Re: Volume Outcomes of Cystectomy—Is It the Surgeon or the Setting?

In an effort to establish predictors of mortality after complex oncologic surgery, Morgan et al. analyzed 7127 patients with urothelial carcinoma of the bladder undergoing radical cystectomy from the Surveillance Epidemiology and End Results–Medicare-linked database between 1992 and 2006. Specifically, they studied the relationship between surgeon volume (SV) and hospital volume (HV) on overall mortality. SV was grouped according to tertiles (1–3, 4–12, and>12 total surgeries); HV was also grouped by tertile (1–15, 16–50, and>50 surgeries). Univariate analysis showed that low SV and lowHVwere each associated with increased mortality; however, multi-variate analysis established that HV rather than SV was significant for survival after radical cystectomy. By includ-ing HV in the SV model, the outcome was attenuated to the point where SV was no longer statistically significant