LAUSR

The cost of bladder cancer care in the USA in 2010 was $4 billion, making it the ninth most expensive cancer to manage, and this is projected to rise to $5.7 billion by 2020 [1]. In this issue of European Urology, Leow et al [2] report the variance in cost of delivering radical cystectomy (RC) using healthcare database records across centres in the USA. Data were extracted from the Premier Healthcare Database for 53 473 patients who underwent RC during a 13-yr period (2003–2015) under the care of 2 317 surgeons in 425 hospitals. The primary aim was to analyse direct costs attributed to RC and the ensuing 90 postoperative days, and identify variables contributing to cost variance. On the basis of their robust multivariate logistic regression model, the authors conclude that postoperative complications, Charleston comorbidity index, and year of RC surgery are predictors of high cost (>90th percentile). The authors acknowledge limitations of using the Premier Healthcare Database, but the study offers an important perspective on the cost of RC. Multiple studies have established the volume-outcome relationship for RC, whereby high-volume centres have significantly fewer complications [3]. Indeed, an analysis of the Premier Healthcare Database (2003–2010) by the same research group showed that surgical volume was inversely related to direct hospital costs and postoperative 90-d complication rates [4]. In the current analysis, Leow and colleagues report that complications were the largest contributing factor to cost variation. While it would seem reasonable to expect that high-volume centres and highvolume surgeons would have lower complication rates and be less costly, this relation was not observed.