Effect of hospital volume on 90-day mortality after radical cystectomy for bladder cancer in Spain

  • Carlos LlorenteEmail author
  • Ana Guijarro
  • Virginia Hernandez
  • Guillermo Fernández-Conejo
  • Elia Perez-Fernandez
  • Stuart Pocock
Original Article



To investigate 90-day mortality rate of RC for bladder cancer in a nationwide population-based study.

Design, setting, and participants

We used mandatory hospital discharge forms of all patients submitted to RC due to bladder cancer in Spain during 2011–2015 (n = 12,154 in 196 hospitals). At present, a centralization policy for RC has not been issued by the health authorities.

Outcome measurements and statistical analysis

We calculated in-hospital, 30-, 60- and 90-day mortality. Average annual RC volume was used as a continuous variable (log-transformed) and also grouped into deciles to identify any potential non-linear relationships. Logistic regression model with mixed effect was performed adjusting for year of surgery, comorbidity, surgical approach, type of admission, age, sex, and hospital size.

Results and limitation

Overall 90-day mortality rate was 6.5%. Lowest mortality rates (3.3% at 90 days) are achieved in hospitals doing more than 38 cases per year. The 90-day adjusted mortality rate is associated with annual average RC volume with a 20.6% decrease per 10 extra RCs/year (95% CI 12.3–28.1% p < 0.001). High Charlson comorbidity index, advanced age, and open surgical approach were the clinical variables associated with higher mortality.


Our study identifies an inverse association between 90-day mortality and hospital volume. High-volume hospitals achieve lower mortality rate within 90 days.


Radical cystectomy Surgical mortality Perioperative outcomes Bladder cancer 



Radical cystectomy


Author contributions

CL: project development, manuscript writing, data collection; AG: data collection, manuscript editing; VH: manuscript editing; GF: manuscript editing; EP: data analysis; SP: data analysis, manuscript editing.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent

For this type of study, formal consent is not required.

Supplementary material

345_2019_2874_MOESM1_ESM.docx (290 kb)
Supplementary material 1 (DOCX 289 kb)


  1. 1.
    Gore JL, Wright JL, Daratha KB, Roberts KP, Lin DW, Wessells H, Porter M (2012) Hospital-level variation in the quality of urologic cancer surgery. Cancer 118:987–996CrossRefGoogle Scholar
  2. 2.
    Gierth M, Zeman F, Denzinger S, Vetterlein MW, Fisch M, Bastian PJ, Syring I, Ellinger J, Muller SC, Herrmann E, Gilfrich C, May M, Pycha A, Wagenlehner FM, Vallo S, Bartsch G, Haferkamp A, Grimm MO, Roigas J, Protzel C, Hakenberg OW, Fritsche HM, Burger M, Aziz A, Mayr R (2018) Influence of body mass index on clinical outcome parameters, complication rate and survival after radical cystectomy: evidence from a prospective European multicentre study. Urol Int 101:16–24CrossRefGoogle Scholar
  3. 3.
    Milenkovic U, Akand M, Moris L, Demaegd L, Muilwijk T, Bekhuis Y, Laenen A, Van Cleynenbreugel B, Everaerts W, Van Poppel H, Dumez H, Albersen M, Joniau S (2018) Impact of neoadjuvant chemotherapy on short-term complications and survival following radical cystectomy. World J Urol.
  4. 4.
    Ghodoussipour S, Ahmadi N, Hartman N, Cacciamani G, Miranda G, Cai J, Schuckman A, Djaladat H, Gill I, Daneshmand S, Desai M (2018) Factors influencing intraoperative conversion from planned orthotopic to non-orthotopic urinary diversion during radical cystectomy. World J Urol.
  5. 5.
    Hollenbeck BK, Daignault S, Dunn RL, Gilbert S, Weizer AZ, Miller DC (2007) Getting under the hood of the volume-outcome relationship for radical cystectomy. J Urol 177:2095–2099CrossRefGoogle Scholar
  6. 6.
    Hautmann RE, de Petriconi RC, Volkmer BG (2010) Lessons learned from 1000 neobladders: the 90-day complication rate. J Urol 184:990–994CrossRefGoogle Scholar
  7. 7.
    Aziz A, May M, Burger M, Palisaar RJ, Trinh QD, Fritsche HM, Rink M, Chun F, Martini T, Bolenz C, Mayr R, Pycha A, Nuhn P, Stief C, Novotny V, Wirth M, Seitz C, Noldus J, Gilfrich C, Shariat SF, Brookman-May S, Bastian PJ, Denzinger S, Gierth M, Roghmann F, PROMETRICS 2011 research group (2014) Prediction of 90-day mortality after radical cystectomy for bladder cancer in a prospective European multicenter cohort. Eur Urol 66:156–163CrossRefGoogle Scholar
  8. 8.
    Hounsome LS, Verne J, McGrath JS, Gillatt DA (2015) Trends in operative caseload and mortality rates after radical cystectomy for bladder cancer in England for 1998–2010. Eur Urol 67:1056–1062CrossRefGoogle Scholar
  9. 9.
    Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE (2002) Hospital volume and surgical mortality in the United States. N Engl J Med 346:1128–1137CrossRefGoogle Scholar
  10. 10.
    Konety BR, Allareddy V, Modak S, Smith B (2006) Mortality after major surgery for urologic cancers in specialized urology hospitals: are they any better? J Clin Oncol 24:2006–2012CrossRefGoogle Scholar
  11. 11.
    Finks JF, Osborne NH, Birkmeyer JD (2011) Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 364:2128–2137CrossRefGoogle Scholar
  12. 12.
    Rosario DJ (2015) Mortality following radical cystectomy: a good start, but how low can we go? Eur Urol 67:1063–1065CrossRefGoogle Scholar
  13. 13.
    Deyo RA, Cherkin DC, Ciol MA (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45:613–619CrossRefGoogle Scholar
  14. 14.
    Burger M, Catto JW, Dalbagni G, Grossman HB, Herr H, Karakiewicz P, Kassouf W, Kiemeney LA, La Vecchia C, Shariat S, Lotan Y (2013) Epidemiology and risk factors of urothelial bladder cancer. Eur Urol 63:234–241CrossRefGoogle Scholar
  15. 15.
    Isbarn H, Jeldres C, Zini L, Perrotte P, Baillargeon-Gagne S, Capitanio U, Shariat SF, Arjane P, Saad F, McCormack M, Valiquette L, Peloquin F, Duclos A, Montorsi F, Graefen M, Karakiewicz PI (2009) A population based assessment of perioperative mortality after cystectomy for bladder cancer. J Urol 182:70–77CrossRefGoogle Scholar
  16. 16.
    Zakaria AS, Santos F, Dragomir A, Tanguay S, Kassouf W, Aprikian AG (2014) Postoperative mortality and complications after radical cystectomy for bladder cancer in Quebec: a population-based analysis during the years 2000–2009. Can Urol Assoc J 8:259–267CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Carlos Llorente
    • 1
    Email author
  • Ana Guijarro
    • 1
  • Virginia Hernandez
    • 1
  • Guillermo Fernández-Conejo
    • 1
  • Elia Perez-Fernandez
    • 1
  • Stuart Pocock
    • 2
  1. 1.Department of Urology and Research UnitHospital Universitario Fundación AlcorconAlcorcónSpain
  2. 2.Department of Medical StatisticsLondon School of Hygiene and Tropical MedicineLondonUK

Personalised recommendations