Francisco Gelpi-Hammerschmidt

Efficacy of High-Intensity Local Treatment for Metastatic Urothelial Carcinoma of the Bladder: A Propensity Score–Weighted Analysis From the National Cancer Data Base

Purpose Evidence from studies of other malignancies has indicated that aggressive local treatment (LT), even in the presence of metastatic disease, is beneficial. Against a backdrop of stagnant mortality rates for metastatic urothelial carcinoma of the bladder (mUCB) at presentation, we hypothesized that high-intensity LT of primary tumor burden, defined as the receipt of radical cystectomy or ≥ 50 Gy of radiation therapy delivered to the bladder, affects overall survival (OS). Patients and Methods We identified 3,753 patients within the National Cancer Data Base who received multiagent systemic chemotherapy combined with high-intensity versus conservative LT for primary mUCB. Patients who received no LT, transurethral resection of the bladder tumor alone, or < 50 Gy of radiation therapy delivered to the bladder were included in the conservative LT group. Inverse probability of treatment weighting (IPTW) -adjusted Kaplan-Meier curves and Cox regression analyses were used to compare OS of patients who received high-intensity versus conservative LT. Results Overall, 297 (7.91%) and 3,456 (92.09%) patients with mUCB received high-intensity and conservative LT, respectively. IPTW-adjusted Kaplan-Meier curves showed that median OS was significantly longer in the high-intensity LT group than in the conservative LT group (14.92 [interquartile range, 9.82 to 30.72] v 9.95 [interquartile range, 5.29 to 17.08] months, respectively; P < .001). Furthermore, in IPTW-adjusted Cox regression analysis, high-intensity LT was associated with a significant OS benefit (hazard ratio, 0.56; 95% CI, 0.48 to 0.65; P < .001). Conclusion We report an OS benefit for individuals with mUCB treated with high-intensity versus conservative LT. Although the findings are subject to the usual biases related to the observational study design, these preliminary data warrant further consideration in randomized controlled trials, particularly given the poor prognosis associated with mUCB.

The Effect of Resident Involvement on Perioperative Outcomes in Transurethral Urologic Surgeries

OBJECTIVE To conduct the first study of intra- and postoperative outcomes related to intraoperative resident involvement in transurethral resection procedures for benign prostatic hyperplasia and bladder cancer in a large, multi-institutional database. DESIGN Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User Files (2005-2012), we abstracted all cases of endoscopic prostate surgery (EPS) for benign prostatic hyperplasia and transurethral resection of bladder tumors (TURBTs). Multivariable logistic regression models were constructed to assess the effect of trainee involvement (postgraduate year [PGY] 1-2: junior, PGY 3-4: senior, PGY ≥ 5: chief or fellow) vs attending only on operative time and length of hospital stay, as well as 30-day complication, reoperation, and readmission rates. RESULTS In all, 5093 EPS and 3059 TURBTs for a total of 8152 transurethral resection procedures were performed during the study period for which data on resident involvement were available. In multivariable analyses, resident involvement in EPS or TURBT was associated with increased odds of prolonged operative times and hospital readmissions in 30 days independent of resident level of training. Resident involvement was not associated with overall complications or reoperation rates. CONCLUSIONS Resident involvement in lower urinary tract surgeries is associated with increased readmissions. Strategies to optimize resident teaching of these common urologic procedures in order to minimize possible risks to patients should be explored.

Trends in utilisation, perioperative outcomes, and costs of nephroureterectomies in the management of upper tract urothelial carcinoma: a 10-year population-based analysis.

To perform a population‐based study to evaluate contemporary utilisation trends, morbidity, and costs associated with nephroureterectomies (NUs), as contemporary data for NUs are largely derived from single academic institution series describing the experience of high‐volume surgeons and it is unclear if the same favourable results occur at a national level.

Contemporary trends in high-dose interleukin-2 use for metastatic renal cell carcinoma in the United States.

BACKGROUND Targeted therapies (TTs) have revolutionized metastatic renal cell carcinoma (mRCC) treatment in the past decade, largely replacing immunotherapy including high-dose interleukin-2 (HD IL-2) therapy. We evaluated trends in HD IL-2 use for mRCC in the TT era. METHODS Our cohort comprised a weighted estimate of all patients undergoing HD IL-2 treatment for mRCC from 2004 to 2012 using the Premier Hospital Database. We assessed temporal trends in HD IL-2 use including patient, disease, and hospital characteristics stratified by era (pre-TT uptake: 2004-2006, uptake: 2007-2009, and post-TT uptake: 2010-2012) and fitted multivariable regression models to identify predictors of treatment toxicity and tolerability. RESULTS An estimated 2,351 patients received HD IL-2 therapy for mRCC in the United States from 2004 to 2012. The use decreased from 2004 to 2008. HD IL-2 therapy became increasingly centralized in teaching hospitals (24% of treatments in 2004 and 89.5% in 2012). Most patients who received HD IL-2 therapy were men, white, younger than 60 years, had lung metastases, and were otherwise healthy. Vasopressors, intensive care unit admission, and hemodialysis were necessary in 53.4%, 33.0%, and 7.1%, respectively. Factors associated with toxicities in multivariable analyses included being unmarried, male sex, and multiple metastatic sites. African Americans and patients with single-site metastases were less likely to receive multiple treatment cycles. CONCLUSIONS HD IL-2 therapy is used infrequently for mRCC in the United States, and its application has diminished with the uptake of TT. Patients are being increasingly treated in teaching hospitals, suggesting a centralization of care and possible barriers to access. A recent slight increase in HD IL-2 therapy use likely reflects recognition of the inability of TT to effect a complete response.

Racial Disparities in Postoperative Complications After Radical Nephrectomy: A Population-based Analysis

OBJECTIVE To perform a population-based study that evaluates contemporary racial disparities in the morbidity profile of patients undergoing radical nephrectomy in the United States. METHODS Using the Premier hospital database (Premier Inc, Charlotte, NC), which collects data from over 600 nonfederal hospitals throughout the United States, we identified patients undergoing a total nephrectomy as their primary procedure and also had a concurrent diagnosis of a kidney mass or cancer from 2003 to 2010. The primary outcome was 90-day major complication rates, based on the Clavien classification system. Multivariate logistic regression models were performed, adjusting for clustering by hospitals and survey weighting to ensure nationally representative estimates. RESULTS The study population included 25,517 patients translating into a weighted sample of 185,135 radical nephrectomies. In a multivariate model including patient, hospital, and surgical characteristics, blacks were more commonly associated with a major complication (odds ratio, 2.1; P <.0001). When we incorporated Charlson comorbidity score into the model, the racial disparity in major complications was attenuated by 36% (odds ratio, 1.7; P <.0001). Adjusting for annual surgical volume in the multivariate model did not alter results. CONCLUSION Our contemporary evaluation of patients undergoing radical nephrectomy in the United States demonstrates that blacks are associated with a markedly elevated rate of major complications as compared to whites. This disparity is possibly a result of unequal access to routine health care.

MP84-20 CHANGING PRACTICE PATTERNS FOR THE MANAGEMENT OF UPPER TRACT UROTHELIAL CARCINOMA WITH NEPHROURETERECTOMY: A 10-YEAR POPULATION-BASED ANALYSIS

INTRODUCTION AND OBJECTIVES: Nephroureterectomy (NU), is the standard treatment for upper tract urothelial carcinoma (UTUC). Minimally invasive (MI) laparoscopic or robotic-assisted approaches have been introduced in an effort to reduce morbidity. We performed a population-based study to assess contemporary trends in utilization, morbidity, and cost of competing approaches for NU in theUS. METHODS: Using the Premier Hospital Database (Premier, Inc., Charlotte, NC), a nationally representative discharge database collecting data from over 600 non-federal hospitals throughout the US, we captured all patients who underwent a NU (ICD9 55.51) with diagnoses of UTUC (ICD9 189.1, 189.2), from 2004 to 2013. We fit regression models, accounting for clustering by hospitals and sample weighting to estimate 90-day postoperative complications, length of stay (LOS), operating room time (OT), and direct hospital costs among open NU and MI NU. RESULTS: The weighted cohort included 17245 open, 13298 laparoscopic, and 3745 robotic NUs. MI NU increased from 36% to 54% from 2004 to 2013 while the annual number of NU’s decreased by nearly 20% during the same period (Figure 1); among the least healthy patients (CCI 2), robotic NU’s accounted for 31% in 2013 as compared to 2% in 2004. The overall 90-day mortality (Clavien 5) and major (Clavien 3-5) complication rates were 1.89% and 9.4% respectively with no statistically significant differences among surgical approach based on adjusted analysis. The LOS was decreased for laparoscopic NU (Incidence Risk Ratio [IRR]: 0.87, p <0.001) and robotic NU (IRR: 0.76, p <0.001) compared to open NUs. OT was 10.35 (p<0.05) and 56.35 (p<0.001) minutes longer for laparoscopic and robotic NU. Adjusted 90day median direct hospital costs were

High-dose interleukin-2 (HD IL-2) for metastatic renal Cell carcinoma (mRCC): Contemporary utilization trends in the United States.

1354 and

The Contemporary Incidence and Sequelae of Rhabdomyolysis Following Extirpative Renal Surgery: A Population Based Analysis.

3533 higher for laparoscopic and robotic NU (p<0.001). CONCLUSIONS: During this contemporary 10-year study, the use of MI NUs increased to over half of procedures with a recent surge in robotic NU’s particularly in the higher comorbidity patients. The national reduction in total NUs performed in the US may reflect a growing enthusiasm for renal sparing options for UTUC. Comparable perioperative outcomes among the three approaches suggest that the morbidity profile may be driven primarily by patient-specific characteristics.

MP63-08 VALIDATION OF THE CAPRINI RISK ASSESSMENT MODEL IN RADICAL CYSTECTOMY PATIENTS

449 Background: Targeted therapies (TT) have revolutionized treatment of mRCC with broad based efficacy and tolerability but ultimately all patients progress. While HD IL-2, the prior standard of care treatment, is associated with significant toxicities, it remains the only agent proven to elicit durable complete responses albeit rarely. This study evaluated trends in HD IL-2 use for patients with mRCC during the TT era. Methods: Our study cohort was comprised of a weighted sample of 2,351 patients with mRCC undergoing HDIL-2 treatment from 2004-2012, from the Premier Hospital Database (Premier Inc., Charlotte, NC), a nationally representative hospital discharge database. We employed descriptive statistics and fitted multivariable regression models, accounting for clustering and weighting, to identify predictors of treatment toxicity and tolerability. Results: We found a progressive decrease in the use of HD IL-2 from 2004 to 2008 with a general upward trend thereafter. HD IL-2 was increasingly concentrat...