Jamie S. Pak

Validation of a frailty index in patients undergoing curative surgery for urologic malignancy and comparison with other risk stratification tools.

OBJECTIVE To retrospectively validate and compare a modified frailty index predicting adverse outcomes and other risk stratification tools among patients undergoing urologic oncological surgeries. MATERIALS AND METHODS The American College of Surgeons National Surgical Quality Improvement Program was queried from 2005 to 2013 to identify patients undergoing cystectomy, prostatectomy, nephrectomy, and nephroureterectomy. Using the Canadian Study of Health and Aging Frailty Index, 11 variables were matched to the database; 4 were also added because of their relevance in oncology patients. The incidence of mortality, Clavien-Dindo IV complications, and adverse events were assessed with patients grouped according to their modified frailty index score. RESULTS We identified 41,681 patients who were undergoing surgery for presumed urologic malignancy. Patients with a high frailty index score of >0.20 had a 3.70 odds of a Clavien-Dindo IV event (CI: 2.865-4.788, P<0.0005) and a 5.95 odds of 30-day mortality (CI: 3.72-9.51, P<0.0005) in comparison with nonfrail patients after adjusting for race, sex, age, smoking history, and procedure. Using C-statistics to compare the sensitivity and specificity of the predictive ability of different models per risk stratification tool and the Akaike information criteria to assess for the fit of the models with the data, the modified frailty index was comparable or superior to the Charlson comorbidity index but inferior to the American Society of Anesthesiologists Risk Class in predicting 30-day mortality or Clavien-Dindo IV events. When the modified frailty index was augmented with the American Society of Anesthesiologists Risk Class, the new index was superior in all aspects in comparison to other risk stratification tools. CONCLUSION Existing risk stratification tools may be improved by incorporating variables in our 15-point modified frailty index as well as other factors such as walking speed, exhaustion, and sarcopenia to fully assess frailty. This is relevant in diseases such as kidney and prostate cancer, where surveillance and other nonsurgical interventions exist as alternatives to a potentially complicated surgery. In these scenarios, our modified frailty index augmented by the American Society of Anesthesiologists Risk Class may help inform which patients have increased surgical complications that may outweigh the benefit of surgery although this index needs prospective validation.

Delay from biopsy to radical prostatectomy influences the rate of adverse pathologic outcomes.

We sought to determine maximum wait times between biopsy diagnosis and surgery for localized prostate cancer, beyond which the rate of adverse pathologic outcomes is increased.

Patterns of care for readmission after radical cystectomy in New York State and the effect of care fragmentation

OBJECTIVE To determine if readmission after radical cystectomy (RC) to the original hospital of the procedure (OrH) vs. readmission to a different hospital (DiffH) has an effect on outcomes. METHODS The New York Statewide Planning and Research Cooperative System database was queried for discharges between January 1, 2009 and November 31, 2012 after RC in New York State. Primary outcome was mortality within 30 and 90 days. Secondary outcomes included length of stay for readmission, rate of transfers/subsequent readmissions, hospital charges per readmission, and, if applicable, length of intensive care unit stays. Multivariate linear regression analyses were performed to adjust for confounding factors in predicting mortality. RESULTS During the study period, 2,338 patients were discharged from 100 New York State hospitals after RC. Overall rate of readmission was 28.5% and 39.7% within 30 and 90 days, respectively. Of all readmitted patients, 80.4% and 77.1% were first readmitted to OrH within 30 and 90 days, respectively. Patients readmitted to OrH were younger (P<0.0005) and had a lower All Patient Refined Severity of Illness (P = 0.004). Patients readmitted to DiffH had shorter length of stay (P<0.0005) and lower hospital charges per readmission (P<0.0005), but higher rates of transfers/subsequent readmissions (P = 0.007) and intensive care unit stays (P = 0.002) at 90 days. Patients initially readmitted to DiffH also had a higher rate of mortality (30d, 7.8% vs. 2.3%, P = 0.002; 90d, 5.2% vs. 2.5%, P = 0.05), but initial readmission status was not significant for mortality when controlling for other variables of interest. CONCLUSION Initial readmission to DiffH vs. OrH after RC was associated with higher rates of mortality, likely owing to underlying differences in the populations.

Gender Differences in the Urology Residency Match—Does It Make a Difference?

OBJECTIVE To assess the differences between the male and female urology resident applicant pool. Urology is a competitive field with a selective match process. Women have historically been a minority in medicine. Although this has equalized, women continue to be underrepresented in urology. MATERIALS AND METHODS All application submitted through the Electronic Residency Application Service to the Columbia University Department of Urology for the 2015 and 2016 match were reviewed. The differences between the cohorts of matched female and male urology applicants were assessed. RESULTS Two hundred fifty-six students in 2015 and 259 students in 2016 submitted applications to Columbia and completed rank lists (60% of the national cohort in 2015 and 62% in 2016). We did find that the overall male applicant pool had a slightly lower number of honors (3 vs 2, P = .02) and higher United States Medical Licensing Examination (USMLE) step 1 score (238 vs 234, P <.001). The only other statistically significant difference between the matched male and female cohorts was the average number of urology subinternships (1.4 [0.9] for men vs 1.18 [0.8] for women, P = .04). CONCLUSION Overall matched male and female applicants appeared to have very similar qualifications. Men had a higher USMLE step 1 score and women had a higher average number of honors. These data support the finding that contemporary male and female residency candidates who matched in urology had comparable achievements, and the criteria for residency selection in both cohorts are similar.

Analysis of Transurethral Resection of the Prostate Costs across New York State Hospitals Using Severity of Illness Score

Introduction: Using data on surgical treatment for benign prostatic hyperplasia we evaluated the effect of beneficiary health status on hospital reported costs. Methods: We examined the records of 9,895 patients in the New York State Hospital Inpatient Cost Transparency database who underwent surgical treatment for benign prostatic hyperplasia, including laser prostatectomy and traditional transurethral resection of the prostate, in New York State from 2009 to 2011. Results: Using the 3M™ APR‐DRG (All Patient Refined Diagnosis Related Group) severity of illness index as a measure of patient preoperative health we found a significant increase in the cost of transurethral resection of the prostate for patients with higher severity of illness scores. We confirmed an increase in the cost and the cost variability of transurethral resection of the prostate for patients with higher severity of illness scores. Conclusions: Our findings illustrate the inherent unpredictability of cost forecasting and budgeting for these patients.

Utilization and Perioperative Outcomes of Partial Cystectomy for Urothelial Carcinoma of the Bladder: Lessons from the ACS NSQIP Database

Introduction: We identified predictors of partial cystectomy in the ACS NSQIP® database of more than 400 hospitals across North America. We also reviewed perioperative outcomes. Methods: We reviewed the records of patients with an ICD‐9 diagnosis of urothelial carcinoma of the bladder who were treated with partial or radical cystectomy from 2007 to 2012. The proportion of patients who underwent partial vs radical cystectomy and the proportion who received neoadjuvant chemotherapy were compared across time. We reviewed 30‐day morbidity and mortality, and determined risk factors. Logistic regression was used to identify factors predictive of undergoing partial vs radical cystectomy. Results: A total of 2,393 patients met study inclusion criteria. The ratio of partial to radical cystectomy was low and stable at 0% to 7% (p = 0.36). While patients undergoing radical cystectomy were more likely to receive neoadjuvant chemotherapy in later years (p <0.001), neoadjuvant chemotherapy use before partial cystectomy was consistently low with time (p = 0.68). The 30‐day morbidity rate after partial and radical cystectomy was 23.3% and 58.1% (p = 0.001), and the 30‐day mortality rate was 1.6% and 2.1%, respectively (p = 0.66). On multivariate regression factors independently associated with partial vs radical cystectomy were cerebrovascular accident history (OR 4.4, p = 0.005), current nonsmoking (OR 0.43, p = 0.032) and lack of trainee participation in the operation (OR 0.28, p <0.001). Conclusions: The ratio of the number of partial to radical cystectomies performed was stable. Cerebrovascular accident history, nonsmoker status and lack of trainee participation were associated with partial cystectomy. Patients treated with radical cystectomy but not those who underwent partial cystectomy were more likely to receive neoadjuvant chemotherapy in later years. Large detailed registries such as ACS NSQIP have important potential use for evaluating trends in urological practice.

MP72-09 ADJUVANT CISPLATIN LEADS TO A LARGER DECLINE IN GFR THAN NEOADJUVANT CISPLATIN IN RADICAL CYSTECTOMY PATIENTS

RESULTS: No significant difference was noted in 5-year CSS between GC NAC (58%) and non-NAC cohorts (61%). The median followup was 19.6 months for GC NAC and 106.5 months for non-NAC. Patients with residual non-muscle-invasive disease (pTis, pTa, pT1) after GC NAC exhibit similar 5-year CSS relative to patients with no residual carcinoma (pT0), p1⁄40.99. NAC pathologic responders ( T1, n1⁄480) demonstrated improved 5-year CSS rates of 90.6% vs. 27.1% (p<0.01) and decreased nodal positivity rates of 0% vs. 41.3% (p<0.01) compared to NAC pathologic non-responders ( pT2). Clinical and pathologic outcomes were inferior in NAC pathologic non-responders compared to the entire RC only treated cohort (pT2-T4). A significantly lower pathologic non-response rate was seen in those able to tolerate sufficient dosing of NAC when patients were stratified by the JHH-DI (p1⁄40.049) which is congruent with NCCN guidelines. A multivariate decision tree model demonstrated age 60 years and clinical stage cT2 as significant of response to NAC (p<0.05). CONCLUSIONS: Pathologic non-responders fare worse than patients proceeding directly to RC alone, suggesting the need to identify clinical features predictive of poor response prior to the initiation of chemotherapy. To this effect, multiple predictive models incorporating clinical, histopathologic, and molecular features are currently being developed to identify patients, prior to the initiation of therapy, that are most likely to benefit or not benefit from GC NAC.

MP64-07 SIMPLIFIED FRAILTY INDEX PREDICTS ADVERSE OUTCOMES IN RADICAL CYSTECTOMY: AN ANALYSIS OF THE ACS- NSQIP DATABASE

INTRODUCTION AND OBJECTIVES: Preoperative malnutrition is a concern for patients undergoing radical cystectomy and may influence both medical and surgical complications post operatively. We seek to identify specific complications related to preoperative nutritional deficiency. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2005-2012 database was reviewed for all patients undergoing a radical cystectomy based on Current Procedural Terminology (CPT) codes (51570, 51575, 51580, 51585, 51590, 51595, 51596, 51597). Patients with missing data on albumin, height, weight, gender and American Society of Anesthesiology (ASA) class were removed. Patients who had an albumin 10% weight loss were considered “nutritionally deficient” (ND). All other patients had “normal nutritional status” (NNS). We also stratified post-operative complication by Clavien grade and summed up patients’ comorbidites to create a “comorbidity count” variable that was entered into multivariate logistic regression. RESULTS: After all exclusions, 1,513 patients underwent a radical cystectomy. Of this cohort, 21.5% (n1⁄4325) were nutritionally deficient while 78.5% had normal nutritional status. Specifically, 18% had an albumin 10% weight loss. The ND group displayed higher rates of any complication (71.1% vs 58.7%, p1⁄4<0.001), Clavien grade 2 (66.8% versus 54.5%, p1⁄4<0.001), and Clavien grade 4 (9.5% vs 6.2%, p1⁄40.037) complications. On multivariate regression, after controlling for age, inpatient status, ASA class, total relative value unit (RVU), operation time and comorbidity count, preoperative nutritional deficiency increased risk of any complication (OR 1.788, 95% CI 1.357-2.356, p1⁄4<0.001) and Clavien grade 2 complications (OR 1.735, 95% CI 1.328-2.267, p<0.001). CONCLUSIONS: Pre-operative nutritional status increases risk of post-operative complications.

MP24-19 PATTERNS OF CARE FOR READMISSION FOLLOWING RADICAL CYSTECTOMY IN NEW YORK STATE: DOES THE HOSPITAL MATTER?

CONCLUSIONS: Hospital readmissions within 90 days of major urologic cancer surgery are associated with a low FTR rate; however, patients readmitted to a SH experienced higher FTR than those readmitted to their original hospital. These findings may inform clinical decision-making around hospital transfers and aid future quality improvement initiatives to reduce the morbidity associated with complex urologic oncology surgeries.