Adam C. Calaway

Assessment of required nodal yield in a high risk cohort undergoing extended pelvic lymphadenectomy in robotic-assisted radical prostatectomy and its impact on functional outcomes

Although high risk prostate cancer patients are most vulnerable to lymph node invasion, the definition of an extended pelvic lymph node dissection (PLND) for this cohort has remained vague. Additionally, there have been compelling data in the rectal cancer literature relating erectile dysfunction to the extent of PLND. Because of the similarities of the dissection templates, we investigated the impact of an extended PLND on urinary and sexual function. In the present study, we were able to determine a minimal lymph node yield necessary for accurate staging of high risk patients. Expanding the analysis to our entire cohort, we found worse potency outcomes in patients with an extended PLND, demonstrating that extended PLND may be counterproductive to the aims of nerve sparing in a lower risk population.

A novel preoperative model to predict 90-day surgical mortality in patients considered for renal cell carcinoma surgery

INTRODUCTION Surgical benefits for renal cell carcinoma must be weighed against competing causes of mortality, especially in the elderly patient population. We used a large cancer registry to evaluate the impact of patient and cancer-specific factors on 90-day mortality (90DM). A nomogram to predict the odds of short-term mortality was created. MATERIALS AND METHODS The National Cancer Database was queried to identify all patients with clinically localized, nonmetastatic disease treated with partial or radical nephrectomy. Using a random sample of 60%, multiple logistic regression with 90DM outcomes were performed to identify preoperative variables associated with mortality. Variables included age, sex, race, co-morbidity score, tumor size, and presence of a thrombus. A nomogram was created and tested on the remaining 40% of patients to predict 90DM. RESULTS 183,407 patients met inclusion criteria. Overall 90DM for the cohort was 1.9%. All preoperative variables significantly influenced the risk of 90DM. Patient age was by far the strongest predictor. Nomogram scores ranged from 0 to 12. Compared to patients with 0 to 1 points, those with 2 to 3 (odds ratio [OR] 2.89, 2.42-3.46; P < 0.001), 4 to 5 (OR 6.25, 5.26-7.43; P < 0.001), and >6 (OR 12.86, 10.83-15.27; P < 0.001) were at incrementally significantly higher odds of 90DM. Being >80 years of age alone placed patients into the highest risk of surgical mortality. CONCLUSIONS Management of localized kidney cancer must consider competing causes of mortality, especially in elderly patients with multiple co-morbidities. We present a preoperative tool to calculate risk of surgical short-term mortality to aid surgeon-patient counseling.

A Prospective Program to Reduce the Clinical Incidence of Clostridium Difficile Colitis Infection after Cystectomy

Purpose: The development of Clostridium difficile infection after cystectomy is associated with significant morbidity and mortality. We implemented a prospective screening program to identify asymptomatic carriers of C. difficile and assessed its impact on clinical C. difficile infection rates compared to historical matched controls. Materials and Methods: Prospective C. difficile screening prior to cystectomy began in March 2015. The 380 consecutive patients who underwent cystectomy before the initiation of screening (control cohort) were matched based on 5 clinical factors with the 386 patients who underwent cystectomy from March 2015 to December 2017 (trial cohort). Patients who screened positive were placed in contact isolation and treated prophylactically with metronidazole. Multivariable models were built on an intent to screen basis and an effectiveness of screening basis to determine whether screening reduced the rate of symptomatic C. difficile infection postoperatively. Results: With the implementation of the screening protocol the C. difficile infection rate declined from 9.4% to 5.5% (OR 0.52, p = 0.0268) in patients on the intent to screen protocol and from 9.2% to 4.9% in those on the effectiveness of screening protocol (OR 0.46, p = 0.0174). Conclusions: C. difficile screening prior to cystectomy is associated with a significant decrease in the rate of clinically symptomatic infection postoperatively. These results should be confirmed in a randomized controlled trial.

PD66-02 ARE ALL RENAL ONCOCYTIC NEOPLASMS CREATED EQUALLY?

with Gleason (p<0.01), being most elevated in ADT/CRPC. A shift in intensity from 1+ to +3 and +2 was observed with progression when all forms of AR were detected, whereas wild-type nuclear AR remained at 1+. Similar observations were made for all forms and wild-type AR in seminal vesicles, lymph nodes and bone metastases. Nuclear AR levels (all forms and wild-type) did not correlate with patient outcome. The nuclear intensity and H score of pY223AR also increased with Gleason of primary tumors (p<0.01), being most elevated in ADT/ CRPC. Again, the pY223AR shifted from 1+ to +3 and +2 in the cell nucleus of primary tumors and metastases. Of interest, nuclear pY223AR correlated with biochemical recurrence (BCR) (Kaplan-Meier; log rank, p<0.0001 at H score1⁄4160). In univariate and multivariate analyses, pY223AR H scores predicted BCR (p<0.0001), PCa specific death (p1⁄40.002) and overall survival (p1⁄40.0002), independently of Gleason, stage and PSA. Also, combining pY223AR H score with PSA, GS and stages improved prognostication (ROC curves). CONCLUSIONS: These findings suggest that activation of Y223 in all forms of AR is key for progression. Also, pY223AR represents a novel biomarker predicting outcome of prostate cancer.

PD52-12 A NOVEL PRE-OPERATIVE MODEL TO PREDICT 90-DAY SURGICAL MORTALITY IN PATIENTS BEING CONSIDERED FOR EXTIRPATIVE SURGERY FOR RENAL CELL CARCINOMA

RESULTS: Nanostring assay was successful in 91 of 111 primary clear cell RCC tumor specimens. Median follow-up for survivors was 108.0 months, during which 79 patients died from RCC. In primary tumors, 18 of 124 genes interrogated were univariately associated with RCC-specific survival (false discovery rate <0.10) and five genes were retained in the multivariable model. After adjusting for clinical and pathological indices previously shown to be predictive of survival in metastatic clear cell RCC, the five gene scoring algorithm remained highly significant (p<0.0001). When expression levels were determined in metastatic tissue, rather than the primary tumor tissue, the five gene scoring algorithm remained significantly associated with survival. CONCLUSIONS: We have identified a panel of genes that predict prognosis in patients with metastatic clear cell RCC and provides significant risk stratification after adjusting for existing models. These genes may provide insight into the biology of metastatic RCC and warrant further investigation.