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Unlabelled: Study Type - Prognosis (cohort). Level of Evidence 2a. What's known on the subject? and What does the study add? The subject of mortality and survival rates after radical cystectomies in high-volume hospitals in comparison to low-volume hospitals has been extensively studied. Postoperative mortality is known to be significantly lower with high-volume providers, but for survival rates there was only a trend forwards this finding. For this reason, we performed this Dutch population-based study on survival rates, to see if we had enough power to support this trend with significant findings. To our knowledge, this is the first study of good quality showing a significant beneficial effect for survival in high-volume hospitals., Objective: • To examine the volume-outcome relationship for carcinoma invading bladder muscle (MIBC) with respect to differences in survival rates among all hospitals in the Netherlands as a guide for regionalization initiatives., Materials and Methods: • This population-based retrospective study included all patients (n= 13 033) newly diagnosed with MIBC during the period 1999-2008 in the Netherlands, selected from the Netherlands Cancer Registry. • Data were collected on demographics, morphology, stage at diagnosis and after surgery, primary treatment, vital status and date of follow-up or death. • The relative survival rate (RSR) per treatment was analysed for age, stage and hospital surgical volume., Results: • Overall 5 and 10-year RSR for all treatments of MIBC was 32% and 25%, respectively. • Although 71.7% of the patients featured stages II and III, radical cystectomy was only performed in only 42% and 44% of these patients, respectively. • Relative survival for MIBC remained unchanged in the two consecutive time periods (1999-2003 and 2004-2008). • In all, 34% of patients diagnosed in low-volume hospitals (<10 cystectomies/year) underwent cystectomy vs 42% of those diagnosed in high-volume hospitals (P= 0.000). • In a multivariate analysis long-term survival (>30 days after surgery) was significantly lower in patients after cystectomy for stage II/III in low-volume hospitals (hazard ratio [HR] 1.17, P= 0.036). A high lymph node count (>20) was associated with a lower risk of death (HR 0.52, P= 0.000)., Conclusions: • The 10-year RSR for patients with MIBC in the Netherlands was modest (25%) and has remained unchanged in the last decade. • The chance of undergoing cystectomy is significantly higher in high-volume hospitals. Long-term survival after cystectomy is higher in high-volume hospitals. • Regionalization of bladder cancer treatments could improve overall outcomes., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Objective: • To further clarify the risk profiles of three clinical types of carcinoma in situ (CIS) of the bladder., Materials and Methods: • Population-based data from the Comprehensive Cancer Centre Middle Netherlands, as part of the nationwide Netherlands Cancer Registry, were used for patients presenting with CIS in the period from 1987 to 2009. • Patients with muscle-invasive bladder cancer on primary diagnosis were excluded. The patients were divided into three groups according to their 'clinical type', being primary, concomitant or secondary CIS., Results: • Overall, 90 patients with CIS were identified with a mean age of 63.4 years, predominantly men (91.1%). Primary CIS (P-CIS) was found in 43 patients (47.8%), concomitant CIS (C-CIS) in 21 patients (23.3%) and secondary CIS (S-CIS) in 26 patients (28.9%). Mean follow up was 81.3 months (range 8-222 months). Recurrence of disease was observed in 68.9% of patients, with significantly more recurrences in the S-CIS group (88.5%). • Progression to muscle-invasive disease was seen in 17 patients (18.9%): eight patients (18.7%) with P-CIS, four (19.0%) with C-CIS and five (19.2%) with S-CIS. Overall, 29 patients underwent a cystectomy, equally distributed over the three groups. The duration of bladder preservation was worse in the C-CIS group but did not differ significantly between the groups. • Overall survival at 5 years was 79.6% for the total group, with poorer results for the C-CIS group, although the difference was not significant., Conclusions: • Carcinoma in situ is clearly an entity that requires meticulous treatment and thorough follow up because of its high recurrence rate (68.9%) and high rate of progression to muscle-invasive bladder cancer (18.9%). • The C-CIS group appears to have a poorer prognosis with a shorter duration of bladder preservation and a worse overall survival., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Objective: To assess treatments and survival of patients with muscle invasive bladder cancer (MIBC) in the Comprehensive Cancer Center Northern Netherlands (CCCN) region., Study Design and Setting: Retrospective cohort analysis. Data of 548 patients with MIBC diagnosed between 1997 and 2002 were collected from the CCCN cancer registry. All had a follow-up of at least 5 years. Logistic regression analysis on treatments as well as survival analysis was performed., Results: The treatments were radical cystectomy in 205/548 (37.5%) patients. TUR plus radiotherapy in 246 (44.9%) and palliation in 97 (17.7%). Multivariate analysis identified TNM stage (P < 0.0001) and age (P < 0.0001) as independent variables for cystectomy. Hospital type and year of diagnosis were not significant different between patients treated by cystectomy versus other type of treatment. TNM stage (P < 0.0001), age (P = 0.0043), and comorbidity (P = 0.0028) were independent variables for disease-specific survival (DSS) after cystectomy., Conclusion: In the CCCN region, only 1/3 of patients with MIBC were treated with radical cystectomy. TNM stage and age were identified as main variables for the choice for cystectomy. TNM stage, age, and comorbidity were independent variables for disease-specific survival after cystectomy.

Purpose: To evaluate the effect of volume of cystectomies in the Greater Amsterdam region on postoperative outcomes., Methods: All primary bladder tumours diagnosed between 1989 and 2003 were selected from the Amsterdam Cancer Registry, a population-based cancer registry (population 3.0 million). For all patients who underwent cystectomy during 1989-2003 at 20 participating hospitals, medical records were reviewed for information on postoperative mortality, locoregional recurrences and relative risk of death. To assess the effect of volume, outcomes at an oncology centre and low-volume hospitals were compared., Results: During 1989-2003 a total of 1,185 cystectomies were performed in 20 hospitals of the Greater Amsterdam region. Postoperative mortality was 3.2%. During 1989-1997, 8% of cystectomies were performed at the oncology centre, increasing to 30% in 1998-2003. Although postoperative mortality at this centre decreased from 4.0% in 1989-1997 to 1.1% in 1998-2003, the latter percentage was not statistically significantly different from the other hospitals during 1998-2003 (OR 0.3; P = 0.09). No statistically significant difference in locoregional recurrence rate and in the relative risk of death was observed between the oncology centre and all other hospitals combined., Conclusions: We observed a lower postoperative mortality rate in the oncology centre compared to the low-volume hospitals; however, this difference did not reach statistical significance. We could neither prove a statistically significant relation between hospital volume, local recurrence rate and survival after cystectomy. To answer the question if centralisation of cystectomies is beneficial more procedures have to be compared.