Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, Canada.
J Urol. 2011 Sep;186(3):824-8. doi: 10.1016/j.juro.2011.04.066. Epub 2011 Jul 23.
In 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.
We 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.
Overall 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.
Our 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.
在非转移性肌层浸润性膀胱癌患者中，根治性膀胱切除术和盆腔淋巴结清扫术代表了一种全面的外科治疗方法。我们假设在高病例量医院进行的根治性膀胱切除术和/或由高病例量外科医生进行的根治性膀胱切除术更有可能包括盆腔淋巴结清扫术。
我们在 1998 年至 2007 年期间在全国住院患者样本中确定了 12274 例接受根治性膀胱切除术治疗的膀胱癌患者。单变量和多变量分析测试了根治性膀胱切除术时医院和手术病例量与盆腔淋巴结清扫率之间的关系。广义估计方程模型用于调整医院和外科医生之间的聚类。
总体而言，70%的患者接受了全面的手术治疗，定义为根治性膀胱切除术和盆腔淋巴结清扫术。盆腔淋巴结清扫率分别为低、中、高年度医院病例量三分位数组的 63%、67%和 80%（p<0.001）。盆腔淋巴结清扫率分别为低、中、高年度手术病例量三分位数组的 64%、68%和 80%（p<0.001）。在多变量分析和调整聚类后，年度医院病例量和年度手术病例量是盆腔淋巴结清扫率的独立预测因素。
我们的研究结果表明，一种潜在的全面手术治疗方法，即根治性膀胱切除术加盆腔淋巴结清扫术，仅提供给一部分患者。年度医院病例量和年度手术病例量是潜在全面膀胱癌手术的重要决定因素。应努力确保几乎所有膀胱癌患者都接受全面的手术治疗。
