- Email: [email protected]
111 ACCURATELY CHARACTERIZING THE MORBIDITY OF RADICAL CYSTECTOMY: DISPOSITION, READMISSION, AND DEATH WITHIN 90 DAYS
Vol. 183, No. 4, Supplement, Sunday, May 30, 2010
THE JOURNAL OF UROLOGY姞
General & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes III Podium 5 Sunday, May 30, 2010
8:00 AM-10:00 AM
109 MOVING TOWARDS BEST PRACTICES FOR EARLY-STAGE BLADDER CANCER John M. Hollingsworth*, Sean Zhang, Zaojun Ye, Brent K. Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: While contemporary practice guidelines for nonmuscle-invasive bladder cancer favor aggressive surveillance and treatment, recent findings reveal no added benefit for patients managed by high- vs. low-intensity providers, suggesting that more care does not always translate into improved outcomes. However, it is possible that some care processes are of higher value than others. Motivated by this, we used cancer registry data to help define best practices for urologists who manage early-stage bladder cancer. METHODS: Using SEER-Medicare data (1992 – 2007), we identified patients with low-grade Ta disease. We established the provider responsible for a patient’s care in the first 2 years following diagnosis. We determined the frequency with which a patient received certain surveillance- and treatment-directed care processes during this time. After fitting 2-level generalized linear mixed models, we generated reliability-adjusted measures for provider use of these care processes, allowing us to sort providers into intensity quartiles. Finally, we used multivariable Cox proportional hazards regression to examine the relationship between a patient’s overall risk of death and his provider’s intensity quartile for a given care process. RESULTS: In total, 5152 patients with low-grade Ta bladder cancer were cared for by 1627 providers. On average, each urologist managed 3.2 (standard deviation [SD], 3.5) patients during the study interval. Stratified by care process, the corresponding provider means for each intensity quartile are displayed below. As the Table shows, patients exposed to the highest users of endoscopic surveillance (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.86 – 1.06), urine cytology (HR, 0.99; 95% CI, 0.89 – 1.10), and intravesical therapy (HR, 0.99; 95% CI, 0.89 – 1.11) had overall survival outcomes that were comparable to those managed by the lowest intensity providers. CONCLUSIONS: Among those patients with the most common form of nonmuscle-invasive bladder cancer, exposure to increasing provider treatment intensity for each of the care processes examined was not associated with improved survival. These data serve to inform best practices in the care of patients with early-stage disease; however, future well-designed clinical trials are still needed.
e45
110 NEOADJUVANT CHEMOTHERAPY AS A PREDICTOR OF COST, READMISSION, AND LENGTH OF STAY IN RADICAL CYSTECTOMY PATIENTS Deep Trivedi*, Jennifer Gordetsky, Guan Wu, Changyong Feng, Susan Messing, Nathaniel Robbins, Thomas Pashalides, Ingrid Mikk, Hani Rashid, Dragan Golijanin, Katia Noyes, Edward Messing, Rochester, NY INTRODUCTION AND OBJECTIVES: There is evidence that receiving neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) results in improved survival over surgery alone in patients with high-stage, muscle invasive bladder cancer. NAC may be underutilized, however, due to reported concerns of increased perioperative complications. Little data exist on whether NAC affects post-operative hospitalization cost, length of stay (LOS), or readmission rate in this group of patients. METHODS: Retrospective billing record and medical chart review of 150 consecutive patients who underwent RC from 1/2006 to 12/2008 was conducted to assess the association between receipt of NAC and initial post-surgical LOS, American Society of Anesthesiologists (ASA) score (when available), intraoperative parameters, and patient demographics. To adjust for the effect of outliers, adjusted LOS was calculated as the mean of LOS values excluding the top 10%. Association between the above variables of interest and use of NAC was examined using Student t-test. Pearson’chi-squared test was used to explore the association between NAC receipt and 90-day readmission status. RESULTS: Two-sample t-tests showed a significant difference in operative time, but no difference in age, mean ASA score, estimated blood loss (EBL), LOS, adjusted LOS, or total post-surgical hospitalization cost between recipents and non-recipents of NAC. Pearson’s chi-square test showed no difference in readmission rate (30.23% vs. 25.00%, p⫽0.63) between these groups. (See table) CONCLUSIONS: In this series, NAC predicts increased operative time but has no significant impact on the readmission rate, duration or cost of initial hospitalization in patients undergoing RC. NeoAdjⴝNo Mean SD 70.26 9.09
N 20
NeoAdjⴝYes Mean SD 66.65 13.39
Variable Age
N 129
ASA
102
2.59
EBL (mL)
123
1381.70
2027.05
19
2071.05
3574.26
Op Time (min) 111
460.24
104.58
17
512.53
93.89
0.637 17
2.57
0.712
P-value 0.13 0.11 0.21 0.02*
Median LOS
127
8
-
20
11
-
Adj. LOS
115
9
3.91
18
10.9
4.49
0.05
10.17
20
21.85
7.69
0.48
20 48,850.00 17,146.00
0.94
Overall LOS
127
Total cost ($)
129 $48,469.00 36,198.00
11.46
-
Source of Funding: None
111 ACCURATELY CHARACTERIZING THE MORBIDITY OF RADICAL CYSTECTOMY: DISPOSITION, READMISSION, AND DEATH WITHIN 90 DAYS Michael Porter*, John Gore, Hunter Wessells, Jonathan Wright, Seattle, WA
Source of Funding: Robert Wood Johnson Foundation Clinical Scholars
INTRODUCTION AND OBJECTIVES: The perioperative morbidity associated with radical cystectomy (RC) has generally been defined by single institution series and analyses of administrative data that yield estimates of in hospital complications and death. Our goal was to describe patient disposition and intermediate term outcomes associated with radical cystectomy using longitudinal population based data. METHODS: Data from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) was analyzed. The CHARS database includes all hospital discharges in Washington State and is linked at the patient level allowing for longitudinal analysis of future hospital admissions. The study cohort was assembled using
e46
THE JOURNAL OF UROLOGY姞
ICD-9 diagnosis and procedure codes for patients undergoing RC to treat bladder cancer in Washington State between 2003 and 2007. Outcomes of interest included 30 and 90 day readmission and death rates, discharge disposition, and overall survival. Multivariate regression was used to identify predictors associated with each outcome. RESULTS: 823 patients (83% male, median age 69 years) were identified as undergoing RC as treatment for bladder cancer. 27% and 38% of patients were readmitted to an acute care hospital within 30 and 90 days of discharge, respectively. Postoperative death occurred during the index hospitalization in 2.1% of the cohort. The 30 and 90 day overall mortality rates were 3.5% and 6.7%, respectively. Routine discharge to home occurred in only 51% of discharges while 10.5% of patients were discharged to a skilled nursing facility and 36.1% were discharged with skilled home medical care. In the multivariate analysis, risk of readmission was similar across 10 year age groups and sex, but was higher among patients with more comorbidities. After adjustment for sex and comorbidity, patients older than 80 were 11 times more likely to require inpatient skilled nursing care at discharge than patients aged 50-59 (OR⫽11.1, 95%CI 3.8-32.8). The overall survival of the cohort at a median follow-up time of 18.4 months was 71.5%. Advancing age and higher comorbidity index were significantly associated with risk of death during the follow-up period. CONCLUSIONS: RC is associated with a high rate of hospital readmission and death within the first 90 days of hospital discharge. Advanced age and higher comorbidity index are associated with increased risk of postoperative death and readmission. Nearly half of all patients require skilled medical care after discharge. Source of Funding: None
112 HOSPITAL-LEVEL VARIATION IN DISPOSITION AND READMISSION AFTER SURGERY FOR UROLOGIC CANCERS John L. Gore*, Jonathan L. Wright, Hunter Wessells, Michael P. Porter, Seattle, WA INTRODUCTION AND OBJECTIVES: Unexplained variation in outcomes after common surgeries may subtend a quality of care concern. Evaluating and understanding variation in surgical outcomes may identify processes and policy measures that effect surgical quality improvement. We sought to examine hospital-level variation in outcomes after inpatient urologic oncology procedures in the state of Washington. METHODS: We accessed Washington state hospital claims (Comprehensive Hospital Abstract Reporting System [CHARS] data) for the years 2003-2007. The CHARS database includes inpatient claims linked at the patient level such that all readmissions and subsequent inpatient procedures are captured. Using International Classification of Diseases, 9th Edition procedure codes, we identified subjects undergoing radical prostatectomy, radical nephrectomy, and radical cystectomy. We measured postoperative length of stay (LOS), death, readmissions, and Agency for Healthcare Quality Patient Safety Indicators (PSIs). We adjusted hospital-level outcomes by patient age and comorbidity. RESULTS: We identified 8,228 men who underwent prostatectomy from 51 hospitals, 3,018 nephrectomy patients from 51 hospitals, and 853 cystectomy patients from 37 hospitals. The Table lists ageand comorbidity-adjusted length of stay, 30-day death rates and 1-year readmission rates by hospital volume quartile for each procedure (* indicates p⬍0.05 compared with volume quartile 4). Complications captured by PSIs were rare. Higher volume hospitals trended toward lower LOS and readmission rates compared with lower volume hospitals. Postoperative death was uncommon after prostatectomy and nephrectomy. Higher volume hospitals had lower 30-day death rates after radical cystectomy than lower volume hospitals, but this difference was not statistically significant. CONCLUSIONS: Hospital-level variation may confound the care of urologic cancer patients in the state of Washington. Hospitals with lower surgical volume had higher death and readmission rates
Vol. 183, No. 4, Supplement, Sunday, May 30, 2010
than higher volume hospitals for radical prostatectomy, radical nephrectomy, and radical cystectomy. Transparent reporting of surgical outcomes and local quality improvement initiatives may ameliorate the variation documented. Table 1. Adjusted rates of readmission, alternate disposition, an d death after inpatient urologic oncology surgeries (* indicates p⬍0.05 for comparison with procedure volume quartile 4). Procedure volume quartile 1 – lowest 2 3 4 - highest Radical prostatectomy LOS (days)
3.0*
2.8*
2.8*
0.6
30-day death (%)
0.00
0.09
0.11
0.11
1-year readmission (no.)
0.17
0.18*
0.14
0.00
LOS (days)
5.0
4.5
4.7
4.5
30-day death (%)
1.8
1.2
1.1
1.1
1-year readmission (no.)
0.56
0.38
0.42
0.34
Radical nephrectomy
Radical cystectomy LOS (days)
9.6
10.6
9.9
9.8
30-day death (%)
4.5
4.2
3.4
0.48
1-year readmission (no.)
0.91
1.1
1.4
0.72
Source of Funding: None
113 IMPACT OF HOSPITAL AND SURGEONS VOLUME ON COMPLICATION RATES AFTER RADICAL CYSTECTOMY: POPULATION BASED STUDY Lars Buda¨us*, Hamburg, Germany; Giovanni Lughezzani, Milano, Italy; Maxine Sun, Rodolphe Thuret, Montreal, Canada; Hendrik Isbarn, Felix Chun, Sascha Ahyai, Roland Dahlem, Hamburg, Germany; Paul Perrotte, Hugues Widmer, Philippe Arjane, Montreal, Canada; Francesco Montorsi, Milano, Italy; Shahrokh F. Shariat, Montreal, Canada; Margit Fisch, Markus Graefen, Hamburg, Germany; Pierre I. Karakiewicz, Montreal, Canada INTRODUCTION AND OBJECTIVES: The hypothesis that practice makes perfect has been previously examined in different types of urologic cancer surgery. We tested the hypothesis, that surgical volume (SV) and hospital volume (HV) predict complication rates after radical cystectomy for urothelial cancer of urinary bladder. METHODS: Between 2003 and 2008 in the state of Florida, 2719 patients underwent a RC for urothelial carcinoma of the bladder. All complications that occurred during hospital stay were recorded in the Florida inpatient database and classified into six different categories according to an established scheme. The effect of surgical volume (SV) and hospital volume (HV), both divided into tertiles, was then tested in univariable and multivariable logistic regression models. The 90% percentile was used as a further reference group. Covariates consisted of age, race, gender and comorbidities. RESULTS: Overall complications occurred in 1043 patients (38.4%). After stratification according to complication type, the following rates were recorded 2.2%; 2.4%; 2.4%; 4.0%; 7.3%; 2.6%; 0.7% 0.8%; 2,5%; 0.8%; 3.2% for vascular, respiratory, urinary, cardiac, infection, hemorrhage and hematoma and wound infection. Analyses that focused on the effect of SV on recorded complication rates showed that low volume surgeons have higher complications compared to intermediate and high volume surgeons. Similarly hospitals with low volume had the highest complication rate vs. intermediate vs. high volume hospitals. In multivariate analysis SV and HV categories (low SV vs. intermediate SV O.R. 1.42 p⬍0.013; low SV vs. high SV 1.47 p⬍0.009) and (low HV vs. intermediate HV O.R. 1.81 p⬍0.0001; low HV vs. high HV 1.83 p⬍0.0001) categories represented independent predictors of overall complication rate. A high surgical volume exerted a protective effect on the recorded rates, even after adjustment for covariates and hospital volume. CONCLUSIONS: High SV and high HV exert a protective effect on inhospital complication rates after radical cystectomy, even after
THE JOURNAL OF UROLOGY姞
General & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes III Podium 5 Sunday, May 30, 2010
8:00 AM-10:00 AM
109 MOVING TOWARDS BEST PRACTICES FOR EARLY-STAGE BLADDER CANCER John M. Hollingsworth*, Sean Zhang, Zaojun Ye, Brent K. Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: While contemporary practice guidelines for nonmuscle-invasive bladder cancer favor aggressive surveillance and treatment, recent findings reveal no added benefit for patients managed by high- vs. low-intensity providers, suggesting that more care does not always translate into improved outcomes. However, it is possible that some care processes are of higher value than others. Motivated by this, we used cancer registry data to help define best practices for urologists who manage early-stage bladder cancer. METHODS: Using SEER-Medicare data (1992 – 2007), we identified patients with low-grade Ta disease. We established the provider responsible for a patient’s care in the first 2 years following diagnosis. We determined the frequency with which a patient received certain surveillance- and treatment-directed care processes during this time. After fitting 2-level generalized linear mixed models, we generated reliability-adjusted measures for provider use of these care processes, allowing us to sort providers into intensity quartiles. Finally, we used multivariable Cox proportional hazards regression to examine the relationship between a patient’s overall risk of death and his provider’s intensity quartile for a given care process. RESULTS: In total, 5152 patients with low-grade Ta bladder cancer were cared for by 1627 providers. On average, each urologist managed 3.2 (standard deviation [SD], 3.5) patients during the study interval. Stratified by care process, the corresponding provider means for each intensity quartile are displayed below. As the Table shows, patients exposed to the highest users of endoscopic surveillance (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.86 – 1.06), urine cytology (HR, 0.99; 95% CI, 0.89 – 1.10), and intravesical therapy (HR, 0.99; 95% CI, 0.89 – 1.11) had overall survival outcomes that were comparable to those managed by the lowest intensity providers. CONCLUSIONS: Among those patients with the most common form of nonmuscle-invasive bladder cancer, exposure to increasing provider treatment intensity for each of the care processes examined was not associated with improved survival. These data serve to inform best practices in the care of patients with early-stage disease; however, future well-designed clinical trials are still needed.
e45
110 NEOADJUVANT CHEMOTHERAPY AS A PREDICTOR OF COST, READMISSION, AND LENGTH OF STAY IN RADICAL CYSTECTOMY PATIENTS Deep Trivedi*, Jennifer Gordetsky, Guan Wu, Changyong Feng, Susan Messing, Nathaniel Robbins, Thomas Pashalides, Ingrid Mikk, Hani Rashid, Dragan Golijanin, Katia Noyes, Edward Messing, Rochester, NY INTRODUCTION AND OBJECTIVES: There is evidence that receiving neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) results in improved survival over surgery alone in patients with high-stage, muscle invasive bladder cancer. NAC may be underutilized, however, due to reported concerns of increased perioperative complications. Little data exist on whether NAC affects post-operative hospitalization cost, length of stay (LOS), or readmission rate in this group of patients. METHODS: Retrospective billing record and medical chart review of 150 consecutive patients who underwent RC from 1/2006 to 12/2008 was conducted to assess the association between receipt of NAC and initial post-surgical LOS, American Society of Anesthesiologists (ASA) score (when available), intraoperative parameters, and patient demographics. To adjust for the effect of outliers, adjusted LOS was calculated as the mean of LOS values excluding the top 10%. Association between the above variables of interest and use of NAC was examined using Student t-test. Pearson’chi-squared test was used to explore the association between NAC receipt and 90-day readmission status. RESULTS: Two-sample t-tests showed a significant difference in operative time, but no difference in age, mean ASA score, estimated blood loss (EBL), LOS, adjusted LOS, or total post-surgical hospitalization cost between recipents and non-recipents of NAC. Pearson’s chi-square test showed no difference in readmission rate (30.23% vs. 25.00%, p⫽0.63) between these groups. (See table) CONCLUSIONS: In this series, NAC predicts increased operative time but has no significant impact on the readmission rate, duration or cost of initial hospitalization in patients undergoing RC. NeoAdjⴝNo Mean SD 70.26 9.09
N 20
NeoAdjⴝYes Mean SD 66.65 13.39
Variable Age
N 129
ASA
102
2.59
EBL (mL)
123
1381.70
2027.05
19
2071.05
3574.26
Op Time (min) 111
460.24
104.58
17
512.53
93.89
0.637 17
2.57
0.712
P-value 0.13 0.11 0.21 0.02*
Median LOS
127
8
-
20
11
-
Adj. LOS
115
9
3.91
18
10.9
4.49
0.05
10.17
20
21.85
7.69
0.48
20 48,850.00 17,146.00
0.94
Overall LOS
127
Total cost ($)
129 $48,469.00 36,198.00
11.46
-
Source of Funding: None
111 ACCURATELY CHARACTERIZING THE MORBIDITY OF RADICAL CYSTECTOMY: DISPOSITION, READMISSION, AND DEATH WITHIN 90 DAYS Michael Porter*, John Gore, Hunter Wessells, Jonathan Wright, Seattle, WA
Source of Funding: Robert Wood Johnson Foundation Clinical Scholars
INTRODUCTION AND OBJECTIVES: The perioperative morbidity associated with radical cystectomy (RC) has generally been defined by single institution series and analyses of administrative data that yield estimates of in hospital complications and death. Our goal was to describe patient disposition and intermediate term outcomes associated with radical cystectomy using longitudinal population based data. METHODS: Data from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) was analyzed. The CHARS database includes all hospital discharges in Washington State and is linked at the patient level allowing for longitudinal analysis of future hospital admissions. The study cohort was assembled using
e46
THE JOURNAL OF UROLOGY姞
ICD-9 diagnosis and procedure codes for patients undergoing RC to treat bladder cancer in Washington State between 2003 and 2007. Outcomes of interest included 30 and 90 day readmission and death rates, discharge disposition, and overall survival. Multivariate regression was used to identify predictors associated with each outcome. RESULTS: 823 patients (83% male, median age 69 years) were identified as undergoing RC as treatment for bladder cancer. 27% and 38% of patients were readmitted to an acute care hospital within 30 and 90 days of discharge, respectively. Postoperative death occurred during the index hospitalization in 2.1% of the cohort. The 30 and 90 day overall mortality rates were 3.5% and 6.7%, respectively. Routine discharge to home occurred in only 51% of discharges while 10.5% of patients were discharged to a skilled nursing facility and 36.1% were discharged with skilled home medical care. In the multivariate analysis, risk of readmission was similar across 10 year age groups and sex, but was higher among patients with more comorbidities. After adjustment for sex and comorbidity, patients older than 80 were 11 times more likely to require inpatient skilled nursing care at discharge than patients aged 50-59 (OR⫽11.1, 95%CI 3.8-32.8). The overall survival of the cohort at a median follow-up time of 18.4 months was 71.5%. Advancing age and higher comorbidity index were significantly associated with risk of death during the follow-up period. CONCLUSIONS: RC is associated with a high rate of hospital readmission and death within the first 90 days of hospital discharge. Advanced age and higher comorbidity index are associated with increased risk of postoperative death and readmission. Nearly half of all patients require skilled medical care after discharge. Source of Funding: None
112 HOSPITAL-LEVEL VARIATION IN DISPOSITION AND READMISSION AFTER SURGERY FOR UROLOGIC CANCERS John L. Gore*, Jonathan L. Wright, Hunter Wessells, Michael P. Porter, Seattle, WA INTRODUCTION AND OBJECTIVES: Unexplained variation in outcomes after common surgeries may subtend a quality of care concern. Evaluating and understanding variation in surgical outcomes may identify processes and policy measures that effect surgical quality improvement. We sought to examine hospital-level variation in outcomes after inpatient urologic oncology procedures in the state of Washington. METHODS: We accessed Washington state hospital claims (Comprehensive Hospital Abstract Reporting System [CHARS] data) for the years 2003-2007. The CHARS database includes inpatient claims linked at the patient level such that all readmissions and subsequent inpatient procedures are captured. Using International Classification of Diseases, 9th Edition procedure codes, we identified subjects undergoing radical prostatectomy, radical nephrectomy, and radical cystectomy. We measured postoperative length of stay (LOS), death, readmissions, and Agency for Healthcare Quality Patient Safety Indicators (PSIs). We adjusted hospital-level outcomes by patient age and comorbidity. RESULTS: We identified 8,228 men who underwent prostatectomy from 51 hospitals, 3,018 nephrectomy patients from 51 hospitals, and 853 cystectomy patients from 37 hospitals. The Table lists ageand comorbidity-adjusted length of stay, 30-day death rates and 1-year readmission rates by hospital volume quartile for each procedure (* indicates p⬍0.05 compared with volume quartile 4). Complications captured by PSIs were rare. Higher volume hospitals trended toward lower LOS and readmission rates compared with lower volume hospitals. Postoperative death was uncommon after prostatectomy and nephrectomy. Higher volume hospitals had lower 30-day death rates after radical cystectomy than lower volume hospitals, but this difference was not statistically significant. CONCLUSIONS: Hospital-level variation may confound the care of urologic cancer patients in the state of Washington. Hospitals with lower surgical volume had higher death and readmission rates
Vol. 183, No. 4, Supplement, Sunday, May 30, 2010
than higher volume hospitals for radical prostatectomy, radical nephrectomy, and radical cystectomy. Transparent reporting of surgical outcomes and local quality improvement initiatives may ameliorate the variation documented. Table 1. Adjusted rates of readmission, alternate disposition, an d death after inpatient urologic oncology surgeries (* indicates p⬍0.05 for comparison with procedure volume quartile 4). Procedure volume quartile 1 – lowest 2 3 4 - highest Radical prostatectomy LOS (days)
3.0*
2.8*
2.8*
0.6
30-day death (%)
0.00
0.09
0.11
0.11
1-year readmission (no.)
0.17
0.18*
0.14
0.00
LOS (days)
5.0
4.5
4.7
4.5
30-day death (%)
1.8
1.2
1.1
1.1
1-year readmission (no.)
0.56
0.38
0.42
0.34
Radical nephrectomy
Radical cystectomy LOS (days)
9.6
10.6
9.9
9.8
30-day death (%)
4.5
4.2
3.4
0.48
1-year readmission (no.)
0.91
1.1
1.4
0.72
Source of Funding: None
113 IMPACT OF HOSPITAL AND SURGEONS VOLUME ON COMPLICATION RATES AFTER RADICAL CYSTECTOMY: POPULATION BASED STUDY Lars Buda¨us*, Hamburg, Germany; Giovanni Lughezzani, Milano, Italy; Maxine Sun, Rodolphe Thuret, Montreal, Canada; Hendrik Isbarn, Felix Chun, Sascha Ahyai, Roland Dahlem, Hamburg, Germany; Paul Perrotte, Hugues Widmer, Philippe Arjane, Montreal, Canada; Francesco Montorsi, Milano, Italy; Shahrokh F. Shariat, Montreal, Canada; Margit Fisch, Markus Graefen, Hamburg, Germany; Pierre I. Karakiewicz, Montreal, Canada INTRODUCTION AND OBJECTIVES: The hypothesis that practice makes perfect has been previously examined in different types of urologic cancer surgery. We tested the hypothesis, that surgical volume (SV) and hospital volume (HV) predict complication rates after radical cystectomy for urothelial cancer of urinary bladder. METHODS: Between 2003 and 2008 in the state of Florida, 2719 patients underwent a RC for urothelial carcinoma of the bladder. All complications that occurred during hospital stay were recorded in the Florida inpatient database and classified into six different categories according to an established scheme. The effect of surgical volume (SV) and hospital volume (HV), both divided into tertiles, was then tested in univariable and multivariable logistic regression models. The 90% percentile was used as a further reference group. Covariates consisted of age, race, gender and comorbidities. RESULTS: Overall complications occurred in 1043 patients (38.4%). After stratification according to complication type, the following rates were recorded 2.2%; 2.4%; 2.4%; 4.0%; 7.3%; 2.6%; 0.7% 0.8%; 2,5%; 0.8%; 3.2% for vascular, respiratory, urinary, cardiac, infection, hemorrhage and hematoma and wound infection. Analyses that focused on the effect of SV on recorded complication rates showed that low volume surgeons have higher complications compared to intermediate and high volume surgeons. Similarly hospitals with low volume had the highest complication rate vs. intermediate vs. high volume hospitals. In multivariate analysis SV and HV categories (low SV vs. intermediate SV O.R. 1.42 p⬍0.013; low SV vs. high SV 1.47 p⬍0.009) and (low HV vs. intermediate HV O.R. 1.81 p⬍0.0001; low HV vs. high HV 1.83 p⬍0.0001) categories represented independent predictors of overall complication rate. A high surgical volume exerted a protective effect on the recorded rates, even after adjustment for covariates and hospital volume. CONCLUSIONS: High SV and high HV exert a protective effect on inhospital complication rates after radical cystectomy, even after