Alice Semerjian

Hospital Charges and Length of Stay Following Radical Cystectomy in the Enhanced Recovery After Surgery Era

OBJECTIVE To report our centers experience with enhanced recovery after surgery (ERAS) pathway for radical cystectomy (RC), specifically evaluating complications, LOS, 30- and 90-day readmissions, and hospital charges. Pathways of this type have been shown to decrease the length of stay (LOS) and postoperative ileus. However, concerns persist that ERAS is costly and increases readmissions. To date, limited studies have evaluated these concerns. MATERIALS AND METHODS Our ERAS protocol was implemented for RC in December 2015. Outcomes in ERAS patients were compared with those in RC patients from the time period before ERAS. Patients were excluded if they underwent concomitant nephroureterectomy. RESULTS Fifty-six consecutive ERAS patients were compared with 54 pre-ERAS patients. The median charge for index hospitalization was

Multiple growth periods predict unfavourable pathology in patients with small renal masses

31,090 in the ERAS group and

Radiotherapy for stage I and II testicular seminomas: Secondary malignancies and survival

35,489 in the pre-ERAS group (P = .036). The median LOS was 5.0 days in the ERAS group and 8.5 days in the pre-ERAS group (P = < .001). The pre-ERAS group had a significantly increased use of nasogastric tube (13.8% vs 30.0%) and parenteral nutrition (6.9% vs 20.4%). The overall complication rate (including infectious, renal, deep vein thrombosis and pulmonary embolism, myocardial infarction and stroke, and respiratory and gastrointestinal-related complications) was similar between the 2 groups (51.7% in the ERAS group and 62.0% in the pre-ERAS group, P = .28). Thirty- and 90-day readmissions also remained similar (19.0% vs 14.8%, P = .55, and 31.0% vs 27.7%, P = .64). The most common readmission reason was infection, specifically urinary tract infection. CONCLUSION Implementation of the ERAS pathway at our center resulted in significantly reduced LOS and total hospital charge, with comparable rates of complication and readmission, highlighting the need for ERAS pathways in patients undergoing RC.

PD67-11 ENHANCED RECOVERY AFTER RADICAL CYSTECTOMY REDUCES COST AND LENGTH OF STAY: THE JOHNS HOPKINS EXPERIENCE.

To use the number of positive growth periods as a characterization of the growth of small renal masses in order to determine potential predictors of malignancy.

Enhanced Recovery After Surgery Protocols to Reduce Morbidity in the Aging Patient

INTRODUCTION Testicular seminoma affects relatively young men with excellent survival outcomes. There has been increasing concern that radiotherapy (RT) leads to secondary malignant neoplasms (SMNs) and subsequent mortality. We evaluated the effect of RT on incidence of SMNs and quantified cancer-related mortality and other causes of death for patients with stage I and II testicular seminoma. MATERIAL AND METHODS A national sample of men (1988-2013) diagnosed with stage IA/IB/IS/IIA/IIB/IIC testicular seminomas from Surveillance, Epidemiology, and End Results were evaluated. Use of RT over time and survival curves (5/10/15-year) was stratified by stage. Log-binomial regression determined relative risk of developing SMNs. Incidence rate ratios (IRR) and age-adjusted Cox proportional hazards models compared overall, cancer-specific survival (CSS), and other cancer-specific survival. Competing-risks regression generated cumulative incidence functions. Prevalence ratios explored excess deaths owing to specific causes. RESULTS A total of 16,463 men were included with 9,126 (55.4%) undergoing RT with markedly decreased use for stage I seminoma in recent years (<20%) and ~50% for stage IIA. RT increased risk of SMNs (relative risk = 1.84 [95% CI: 1.61-2.10, P<0.01]). Survival rates were excellent (15-year CSS for stage I [≥99%], stage IIA [98.1%], stage IIB-C [96%-97%]). RT was associated with improved CSS for stage IB and IIA, but demonstrated less benefit for stage IA (IRR = 0.63 [95% CI: 0.35-1.14, P = 0.10]) with worse other cancer-specific survival (IRR = 1.80 [95% CI: 0.97-3.59, P = 0.05]). Gastrointestinal, respiratory, urinary, and hematologic malignances accounted for 84% of SMN deaths. CONCLUSIONS RT offers excellent CSS for men with stage I/II seminoma and an increased risk of SMN later in life. Future studies should better evaluate risk-stratification for stage IB patients.

Extraperitoneal Robot-Assisted Radical Prostatectomy: Indications, Technique and Outcomes

lymph node dissection, and number of lymph nodes removed. Perioperative outcomes measured included length of stay (LOS), 30-day and 90-day postoperative mortality rates, as well as 30-day readmission following surgery. To minimize selection bias, observed differences in baseline characteristics between patients who received RARC vs. ORC were controlled for using a weighted propensity score analysis. Using weighted data, all endpoints were assessed using propensity-adjusted logistic regression analyses. RESULTS: Of 9,561 patients who underwent RC, 2,048 (21.4%) and 7,513 (78.6%) underwent RARC and ORC, respectively. The use of RARC has increased over time, from 16.7% in 2010 to 25.3% in 2013. With regard to oncologic outcomes, RARC was associated with similar positive surgical margins (9.4% vs. 10.7% OR:0.86, 95%CI 0.72-1.04, p1⁄40.12), higher rates of lymphadenectomy (96.4% vs. 92.0%, OR: 2.31, 95%CI 1.68-3.19, p<0.001), higher median lymph node count (17 vs. 12, p<0.001) and higher rates of lymph node count above the median (56.8% vs. 40.4%, OR: 1.95, 95%CI 1.56-2.43, p<0.001). With regard to postoperative outcomes, receipt of RARC was associated with a shorter median LOS (7 vs. 8, p<0.001), lower rates of pLOS (45.1% vs. 54.8%, OR: 0.68, 95%CI 0.58-0.79, p<0.001), lower 30-day (1.5% vs. 2.8%, OR: 0.49, 95%CI 0.29-0.82, p1⁄40.007) and 90day postoperative mortality (5.0% vs. 6.8%, OR: 0.72, 95%CI 0.54-0.95, p1⁄40.023). CONCLUSIONS: Our large contemporary study shows the increased adoption of RARC between 2010 and 2013, with currently more than 1 out of 4 patients undergoing RARC. RARC was associated with higher LN counts, shorter LOS and lower postoperative mortality.

Identifying Current Trends in the Urologic Oncology Workforce: Does Completion of Fellowship Significantly Change Future Practice?

Enhanced recovery after surgery protocols have the potential to reduce postoperative morbidity after major urologic surgery for the aging patient.

PD59-12 PREDICTING LOW METASTATIC POTENTIAL TUMORS USING CLINICAL RADIOGRAPHIC SIZE: A SYSTEMATIC REVIEW OF THE LITERATURE.

Purpose of ReviewExtraperitoneal robot-assisted radical prostatectomy (eRARP) is an alternative to the more commonly employed transperitoneal RARP (tRARP) for treatment of clinically localized prostate cancer. The purpose of this review is to discuss indications in which eRARP would be a more favorable approach in comparison to tRARP. In addition, we will discuss the safety and technique of eRARP.Recent FindingsRecently published work has highlighted the outcomes and safety of eRARP in comparison to tRARP; specifically that eRARP is not inferior to tRARP. In addition, eRARP may be preferred in certain circumstances. For example, Ludwig et al. recently discussed the concomitant repair of inguinal hernia during eRARP.SummaryExtraperitoneal RARP is a safe and effective alternative to tRARP. With previous knowledge and experience with tRARP, urologists can adapt the extraperitoneal approach without difficulty. This approach is useful for specific situations in which tRARP may be challenging.

PD53-05 RISK OF SECONDARY MALIGNANCY AND CAUSES OF DEATH AFTER RADIATION THERAPY FOR TESTICULAR SEMINOMAS

Introduction: To assess fellowship impact on subsequent practice type and case mix, we compared urologists who completed a urologic oncology fellowship to urologists who did not complete a fellowship. Methods: Annualized case log data were obtained from the American Board of Urology from 2004 to 2016, including initial certification (C1) and recertifications 1 (R1) and 2 (R2). We evaluated trends in major urologic oncology case volume using relevant CPT codes. Surgeon specific data, including fellowship training, practice type and practice area population, were analyzed using chi-square and 2-sample t-tests. Results: Oncology fellows (338) were more likely than nonfellows (7,785) to practice in larger population areas (p <0.001) and practice in academics (p <0.001). Oncology fellows performed nearly 3 times as many major oncology cases as nonfellows at each certification cycle (C1—29.7 vs 12.5, R1—32.3 vs 13.5, R2—30.5 vs 11.5; p <0.001 for all) and maintained case volumes over time. Oncology fellows performed significantly more major cases in kidney, bladder and prostate cancer across all certification points than nonfellows, and continued to perform these cases at a similar frequency at all certification cycles. Moreover, during the period studied oncology fellows performed an increasing percentage of overall major oncologic cases (from 8.9% in 2004 to 13.3% by 2016). Conclusions: Completion of urologic oncology fellowship is associated with performing and maintaining a high volume of major oncology cases over recertification cycles, with academic practice and with practicing in large population centers. This information may be useful to urology residents considering oncology fellowship opportunities.

MP80-15 RETROPERITONEAL LYMPH NODE DISSECTION FOR TESTICULAR SEMINOMAS: POPULATION-BASED STAGE-BY-STAGE SURVIVAL OUTCOMES

RESULTS: The median age at diagnosis was 73 (IQR 64, 80) with a median LRM size of 4.9cm (IQR 4.0, 6.7). Median follow up was 4 years (IQR 2.2, 7.3). Charlson comorbidity index was 2 in 59% of patients, and 32% had other non-renal malignancies. 19% of patients had or developed non-RCC metastasis from another malignancy. Median LRM growth rate was 0.4 cm/year (IQR 0.1, 0.8). We did not find a significant association between clinical factors and LRM growth. AS was discontinued in 34 patients who underwent surgical intervention after a median follow up of 1.9 years, 88% had malignant disease. Among 56 patients who underwent surgery or biopsy during AS, 82% had malignant histology. Median follow up for patients who did not undergo surgery was 3.3 years (IQR 1.9, 5.0). In total, 10 patients developed metastatic RCC (3 of whom died from RCC), and 29 patients died from other causes. Four treated patients progressed to RCC metastases, and 3 RCC-related mortality. Median follow up for metastasis free survivors was 4 years (IQR 2.2, 6.8). The 5-year probability of nonRCC related death and RCC metastasis was 26% and 7%, respectively. CONCLUSIONS: In highly comorbid patients, such as those with other advanced malignancies, active surveillance and expectant management of LRM has a low likelihood for RCC progression which is overshadowed by the risk of non-RCC related death. This data supports the use of surveillance of LRM as an acceptable strategy for selected patients with competing risks from other serious illnesses.