PURPOSE OF REVIEW: There is heightened awareness and trends towards centralizing high-risk, complex surgeries such as radical cystectomy to minimize complications and improve survival. However, after nearly a decade of mandated and/or passive centralization of care, debate regarding its benefits and harms continues. RECENT FINDINGS: During the past decade, mandated and passive centralization has led to an increase in radical cystectomies performed in high-volume hospitals (HVHs) and, perhaps by high-volume surgeons (HVS), in addition to efforts to increase the uptake of multidisciplinary strategies in the management of radical cystectomy patients. Consequently, 30 and 90-day mortality rates and overall survival have improved, and major complications and transfusion rates have decreased. Factors impacting surgical quality, such as negative surgical margin(s), pelvic lymphadenectomy and/or lymph node yield rates have increased. However, current studies have not demonstrated a coadditive impact of centralization on oncological outcomes (i.e. cancer-specific and recurrence-free survival). The benefits of centralization on oncologic survival of radical cystectomy remain unclear given the varied definitions of HVHs and HVSs across studies. In fact, centralization of radical cystectomy could lead to an increase in patient load in HVHs and for HVSs, thereby leading to longer surgery waiting times, a factor that is important in the management of muscle-invasive bladder cancer. SUMMARY: The benefits of centralization of radical cystectomy with multidisciplinary management are shown increasingly and convincingly. More studies are necessary to prospectively test the benefits, risks and harms of centralization.

Cancer Prognostics and Health outcomes Unit University of Montreal Health Center Montreal Quebec Canada

Department of Urology Medical University of Vienna Vienna Austria

Department of Urology Medical University of Vienna Vienna Austria Department of Special Surgery Jordan University Hospital The University of Jordan Amman Jordan Department of Urology Weil Cornell Medical College New York New York Department of Urology University of Texas Southwestern Dallas Texas USA Karl Landsteiner Institute of Urology and Andrology Vienna Austria Department of Urology 2nd Faculty of Medicine Charles University Prague Czech Republic European Association of Urology Research Foundation Arnhem the Netherlands

Department of Urology Medical University of Vienna Vienna Austria Department of Urology King Faisal Medical City Abha Saudi Arabia

Department of Urology Medical University of Vienna Vienna Austria Department of Urology The Jikei University School of Medicine Tokyo Japan

Division of Urological Surgery and Center for Surgery and Public Health Harvard Medical School Brigham and Women's Hospital Boston Massachusetts USA

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