Janet E. Baack Kukreja

Effectiveness and safety of extended-duration prophylaxis for venous thromboembolism in major urologic oncology surgery

PURPOSE To examine the association between extended-duration prophylaxis (EDP), low-molecular-weight heparin prophylaxis for 28 days after surgery for urologic cancer in patients at high risk of developing a venous thromboembolism (VTE), the risk of VTE, and the complications resulting from VTE prophylaxis. MATERIALS AND METHODS The cohort included 332 patients at high risk for VTE who were surgically treated for urologic cancer from June 2011 to June 2014. Adherence to VTE prophylaxis protocol, VTEs, and complications within 365 days from surgery were tracked. Patients were grouped as follows: (1) per protocol in-hospital prophylaxis with EDP (n = 107), (2) per protocol in-hospital prophylaxis without EDP (n = 42), (3) not per protocol in-hospital prophylaxis with EDP (n = 83), and (4) not per protocol in-hospital prophylaxis without EDP (n = 100). The risk of VTE was compared between the 4 groups using the Cox model, with adjustment for baseline risk factors. RESULTS The rates of VTEs and median times to VTE were 7% and 58 days in group 1, 17% and 44 days in group 2, 17% and 46 days in group 3, and 21% and 15 days in group 4, respectively. Adjusted hazard ratios (HR) for VTE were HR = 0.27 (95% CI: 0.11-0.70) for groups 1 vs. 4; HR = 0.66 (95% CI: 0.25-1.60) for groups 2 vs. 4; and HR = 0.66 (95% CI: 0.29-1.26) for groups 3 vs. 4 with a trend of P = 0.002. The incidence of complications from VTE prophylaxis was not significantly different between the groups, with a rate of 8% in group 1, 17% in group 2, 6% in group 3, and 12% in group 4 (P = 0.33). CONCLUSIONS In high-risk urologic cancer surgery patients, a clinical protocol, with perioperative and EDP, is safe and effective in reducing VTE events.

Are we doing “better”? The discrepancy between perception and practice of enhanced recovery after cystectomy principles among urologic oncologists

PURPOSE The concept of enhanced recovery after surgery has been around since the 1990s when it was first introduced as a means to improve postoperative recovery of general surgical patients. In the field of urology, the uptake of enhanced recovery pathways has been slow for unclear reasons. Recently, interest in enhanced recovery after cystectomy (ERAC) has been increasing, but the current urologic oncology practice patterns remain unclear. In this study, we investigate modern perioperative patterns of care and rates of application of ERAC principles by cystectomy surgeons. MATERIALS AND METHODS ERAC principles were identified by reviewing urology and general surgery literature. An adapted version of The Royal College of Surgeons of England fast-track surgical principles survey was used. Preoperative education, bowel preparation avoidance, nasogastric tubes avoidance, normothermia, opioid avoidance, early ambulation, and early feeding were all practices queried with the survey. Surveys were distributed electronically to faculty of Society of Urologic Oncology fellowships with bladder cancer as a special area of interest. Additional participants were identified by recent publications on cystectomies for bladder cancer. In total, 128 surveys were e-mailed to the previously identified experts. Of these, 61 (48%) completed the survey. Responses were classified as congruent with commonly accepted ERAC principles (ERAC group) or noncongruent (non-ERAC group). Chi-square test was used for categorical variables and Wilcoxon-Mann-Whitney for ordinal variables. RESULTS Of the urologists who classified themselves in the ERAC group (64%), the average length of stay was reported to be 6.1 days and 7.2 days in the non-ERAC group (P = 0.02). Only 20% were practicing all interventions. Among the ERAC surgeons 1, 2 or 3 of the interventions were omitted by 13%, 25%, and 23% of the respondents, respectively. Significant differences were found between the self-reported ERAC adopters and nonadopters in the use of bowel preparation (P = 0.01), nasogastric tubes (P = 0.007), alvimopan (P<0.001), and the average day of advancement to clear liquids (P<0.001). There were no differences in postoperative ambulation and opiate or nonsteroidal anti-inflammatory drug use. Lack of convincing evidence was cited as the main reason for the non-ERAC group not yet implementing an ERAC pathway followed by lack of resource availability. CONCLUSION Urologists who consider themselves as practicing ERAC do not universally practice all of the pathway tenets. A significant gap exists between self-perception and practice of enhanced recovery. ERAC implementation is challenging but represents a significant opportunity to improve the quality of care for cystectomy patients.

Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

To determine if patients managed with a cystectomy enhanced recovery pathway (CERP) have improved quality of care after radical cystectomy (RC), as defined by a decrease in length of hospital stay (LOS) without an increase in complications or readmissions compared with those not managed with CERP.

The Future of Enhanced Recovery for Radical Cystectomy: Current Evidence, Barriers to Adoption, and the Next Steps

Radical cystectomy (RC) is a complex procedure that can involve long postoperative hospital stays and complicated, burdensome recoveries. Enhanced recovery after surgery is a broad term encompassing an overall approach to perioperative management of postsurgical patients and is becoming more widely accepted for cystectomy patients. This review examines the current evidence for using enhanced recovery protocols for RC as well as current rates of adoption of enhanced recovery among urologists performing RC. We also discuss the next steps for overcoming barriers to the widespread implementation of enhanced recovery for RC.

Bladder cancer incidence and mortality in patients treated with radiation for uterine cancer

To estimate the effect of radiation therapy (RT) administered for uterine cancer (UtC) on bladder cancer (BC) incidence, tumour characteristics at presentation, and mortality.

PD41-05 THE ROLE OF METASTATIC BURDEN IN CYTOREDUCTIVE/CONSOLIDATIVE RADICAL CYSTECTOMY

Purpose To describe our institutional experience with cytoreductive/consolidative radical cystectomy (CCRC) for metastatic urothelial carcinoma (UC) and to investigate clinicopathologic features predicting prolonged cancer specific survival (CSS) following CCRC.

Antibiogram Directed Prophylaxis for Transrectal Prostate Biopsy: An Application of Recommendations in the Setting of High Fluoroquinolone Escherichia coli Resistance

Introduction: We investigated local resistance patterns to guide antibiotic use for the prevention of infections associated with transrectal prostate biopsy with ultrasound guidance. Methods: Per the AUA (American Urological Association) recommendations (2014 and 2016) for transrectal prostate biopsy with ultrasound guidance prophylaxis, local antibiogram resistance was reviewed. Rates of Escherichia coli fluoroquinolone resistance were between 20% and 28%. Thus, the antibiotics chosen were a single dose of oral ciprofloxacin and intramuscular ceftriaxone at least 30 minutes before transrectal prostate biopsy with ultrasound guidance. Data were reviewed retrospectively between July 2012 and December 2015. There was no standard prophylaxis before protocol implementation in August 2014. Univariable analyses were performed with appropriate testing followed by multivariable logistic regression. Results: Of 2,351 biopsies 799 were performed in patients in the protocol group. Before protocol implementation 26 different antibiotic regimens were used. The protocol group had significantly more cases of chronic kidney disease, a history of cancer, larger prostate volume and greater number of cores during transrectal prostate biopsy with ultrasound guidance. The overall hospital admission rate after transrectal prostate biopsy with ultrasound guidance was 1.35% for the nonprotocol group and 0.4% for the protocol group (p = 0.026). The incidence of organisms with antimicrobial resistance in blood and urine decreased from 20.7% (23 cases) in the nonprotocol group and 7.1% (4) in the protocol group (p=0.030). All positive blood cultures occurred in the nonprotocol group and all were ciprofloxacin resistant E. coli. On multivariable logistic regression those patients requiring hospitalization were 12.9 (95% CI 2.81–58.96) times more likely to have resistant organisms cultured (p=0.001). Conclusions: The transrectal prostate biopsy with ultrasound guidance antibiotic prophylaxis protocol decreased unwanted variation among practitioners, which is ultimately associated withimproved quality. Antibiogram directed prophylaxis where there is high fluoroquinolone resistance maintains low infection and hospital admission rates after transrectal prostate biopsy with ultrasound guidance.

Immediate Postoperative Care Following Robot-Assisted Radical Prostatectomy

Increased experience with robot-assisted radical prostatectomy (RARP) has been associated with decrease in postoperative hospital stay (Pierorazio et al., BJU Int 2013;112:45–53). A formal care program for a recovery pathway after RARP has been responsible for this decrease, allowing many institutions to consistently discharge patients the morning of postoperative day (POD) 1. Important elements of an RARP pathway include patient education, early postoperative feeding, avoiding postoperative ileus, early ambulation, pain control, appropriate antibiotic administration, and pelvic drain removal prior to discharge. A system-wide commitment is needed in all phases of RARP care to have a consistent and successful care pathway. A RARP care pathway not only can promote consistent discharge on POD 1, but also can decrease variation in practices and decrease complications.

Measuring success after radical cystectomy: Feasibility of a novel composite endpoint ("poor recovery") to quantify outcomes after surgery.

357 Background: Given the predilection of invasive bladder cancer toward older sicker patients and the complexity of radical cystectomy (RC), it is not surprising many patients experience prolonged, difficult recoveries. There is growing interest in identifying ways to improve recovery after RC. To date, studies have focused on inpatient length of stay (LOS) as the primary measure of recovery improvement efforts. Given that many patients suffer complications after discharge and require hospital readmission, inpatient LOS may not be the most useful measure. We propose a novel endpoint – “Poor Recovery” – as a more encompassing measure of outcomes after RC. Methods: A comprehensive perioperative multidisciplinary algorithm known as the Optimized Surgical Journey (OSJ) has been in development at our institution over the last 18 months. We selected 50 patients who underwent RC with the OSJ algorithm and 50 patients who underwent RC with usual care during the same time period. Poor Recovery was defined by inpa...

Aggressive Inflammatory Myofibroblastic Tumor of the Urinary Bladder in Children

Inflammatory myofibroblastic tumor (IMT) of the genitourinary tract is a well- known entity. The majority of the literature characterizes IMT of the bladder as a benign, slow growing tumor in children. We present two cases of aggressive IMT. Although rhabdomyosarcoma is more common, IMT should remain within the differential diagnosis for any bladder mass found in a child or young adult. The diagnosis of IMT is important in preventing unnecessary diagnostic procedures and guiding the appropriate treatment.