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The importance of hospital and surgeon volume as major determinants of morbidity and mortality after radical cystectomy for bladder cancer: a systematic review and recommendations by the European Association of Urology muscle-invasive and metastatic bladder cancer guideline panel

  • Harman M. Bruins 1,
  • Erik Veskimäe 2,
  • Virginia Hernández 3,
  • Yann Neuzillet 4,
  • Richard Cathomas 5,
  • Eva M. Compérat 6,
  • Nigel C. Cowan 7,
  • Georgios Gakis 8,
  • Estefania Linares Espinós 9,
  • Anja Lorch 10,
  • Maria J. Ribal 11,
  • Mathieu Rouanne 4,
  • George N. Thalmann 12,
  • Yuhong Yuan 13,
  • Antoine G. van der Heijden 14,
  • J. Alfred Witjes 14
1 Department of Urology, Zuyderland Medisch Centrum, Heerlen/Sittard-Geleen, The Netherlands 2 Department of Urology, Tampere University Hospital, Tampere, Finland 3 Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain 4 Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France 5 Department of Medical Oncology, Kantonsspital Graubünden, Chur, Switzerland 6 Department of Pathology, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hopital Tenon, Paris, France 7 Department of Radiology, The Queen Alexandra Hospital, Portsmouth, UK 8 Department of Urology and Pediatric Urology, University of Würzburg, Würzburg, Germany 9 Department of Urology, Hospital Universitario La Paz, Madrid, Spain 10 Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland 11 Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain 12 Department of Urology, Inselspital, University Hospital Bern, Switzerland 13 Department of Medicine, Health Science Centre, McMaster University, Hamilton, Ontario, Canada 14 Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands

Publication: European Urology Oncology, December 2020


In bladder cancer patients treated with radical cystectomy (RC), controversy exists regarding the impact of the annual hospital volume (HV) and/or surgeon volume (SV) on oncological outcomes and quality of care.


A systematic review was performed to evaluate the impact of HV and SV on clinical outcomes. Primary outcomes included in-hospital, 30-d, and 90-d mortality. Secondary outcomes included complications, long-term survival, positive surgical margin rate, lymphadenectomy performance, length of hospital stay, neobladder performance, and blood loss/transfusion rate.

Evidence acquisition

Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched. Comparative studies published after the year of 2000 including patients who underwent RC for bladder cancer were eligible for inclusion. Partial cystectomy was an exclusion criterion. Risk of bias (RoB) assessment was performed according to the ROBINS-1 tool.

Evidence synthesis

After screening of 1190 abstracts, 39 studies recruiting 549 542 patients were included. All studies were retrospective observation cohort studies (level of evidence 3). Twenty-two studies reported on HV only, six studies on SV only, and 12 on both. Higher HV, specifically an HV of >10, was associated with improved primary and secondary outcomes in most studies. In addition, there is some evidence that an HV of >20 improves outcomes. For SV, limited and conflicting data are reported. Most studies had moderate to high RoB. The results were synthesized narratively.


Acknowledging the lower level of evidence, HV is likely associated with in-hospital, 30- and 90-d mortality, as well as the secondary outcomes assessed. Based on this study, the European Association of Urology Muscle-invasive and Metastatic Bladder Cancer Guideline Panel recommends hospitals to perform at least 10, and preferably >20, RCs annually or refer the patient to a center that reaches this number. For SV, limited and conflicting data are available. The available evidence suggests HV rather than SV to be the main driver of perioperative outcomes.

Expert's summary

By Dr. Soria 

Radical cystectomy, eventually preceded by neoadjuvant chemotherapy, represents the standard treatment for very high-risk non-muscle invasive and muscle-invasive bladder cancer patients. Radical cystectomy is a morbid procedure afflicted by a high rate of postoperative complications and a non-negligible rate of postoperative mortality, even in referral centers. Data from large retrospective series show a 90-days overall complications’ rate ranging from 35% and 50%, and a postoperative mortality rate between 1% and 6%.

The results of this systematic review and meta-analysis confirm the importance of hospital volume rather than that of surgeon volume as predictor of perioperative outcomes. This is probably the consequence of several factors. The introduction of ERAS (Enhanced Recovery After Surgery) protocol, aiming to accelerate patient recovery and improve surgical outcomes through standardized evidence-based perioperative care, demonstrated to be able to improve perioperative outcomes such as the length of stay and, in some studies, the complications’ rate. The ERAS protocol brings into play several different specialists such as nurses, nutritionists, physiotherapists, surgeons and anesthesiologists and, therefore, its adoption is obviously allowed and facilitated in referral centers. Moreover, an early identification as well as a correct and prompt management of complications occurring after radical cystectomy is of crucial importance ad relays on the experience of the entire team.

Notably, based on the findings of this review, the EAU expert panel recommended hospitals to perform at least 10, and preferably more than 20, cystectomies per year to be considered a referral center. This is an important step forward towards the centralization of treatment, that already demonstrated to be essential to provide the best available care by improving several process-related indicators including consultation with multidisciplinary teams (with a subsequent increase in the administration of neoadjuvant chemotherapy), recognition and treatment of rare histological variants as well as performance of adequate lymph-node dissection.  

Expert's comment

In this systematic review the authors aimed to evaluate the impact of hospital and surgeon volume on oncological outcomes and quality of care among patients undergoing radical cystectomy for bladder cancer. Primary outcomes of interest included in-hospital, 30-days and 90-days mortality while secondary outcomes were complications, long-term survival, positive surgical margin rate, lymphadenectomy performance, length of stay, neobladder performance and blood loss/transfusion rate. Hospital volume was associated with in-hospital, 30-d and 90-d mortality as well as with all the secondary outcomes. Conversely, no clear association between surgeon volume and primary and secondary outcomes was observed. Based on these findings, the EAU panel recommends hospitals to perform at least 10 and preferably >20 radical cystectomies per year or to refer the patient to a center that reaches these numbers to provide the best quality of care to bladder cancer patients undergoing radical cystectomy.