C.J. Stimson

Early and Late Perioperative Outcomes Following Radical Cystectomy: 90-Day Readmissions, Morbidity and Mortality in a Contemporary Series

PURPOSE Radical cystectomy remains associated with significant morbidity. Most series report outcomes with relatively short-term followup that may underestimate the true magnitude of the procedure and many report length of hospital stay but ignore readmission rates. We analyzed the predictors of early (30 days or less), late (31 to 90 days) and cumulative 90-day hospital readmissions, as well as morbidity and mortality rates. MATERIALS AND METHODS We reviewed our prospectively collected database of 753 patients who underwent radical cystectomy for urothelial cancer between January 2001 and December 2007. We examined the relationship between clinical variables and readmission rates during the early, late and 90-day postoperative period, and reviewed mortality and perioperative morbidity rates. RESULTS There were 200 (26.6%) patients readmitted in the first 90 days following radical cystectomy. Of these patients 148 (19.7%) were readmitted early, 81 (10.8%) were readmitted late, and 29 (3.9%) had an early and late readmission. Logistical regression revealed gender (OR 1.50, 95% CI 1.00-2.27, p = 0.05), age adjusted Charlson comorbidity index (OR 1.19, 95% CI 1.06-1.34, p = 0.003) and any postoperative complications before discharge home (OR 1.84, 95% CI 1.19-2.83, p = 0.006) as independent predictors of 90-day readmission. The 30 and 90-day mortality rates were 2.1% (16) and 6.9% (52), respectively. CONCLUSIONS Readmission rates after radical cystectomy are significant, approaching 27% within the first 90 days. Gender and age adjusted Charlson comorbidity index were independent predictors providing preoperative information identifying patients more likely to require readmission or possibly to benefit from a longer initial hospital stay.

Determining factors for hospital discharge status after radical cystectomy in a large contemporary cohort

PURPOSE We describe hospital discharge status in patients after radical cystectomy for bladder cancer. We determined factors affecting discharge status. MATERIALS AND METHODS The 445 patients underwent radical cystectomy for urothelial carcinoma from January 2004 to December 2007. Patients were grouped by hospital discharge status into 1 of 4 groups, including home under self-care without services, home with home health services, subacute, rehabilitation or skilled nursing facility, or hospice/in-hospital mortality. We compared clinical, perioperative and pathological variables in these groups. We also examined the association of discharge status with the hospital readmission rate and 90-day mortality. RESULTS Of the 440 patients 250 (56.8%), 145 (32.9%), 39 (8.9%) and 6 (1.4%) were in the home without services, home with services, facility and mortality groups, respectively. On multivariate analysis older age, lower preoperative albumin, unmarried status and higher Charlson comorbidity index were predictors of discharge home with services while older age, poor preoperative exercise tolerance and longer hospital stay predicted discharge to a facility. Patients in the facility group were more likely to die within 90 days of surgery than those who returned home independently or with services. There was no difference in the likelihood of rehospitalization. CONCLUSIONS Sociodemographic factors, preoperative performance status, and comorbidities and perioperative factors contribute to the discharge decision after radical cystectomy. Some subgroups can be predicted to have increased postoperative care needs and may be appropriate targets for disposition planning preoperatively.

Preoperative Hydronephrosis Predicts Extravesical and Node Positive Disease in Patients Undergoing Cystectomy for Bladder Cancer

PURPOSE Preoperative hydronephrosis may be associated with a worse outcome in patients who undergo radical cystectomy for invasive bladder cancer. We characterized the prognostic significance of hydronephrosis, and its relationship to cancer stage and outcome. We also evaluated concordance between the side of identifiable hydronephrosis and concomitant pelvic lymph node metastasis. MATERIALS AND METHODS We analyzed information from our prospectively collected database of patients who underwent radical cystectomy for bladder cancer from January 2001 to December 2007. We examined the relationship between hydronephrosis and clinical variables as well as survival outcome. Hydronephrosis was diagnosed intraoperatively or by radiographic imaging within 3 months of radical cystectomy. RESULTS Of 753 patients 244 (32%) were diagnosed with hydronephrosis. Logistic regression modeling revealed that hydronephrosis was an independent predictor of extravesical disease (OR 2.01, 95% CI 1.37 to 2.96, p <0.001) and node positive disease (OR 1.94, 95% CI 1.29 to 2.91, p = 0.001). Of patients with hydronephrosis 88 (36.1%) had concomitant node positive disease and 74 (30.3%) had node positive disease on the same side as hydronephrosis. Thus, hydronephrosis predicted the side of nodal involvement in 74 of 88 patients (84%) with identifiable hydronephrosis and node positive disease. CONCLUSIONS Hydronephrosis is an independent predictor of advanced bladder cancer stage, and it predicts extravesical disease and node positive disease. Thus, it could prove useful to select patients for neoadjuvant chemotherapy before surgery. The strong correlation between hydronephrosis side and nodal metastasis may have implications for surgical staging and approach.

Medical Malpractice Claims Risk in Urology: An Empirical Analysis of Patient Complaint Data

PURPOSE Patient complaints are associated with physician risk management experience, including medical malpractice claims risk, and small proportions of physicians account for disproportionate shares of claims. We investigated whether patient complaint experience differs among urologists, and whether urological subspecialists generate distinct quantities and types of complaints. MATERIALS AND METHODS This retrospective study examined 1,516 unsolicited patient complaints filed against 268 urologists. Patient complaint and urological subspecialty data were collected from January 1, 2004 through December 31, 2007 for 15 geographically diverse health systems. The cohort urologists were assigned medical malpractice claims risk scores and complaint type profiles. A weighted sum algorithm produced risk scores from 4 consecutive years of complaint data and complaint type profiles were generated using a standardized coding system. Statistical analyses tested the associations among risk score, complaint type profile and urological subspecialty. Complaint type profile and subspecialty distribution were assessed for urologists in the cohort top decile for risk scores. RESULTS Overall 125 (47%) urologists were associated with 0 patient complaints, while 30 (11%) urologists were associated with 758 (50%) of the patient complaints. Subspecialty and distribution of risk scores were significantly associated (p <0.001). Calculi and oncology subspecialist distributions suggest greater overall risk. Complaint types also varied among subspecialists (p = 0.02). There was no association between top decile urologists and complaint type profile (p = 0.19). CONCLUSIONS Unsolicited patient complaints were nonrandomly distributed among urologists and urological subspecialties. Monitoring patient complaints may allow for early identification of and intervention with high risk urologists before malpractice claims accumulate.

Locoregional Small Cell Carcinoma of the Bladder: Clinical Characteristics and Treatment Patterns

PURPOSE Because small cell carcinoma of the bladder is a relatively rare tumor type, literature about its treatment remains limited. We determined patterns of care and survival after treatment in what is to our knowledge the largest series to date of patients with locoregional small cell carcinoma of the bladder. MATERIALS AND METHODS We identified patients with localized/locally advanced (cTis-cT4, cN0 or cM0) bladder small cell carcinoma diagnosed between 1998 and 2010 from the National Cancer Database (NCDB). Treatment was categorized as bladder preservation therapy, radical cystectomy alone, bladder preservation therapy with multimodal treatment or radical cystectomy plus multimodal treatment. We performed Kaplan-Meier overall survival analysis to evaluate differential survival between treatment groups. RESULTS A total of 625 patients met study inclusion criteria. Median age at diagnosis was 73 years (range 36 to 90) and 65% of patients presented with cT2 disease. Patients were treated with bladder preservation therapy (174 or 27.8%), bladder preservation therapy plus multimodal treatment (333 or 53.3%), radical cystectomy alone (46 or 7.4%) and radical cystectomy plus multimodal treatment (72 or 11.5%) with a 3-year overall survival rate of 23% (95% CI 15-32), 35% (95% CI 30-45), 38% (95% CI 17-60) and 30.1% (95% CI 16-47), respectively. Overall survival was most favorable for radical cystectomy alone plus neoadjuvant chemotherapy with a 3-year rate of 53% (95% CI 19-79). CONCLUSIONS In the United States locoregional small cell carcinoma of the bladder develops predominantly in white males, in whom treatment is performed at metropolitan, comprehensive community cancer centers. Most patients were treated with bladder preservation therapy and most received multimodal therapy. Patients who received neoadjuvant chemotherapy followed by radical cystectomy had the most favorable survival.

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

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?

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.

MP54-04 HOSPITALIZATION AND READMISSION COSTS AFTER RADICAL CYSTECTOMY IN A NATIONALLY REPRESENTATIVE SAMPLE: NEOBLADDER VS. ILEAL CONDUIT

physical capacity (86%), followed by improvement of incontinence (81%) and reduction of mental distress (31%). During FT 25.9% of patients had a urinary tract infection requiring antibiotics and 8.6% had a symptomatic metabolic acidosis. Only 18.1% were under antithrombotic medication at the beginning of FT. Antibiotic use decreased from 19.8% to 17.3%. Incontinence pad use increased from 2.14 to 2.55 pads per day on average. At the end of FT, patients indicated improvement of incontinence, physical capacity and mental distress in 60.5%, 74.1% and 30.86%. CONCLUSIONS: Compared to the preand perioperative management of BC, there is a scarcity of studies investigating FT of BC. A multitude of significantly different FT models have been implemented in different countries. Both from the economic as well as medical point of view high-quality FT must be strived for. Our study gives insights into the current state of FT in Germany and shows both benefits as well as unsolved challenges.

OP3-11 INGUINAL LYMPHADENECTOMY IN PENILE CANCER: RESULTS FROM THE NATIONAL CANCER DATABASE

INTRODUCTION AND OBJECTIVES: Induction chemotherapy for International Germ Cell Cancer Collaborative Group (IGCCCG) good risk metastatic testicular cancer includes either 3 cycles of bleomycin, etoposide, and cisplatin (BEP) or 4 cycles of etoposide and cisplatin (EP). We sought to examine the differences in active cancer in the retroperitoneum (RP) between patients receiving BEPx3 compared to EPx4. METHODS: The Indiana University Testis Cancer database was queried to identify IGCCCG good risk patients who received either BEPx3 or EPx4 induction chemotherapy prior to PC-RPLND. The primary outcome of RP histology was categorized as active cancer (yes/no). The association between use of bleomycin in the induction regimen with active cancer in the RP was tested with logistic regression. A propensity score-adjusted analysis was undertaken to adjust for potential imbalances among men receiving BEP or EP. RESULTS: A total of 226 patients met inclusion criteria, some of which were treated at outside institutions. One hundred seventy-nine men (79%) received BEPx3 while 47 (21%) received EPx4. The median age of the BEP group was 27 years (range: 15-50) compared to 30 years (range: 18-71) in the EP group. The BEP group had surgery in earlier years, more often had a right sided primary tumor, and a component of embryonal cell carcinoma in the primary tumor (all p<0.05). The incidence of activecancer in theRPspecimenatPC-RPLNDwassignificantlyhigher in the EPx4 group compared to the BEPx3 group (31.9% vs. 7.8%, p<0.01). This significant difference between the BEP and EP groups remained in the propensity-adjusted analysis (25.5% vs. 8.4%, p1⁄40.01). CONCLUSIONS: There was a higher incidence of active cancer in the RP specimen in good risk patients who receive 4 cycles of induction EP chemotherapy compared to men receiving 3 cycles of BEP in this retrospective analysis.