[A Swiss Urological Society register of cystectomies to improve surgical quality]. / Un registre des cystectomies de la Société suisse d'urologie pour une meilleure qualité chirurgicale.

In the era of highly specialised medicine, the Swiss Urological Society has set up a national register from January 2019 that will prospectively record all data relating to cystectomies. Doctors will be able to use this information to compare their activities at national level, refine surgical techniques and optimise the perioperative management of cystectomy patients. This article presents the register and provides an initial assessment of cystectomy surgery activity in Switzerland over the first four years of its set up.

Dans l'ère de la médecine hautement spécialisée, la Société suisse d'urologie a mis au point dès janvier 2019 un registre national permettant de répertorier prospectivement l'ensemble des données relatives aux cystectomies. Les médecins profitent de ces renseignements pour comparer leur activité au niveau national, affiner les techniques chirurgicales et optimiser la prise en charge périopératoire des patients opérés d'une cystectomie. Cet article est consacré à la présentation du registre et offre un bilan initial de l'activité chirurgicale de cystectomie en Suisse au cours des quatre premières années de sa mise en place.

Contemporary rates of adherence to international guidelines for pelvic lymph node dissection in radical cystectomy: a population-based study.

OBJECTIVE: To examine the rates of adherence to guidelines for pelvic lymph node dissection (PLND) in patients treated with radical cystectomy (RC) and to identify predictors of omitting PLND. MATERIALS AND METHODS: We relied on 66,208 patients treated with RC between 2004 and 2013 within the National Inpatients Sample (NIS) database. We examined the rates of PLND according to year of surgery, patient and hospital characteristics. Univariate and multivariate logistic regression analyses assessed the probability of PLND use, after adjusting for year of surgery, age, gender, race, comorbidities, hospital location, teaching status and hospital surgical volume. RESULTS: Overall, PLND was performed on 54,223 (81.9%) RC patients. The rates PLND at RC significantly increased over the study period from 72.3% in 2004 to 85.9% in 2013, (p < 0.001). Barriers to PLND at RC consisted of female gender (OR: 1.31; 95% CI 1.25-1.38; p < 0.001), African American race (OR: 1.21; 95% CI 1.10-1.32; p < 0.001), intermediate (OR: 1.78; 95% CI 1.68-1.88; p < 0.001) or low surgical volume institutions (OR: 2.59; 95% CI 2.44-2.74; p < 0.001), non-teaching institution status (OR: 1.21; 95% CI 1.15-1.27; p < 0.001) and rural hospital location (OR: 1.13; 95% CI 1.01-1.25; p = 0.03). CONCLUSIONS: It is encouraging to note increasing rates of PLND at RC over time. Both patients and hospital characteristics influence PLND rates. More efforts should be aimed at reducing inequalities in PLND at RC due to these highly modifiable variables.

Clinical and cost effectiveness of hexaminolevulinate-guided blue-light cystoscopy: evidence review and updated expert recommendations.

CONTEXT: Non-muscle-invasive bladder cancer (NMIBC) is associated with a high recurrence risk, partly because of the persistence of lesions following transurethral resection of bladder tumour (TURBT) due to the presence of multiple lesions and the difficulty in identifying the exact extent and location of tumours using standard white-light cystoscopy (WLC). Hexaminolevulinate (HAL) is an optical-imaging agent used with blue-light cystoscopy (BLC) in NMIBC diagnosis. Increasing evidence from long-term follow-up confirms the benefits of BLC over WLC in terms of increased detection and reduced recurrence rates. OBJECTIVE: To provide updated expert guidance on the optimal use of HAL-guided cystoscopy in clinical practice to improve management of patients with NMIBC, based on a review of the most recent data on clinical and cost effectiveness and expert input. EVIDENCE ACQUISITION: PubMed and conference searches, supplemented by personal experience. EVIDENCE SYNTHESIS: Based on published data, it is recommended that BLC be used for all patients at initial TURBT to increase lesion detection and improve resection quality, thereby reducing recurrence and improving outcomes for patients. BLC is particularly useful in patients with abnormal urine cytology but no evidence of lesions on WLC, as it can detect carcinoma in situ that is difficult to visualise on WLC. In addition, personal experience of the authors indicates that HAL-guided BLC can be used as part of routine inpatient cystoscopic assessment following initial TURBT to confirm the efficacy of treatment and to identify any previously missed or recurrent tumours. Health economic modelling indicates that the use of HAL to assist primary TURBT is no more expensive than WLC alone and will result in improved quality-adjusted life-years and reduced costs over time. CONCLUSIONS: HAL-guided BLC is a clinically effective and cost-effective tool for improving NMIBC detection and management, thereby reducing the burden of disease for patients and the health care system. PATIENT SUMMARY: Blue-light cystoscopy (BLC) helps the urologist identify bladder tumours that may be difficult to see using standard white-light cystoscopy (WLC). As a result, the amount of tumour that is surgically removed is increased, and the risk of tumour recurrence is reduced. Although use of BLC means that the initial operation costs more than it would if only WLC were used, over time the total costs of managing bladder cancer are reduced because patients do not need as many additional operations for recurrent tumours.

Using propensity scores to estimate the cost-effectiveness of medical therapies.

The cost-effectiveness ratio is a popular statistic that is used by policy makers to decide which programs are cost-effective in the public health sector. Recently, the net monetary benefit has been proposed as an alternative statistical summary measure to overcome the limitations associated with the cost-effectiveness ratio. Research on using the net monetary benefit to assess the cost-effectiveness of therapies in non-randomized studies has yet to be done. Propensity scores are useful in estimating adjusted effectiveness of programs that have non-randomized or quasi-experimental designs. This article introduces the use of propensity score adjustment in cost-effectiveness analyses to estimate net monetary benefits for non-randomized studies. The uncertainty associated with the net monetary benefit estimate is evaluated using cost-effectiveness acceptability curves. Our method is illustrated by applying it to SEER-Medicare data for muscle invasive bladder cancer to determine the most cost-effective treatment protocol.

Influence of patient age and co-morbidity on outcome of a collaborative care pathway after radical prostatectomy and cystoprostatectomy.

PURPOSE: We determined whether standardized care patterns developed with a collaborative care methodology can be applied successfully across all patient groups with favorable effects on cost and quality. MATERIALS AND METHODS: We retrospectively analyzed financial and clinical outcomes in 109 radical retropubic prostatectomy and 47 radical cystectomy cases. Patients older than 70 years and/or with an American Society of Anethesiology status of 3 or greater were compared to younger, healthier patients undergoing these procedures. RESULTS: Standardized care patterns resulted in favorable financial and clinical outcomes in high and low risk patient groups. The only apparent difference was an increased need for rehospitalization after discharge for patients undergoing radical prostatectomy with a high American Society of Anesthesiology status. CONCLUSIONS: Standardized care patterns developed with a collaborative care methodology provide a high quality, cost-efficient approach to medical care. This methodology is applicable to all patient groups and is highly compatible with current medical practice.