I am interested in knowing how many "radical cystectomies" are
performed in Japan in a year (more recent data would be best).  A
radical cystectomy is a procedure for patients who have muscle
invasive bladder cancer - it essentially is the removal of the bladder
and some of the surrounding organs.  It is a generic term for the
procedure done in both men and women.  However, if the terms get
gender specific, the procedures can be referred to as "radical
cystoprostatectomy" in men and "anterior pelvic exenteration" in
women.

Hi ericl128-ga, and thanks for your question.  I was surprised at how
difficult this information was to come by.  Multiple searches at
multiple times over the past month turned up nothing at the World
Health Organization, Japanese Ministry of Health, the Japanese
Urological Association, and other sources.  I was finally able to come
up with two sources of information for you from an Ovid Medline
search.  Here is the first reference and summary:

Nishiyama H. Habuchi T. Watanabe J. Teramukai S. Tada H. Ono Y.
Ohshima S. Fujimoto K. Hirao Y. Fukushima M. Ogawa O. Clinical outcome
of a large-scale multi-institutional retrospective study for locally
advanced bladder cancer: a survey including 1131 patients treated
during 1990-2000 in Japan. [Journal Article. Multicenter Study]
European Urology. 45(2):176-81, 2004 Feb.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14734003&query_hl=1&itool=pubmed_docsum

Unfortunately, this study is not available freely online. You can
request a free reprint from Dr. Ogawa at this address:
ogawao@kuhp.kyoto-u.ac.jp


Here is the abstract of this article, for convenience:

"We conducted a multi-institutional analysis to establish the
contemporary clinical outcome of invasive bladder cancer treated with
radical cystectomy in Japan. METHODS: A total of 1131 consecutive
patients who underwent radical cystectomy for invasive bladder cancer
between January 1990 and December 2000 at 32 hospitals were
retrospectively analyzed. RESULTS: Histopathological analysis
demonstrated that 1042 patients (92.1%) harbored transitional cell
carcinomas (TCCs), whereas 89 patients (7.9%) presented non-TCCs,
including squamous cell carcinoma and adenocarcinoma. Pelvic
lymphadenectomy was performed in 1013 patients in total, and
pathologically confirmed lymph node metastases were found in 162
(16.0%). The overall survival at 5 years was 68.0% and most deaths
(79.0%) occurred within 3 years. Multivariate analysis demonstrated
that gender, clinical stage, pathological stage, lymph node
involvement and lymph node dissection were the independent predictive
factors for survival, whereas histological type, sex and grade had no
significant impact on survival. CONCLUSIONS: These clinical results
demonstrate that radical cystectomy with lymph node dissection results
in good survival for invasive bladder cancer, providing standard data
with which other forms of therapy can be compared."

____________

While this is not a formal survey of all procedures performed in Japan
over the 10 year interval discussed in the study, it does cover 32
institutions and is likely the most comprehensive study of radical
cystectomies performed in Japan during the period from 1990-2000.  I
was unable to find any more recent data.  The list of participating
institutions was as follows:

"Okazaki Shimin Hospital, Osaka Red Cross Hospital, Osaka Gyomeikan
Hospital, Himeji National Hospital, Hirao Hospital, Hoshigaoka
Welfare-Annuity Hospital, Kashiwara Hospital, Kobe City General
Hospital, Komaki Shimin Hospital, Kurashiki Central Hospital, Kyoto
National Hospital, Kyoto University, Nagoya Memorial Hospital,
Matsuzaka Hospital, Nara Prefectural Mimuro Hospital, Nagoya
University, Nara Prefectural Nara Hospital, Nara Medical University,
National Cancer Center, Nishi-Kobe Medical Center, Saiseikai Nara
Hospital, Saiseikai Chuwa Hospital, Shakaihoken Chukyo Hospital,
Shizuoka General Hospital, Shizuoka City Hospital, Shimada Municipal
Hospital, Takanohara Central Hospital, Tane General Hospital, Tenri
Hospital, Yamatotakada City Hospital. "


According to this study, there were 1131 radical cystectomies
performed in Japan between 1990 and 2000.  Assuming a constant rate
for this procedure, this would be 113 radical cystectomies per year.


You can see the breakdown of the reasons for which these radical
cystectomies were performed in Table 1 of the above study, which you
can find here:
http://img517.imageshack.us/img517/8954/05qg.gif

Here is a summary of this table:

"Among the 1131 consecutive TCC patients undergoing radical
cystectomy, histopathological analysis demonstrated that 1042 patients
(92.1%) harbored TCCs, whereas 89 patients (7.9%) presented non-TCCs;
38 SCCs, 23 adenocarcinoma, and 28 miscellaneous tumors. Mean patient
age was 66.0 years (range 31?89) and 64.5 (range 37?85) in the TCC and
non-TCC group, respectively. The male/female ratio and follow-up
duration in both groups were similar, as shown in Table 1."

Table 3 gives a breakdown of the survival of Transitional Cell
Carcinoma (TCC) vs. non-TCC.  You can find this table here:
http://img517.imageshack.us/img517/8808/08km.gif


The article cited above goes on to analyze these data for survival
predictions, etc., which may or may not be of interest to you.

========================

Here is the reference for the second study:

Takahashi A, Tsukamoto T, Tobisu K, Shinohara N, Sato K, Tomita Y,
Komatsubara S, Nishizawa O, Igarashi T, Fujimoto H, Nakazawa H,
Komatsu H, Sugimura Y, Ono Y, Kuroda M, Ogawa O, Hirao Y, Hayashi T,
Tsushima T, Kakehi Y, Arai Y, Ueda S, Nakagawa M.  Radical cystectomy
for invasive bladder cancer: results of multi-institutional pooled
analysis.  Jpn J Clin Oncol. 2004 Jan;34(1):14-9.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15020658&query_hl=3&itool=pubmed_docsum

The full text of this study is available for free online from the link
above or from this link:
http://jjco.oxfordjournals.org/cgi/content/full/34/1/14


The second reference is a similar large scale study of radical
cystectomy for invasive bladder cancer, studying patients between
1991-1995. All together, this study looked at 518 patients for the 5
year period, or approximately 104 procedures per year.  This is
roughly in agreement with the estimate of approximately 113 procedures
from the previous study.  Patients in this study came from a total of
21 hospitals.  The participating hospital list can be found in the
Acknowledgment section of the paper.  The authors, like in the
previous study, go on to analyze survival rates, additional therapy
received, etc.

========================

You may also be interested in this journal article, although it does
not have the large scale of the ones cited above:


Hara S, Miyake H, Fujisawa M, Okada H, Arakawa S, Kamidono S, Hara I. 
Prognostic variables in patients who have undergone radical cystectomy
for transitional cell carcinoma of the bladder.  Jpn J Clin Oncol.
2001 Aug;31(8):399-402.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11574634&query_hl=3&itool=pubmed_docsum

The full text of this article is also available for free from the
above link, or from this one:
http://jjco.oxfordjournals.org/cgi/content/full/31/8/399

========================

I hope this information is useful.  Please feel free to request
clarification prior to rating.

Best,

          -welte-ga

---

Request for Answer Clarification by ericl128-ga on 28 Dec 2005 06:30 PST

Hello welte-ga.  Thanks for looking for the information, seems like it
took a significant amount of time, and I agree that those articles may
the most comprehensive in the public domain - I appreciate the effort.

On a first blush, these numbers (approx 113 per year) seem extremely
low.  Two things concern me - the first is that the studies cited
below are intended to report the outcomes associated with the
procedure, rather than predict the incidence of the procedure itself. 
It would be interesting to know what % of hospitals those mentioned
below are of the total Japanese health system, and then we could scale
up the number accordingly as a better guess?

Secondarily, as a sanity check, I compared the procedure rate to that
in the US.  I know it's a bad call to assume that the patient care
pathway in Japan is similar to the US, but without any better
information, it probably could be a clue as to the magnitude.  We know
that there are ~63,000 cases of bladder cancer diagnosed each year in
the US and there are ~7,000 cystectomies performed (about 11%).  We
also know that there are ~13,000 reported cases of bladder cancer in
Japan each year.  11% of 13,000 would put us in the 1,400 procedures
per year range - approximately 10X higher than what is reported below.
 I would think the numbers would be in a similar ball park (perhaps 5
- 15% of the reported incidence?)?

Let me know what you think, and if there is any way you know of to
come at this from a different angle.

Best,
  -ericl128

---

Clarification of Answer by welte-ga on 28 Dec 2005 12:02 PST

Hi again,

I agree with your observation that the cystectomy rates in the papers
I cited do not seem to fit with incidence and surgery rates from the
US.  One possible source for this discrepancy is, as you suggest, that
not all hospitals in Japan were included in these studies.  Another
contributing factor is likely that not all patients at each of the
hospitals listed was reported.  This occurs, for example, when not all
of the surgeons at an institution are interested in participating in
the study and there isn't a formal program at the hospital to collect
all of the patients going through.


Another approach is to go after the data directly from the Japanese
health registries, which I was initially unable to locate.  This data
is analyzed and tabulated in this text:

Cancer Treatment and Survival Site-Specific Registries in Japan (Gann
Monograph on Cancer Research)
http://www.amazon.com/gp/product/0849377781/104-9089673-4298302?n=283155

From page 183 of this text, we get the breakdown of cystectomies
performed in Japan from 1982-1987.  Although somewhat dated, the total
rates are roughly constant over that time period.  There was an
increase in the number of radical cystectomies from 10.6% in 1982 to
17.1% in 1987.  These data are summarized in Table IV on page 183. 
You can find a low resolution version of this table here:

http://img413.imageshack.us/img413/5013/snapshot200512281443599co.jpg

You can view the entire page either by searching print.google.com:
http://books.google.com/books?ie=UTF-8&hl=en&id=LgtgsxgkD70C&dq=cystectomies+japan&prev=http://books.google.com/books%3Fq%3Dcystectomies%2Bjapan&lpg=PA184&pg=PA183&sig=by7crNeS2jU1dQamSJMk6Foe-64

or via Amazon:
http://www.amazon.com/gp/reader/0849377781/ref=sib_vae_pg_183/104-9089673-4298302?%5Fencoding=UTF8&keywords=183&p=S05H&twc=10&checkSum=03kO%2Bkwtrj6eSJcdyUdbbKDAzUf6akhOs4iyX%2FRBxv4%3D#reader-page

The above links may expire, so you can search, for example, from Google as follows:

Go to print.google.com
Search for 
cystectomies japan

Only one book comes up (the one above).  Clicking the link takes you
to page 184, and you can go back one page to page 183.  Beware, you
can only view a limited number of pages of any given book before you
are locked out.  There are multiple links at the left of each page
where you can purchase the book.



I hope this is more useful.  Let me know if you require further clarification.

          -welte-ga



==============================


Below is some more data on the total number and types of hospitals in
Japan, which you may or may not find useful.

_____

According to this article, there were 256 national hospitals in Japan in 1993.

Ohida T, Osaki Y, Kobayashi Y, Sekiyama M, Minowa M.  Smoking
prevalence of female nurses in the national hospitals of Japan.  Tob
Control. 1999 Summer;8(2):192-5.

http://tc.bmjjournals.com/cgi/content/full/8/2/192

_____

This article states that there were 42 main hospitals associated with
national universities in Japan in 2002.  This obviously underestimates
the total number of hospitals in the country, but gives some idea of
the mix of academic (university) and private hospitals.  In fact,
about 81% of hospitals in Japan are private (see reference below).

Katsuya Kanda, Mieko Ozawa, Rumiko Irimura. Allocation of Nursing Time
at University Hospitals in Japan. J Nurs Studies N C N J Vol.1 No.1
2002. pp. 17-26.

http://www.ncn.ac.jp/kiyo/ar/2002jns-ncnj05.pdf

_____

Marugame T, Kaneko S.  Comparison of bladder cancer mortality in five
countries: France, Italy, Japan, UK and USA from the WHO Mortality
Database (1960-2000).
Jpn J Clin Oncol. 2005 Jun;35(6):357-60.

Full text is here:
http://jjco.oxfordjournals.org/cgi/content/full/35/6/357

===================

Other articles of potential interest:

Matsui Y. Nishiyama H. Watanabe J. Teramukai S. Ono Y. Ohshima S.
Fujimoto K. Hirao Y. Fukushima M. Ogawa O. The current status of
perioperative chemotherapy for invasive bladder cancer: a
multiinstitutional retrospective study in Japan. [Journal Article]
International Journal of Clinical Oncology. 10(2):133-8, 2005 Apr.

You can request a reprint from Dr. Ogawa (author of one of the other
article I cited):
ogawao@kuhp.kyoto-u.ac.jp

This article looks primarily at chemotherapy, but was interesting in
that it includes data from 32 institutions, only 3 of which are
university affiliated.  Clearly none of these studies is
comprehensive.

=========

An excellent overview of the Japanese health care system can be found
here, along with comparisons to the US system, written by Dr. Victor
G. Rodwin, Professor of Health Policy and Management at NYU:

http://www.nyu.edu/projects/rodwin/lessons.html
http://www.nyu.edu/projects/rodwin/

From this report, about 90% of the hospitals with more than 20 beds in
Japan are classified as "general hospitals," the majority of which are
small private facilities.  There are an average of 163 beds per
hospital.  There are 15.8 beds per 1,000 population.  The population
of Japan is 127,417,244.  This means a total of about 2,013,192 beds
or about 12,351 hospitals (if they are all "average").  It turns out
the the distribution of hospitals is not equal around this mean, and
the number of hospitals dipped below 10,000 in 1992 according to this
source:

http://www.stat.go.jp/english/index/official/215.htm#2

The full report is available in two volumes for 4,200 and 5,250 yen:
http://www.hws-kyokai.or.jp/33publications-list2-eng.htm#medical%20institutions

According to this report, there are 9,168 hospitals in Japan as of 2003:
http://www.jcer.or.jp/research/kenrep/kenrep031210e.pdf

"There are 9,168 hospitals in Japan as of 2003.  This number is 
overwhelmingly large compared to the U.S. when the difference in 
population is taken into account.  Public hospitals, established and 
run by prefectures and municipals (cities and towns), stood at 1,080 
in July 2003.  Public hospitals, together with 324 national hospitals, 
threaten the economic activities of private hospitals."


http://books.google.com/books?id=VyNYL_XAul0C&dq=surgical+procedures+performed+in+japan&oi=print&pg=PA102&sig=-7wBdjs36FGQLd9O3UeioFi26xk&prev=://www.google.com/search%3Fhl%3Den%26q%3Dsurgical%2Bprocedures%2Bperformed%2Bin%2Bjapan%26btnG%3DGoogle%2BSearch

Thanks Welte-ga.  This was very helpful, and I think as thorough as possible!