Setting standards for cystectomy using the British Association of Urological Surgeons Complex Operations Reports, 2016-2018

Objective: To produce comprehensive standards for cystectomy using contemporary data collected across a nation. Patients and methods: Surgical departments upload cystectomy data to the British Association of Urological Surgeons (BAUS) Complex Operations Database. Analysis of 2016-2018 data was performed for all recorded 5288 patients undergoing cystectomy in England. Logistic regression with general linear models was used to assess differences in patient selection between operative modalities. Analysis involved assessment of case selection, operative decisions and outcomes, case volume and pathological outcomes. Results: Using national Hospital Episode Statistics, the BAUS cystectomy dataset was estimated 93% complete. Median age was 70 years (interquartile range 63-75) and 75% were male. Charlson comorbidity index <= 2 was reported in 87%. Primary treatment of muscle-invasive bladder cancer accounted for 46% of cases. Commonest preoperative disease stages were T2N0 and T1N0 (35% and 25% respectively). Robotic-assisted (RAC), laparoscopic (LC) and open cystectomy (OC) were performed in 41 %, 5.5% and 54% of cases respectively. T-stage distribution differed by operative modality. Transfusion rates were 3.7% for RAC, 6.0% for LC and 18% for OC. Increasing positive surgical margin rates were observed with increasing T-stage, up to T3. The conversion-to-open rate for minimally-invasive surgery was 1.7%. Median annual centre and surgeon case volumes were highest for RAC. Median length of stay was 7, 10 and 10 days for RAC, LC and OC respectively. Postoperative histological upstaging was common (33% of cT1, 50% of cT2 cases). Lymph node positive rates were 28% for muscle-invasive bladder cancer. Conclusion: Analysis of this data provides understanding of 'real-world' cystectomy practice. Presentation of data specific to operative modality allows surgeons and centres to benchmark their respective practices. These findings offer to enhance patient and public understanding beyond that currently facilitated by publicly-facing information sources. They carry relevance by describing a near-complete and large volume of modern practice in a publicly funded healthcare system.