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Variations in pelvic lymph node dissection in invasive bladder cancer: A Dutch nationwide population-based study
Tom Johannes Noël Hermans1, Elisabeth Ernestine Fransen van de Putte1, Laurent Marie Constant Leo Fossion2
1Division of Urology, Department of Surgical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
Objectives:
To assess temporal trends in radical cystectomy (RC) and pelvic lymph node dissection (PLND) and the effect of centralization of care in the Netherlands between 2006 and 2012.
Patients And Methods:
This nationwide population-based study included 3524 patients from the Netherlands Cancer Registry who underwent RC as the primary treatment for cT1-4a, N0 or Nx, M0 urothelial carcinoma. Annual application rates of PLND, median LNC, and rates of node-positive disease (pN+) were compared by linear-by-linear association. Multivariable logistic regression was performed to identify patients׳ and hospital characteristics associated with PLND and LNC≥10, and to study associations between LNC and pN+disease.
Results:
In total, 3,191 (91%) patients had PLND during RC and the use increased from 84% in 2006 to 96% in 2012 (P<0.001). Owing to centralization of care in 2010 (at least 10RCs/y/hospital), significantly more patients were treated in high-volume hospitals (≥20RC per year) in 2011 and 2012. PLND use was highest in males, younger patients and in academic, teaching, and high-volume hospitals (≥20RC per year). In 2012, PLND application rates were comparable for academic, teaching, and nonteaching hospitals (P = 0.344). Median LNC increased from 7 in 2006 to 13 in 2012 (P<0.001), 55% had an LNC≥10 (63% in 2012). Furthermore, lymph node count (LNC)≥10 was associated with cT3-4a and, pN+disease, R0 and treatment in academic, teaching, or high-volume hospitals (≥20RC per year). Rate of pN+disease increased from 18% to 24% between 2006 and 2012 (P = 0.014). This trend was significantly associated with increased LNC on a continuous scale (odds ratio = 1.03).
Conclusions:
After centralization of care, PLND during RC for cT1-4a, N0 or Nx, M0 urothelial carcinoma has become standard in all types of Dutch hospitals. The increase in LNC between 2006 and 2012 was associated with a higher incidence of pN+disease and suggests more adequate template extension and adherence to contemporary guidelines in recent years.
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