poorly performed operation can impact patient survival. Careful attention to bladder margins, specimen handling and lymph node dissection require years of experience to master.”  

The majority of high-volume hospitals were academic centers with research and teaching capabilities. The other practice types included community cancer centers and comprehensive community cancer centers designated by the National Cancer Institute.

The investigators acknowledged that cancer stage, the percentage of patients with positive surgical margins, and practice type were significantly different between high- and low-volume centers. High-volume hospitals, for example, operated on more patients with bladder cancer below T2. Positive margins occurred among a greater proportion of patients at low-volume hospitals (9.8% vs 8.7%). When these variables were accounted for in the multivariable model, RARC volume retained its association with survival outcomes.

Lewicki P, Golombos D, O’Malley P, et al. Impact of surgical volume on survival following RARC in a large, national cohort. Presented at the American Urological Association annual meeting in Chicago on May 14, 2017. Poster MP54-06.