Joseph Rodriguez

The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy.

OBJECTIVES Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort to decrease the rate of infectious complications, we instituted a broader, culture-based preoperative antimicrobial regimen, including fungal coverage, and studied its effect on infectious complications after RC. MATERIALS AND METHODS In May 2013, antimicrobial prophylaxis for RC was changed at our institution after review of previous positive cultures. Ampicillin-sulbactam 3g, gentamicin 4mg/kg, and fluconazole 400mg replaced cefoxitin. Patients undergoing RC from May 2011 to May 2014 were included. Before and after implementation of the new regimen, 30-day infectious complications (positive blood culture, urinary tract infection, wound infection, abscess, and pneumonia) and adverse events (Clostridium difficile, readmission, and mortality) were compared. Multivariate logistic regression was used to identify independent risk factors for infection while controlling for covariates. RESULTS In total, 386 patients were studied (258 before the change and 128 after). The overall infection rate decreased with the new regimen (41% vs. 30%, P = 0.043) with improvements in wound (14% vs. 6%, P = 0.025) and fungal (10% vs. 3%, P = 0.021) infections. Median length of stay decreased from 8 (interquartile range [IQR]: 7-12) to 7 (IQR: 7-10) days (P = 0.008). On multivariate analysis, the new regimen decreased the risk of infections (odds ratio [OR] = 0.58, 95% CI [0.35-0.99], P = 0.044) whereas body mass index, operating room time, smoking, and total parenteral nutrition increased the risk (all P< 0.05). CONCLUSIONS Risk factors for infection after RC include body mass index, operating room time, smoking, and total parenteral nutrition use. Changing from cefoxitin to broader, culture-directed antimicrobial prophylaxis, based on institutional data to include antifungal coverage, decreased postoperative infections.

Thirty-day Morbidity of Abdominal Sacrocolpopexy Is Influenced by Additional Surgical Treatment for Stress Urinary Incontinence

OBJECTIVE To assess the impact of concurrent anti-incontinence procedure (AIP) at time of abdominal sacrocolpopexy (ASC) on 30-day complications, readmission, and reoperation. METHODS The American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2013 was queried to identify patients who underwent ASC with or without AIP. We assessed baseline characteristics and 30-day perioperative outcomes including complications, readmission, and reoperation. RESULTS There were 4793 patients who underwent ASC, of whom 1705 underwent concurrent AIP (35.6%). The majority of patients (4414, 92.1%) were treated by a gynecologist, but those treated by a urologist were older, had higher American Society of Anesthesiologists (ASA) class, and had increased frailty. Rates of 30-day postoperative urinary tract infection (UTI) and overall complication were higher among women who underwent concurrent AIP (4.75% vs 2.33%, P <.001; 7.74% vs 6.02%, P = .02). On multivariate analysis controlling for age, body mass index, approach, ASA physical status, modified frailty index, resident involvement, and surgeon specialty, AIP was associated with increased odds of UTI (odds ratio 2.20, 95% confidence interval 1.14-4.13, P = .02) and increased odds of overall complication (odds ratio 1.80, 95%confidence interval 1.10-2.93, P = .02). Thirty-day readmission and reoperation rates did not differ between the groups. CONCLUSION AIP performed at the time of ASC are associated with higher rates of 30-day postoperative UTI but do not impact 30-day readmission or reoperation. The decision to perform AIP at the time of ASC should be made following a thorough discussion of the risks and benefits, including the potential for increased UTI with concurrent AIP.

MP46-13 EVALUATING THE ROLE OF PERIOPERATIVE ANTIBIOTICS IN PREVENTING ARTIFICIAL URINARY SPHINCTER EXPLANTATION: ANALYSIS OF A LARGE NATIONAL PROSPECTIVE DATABASE

p1⁄40.543 (UTI)], patient satisfaction [p1⁄40.913, 0.863, 0.913, 0.552], pain rates [p1⁄40.389, 0.389, 0.637, 0.160], and IQOL scores [p1⁄40.522]. Regarding the surgical procedure, duration of perioperative antibiotics prophylaxis significantly effected long-term pain rates (p1⁄40.036), patient satisfaction rates (p1⁄40.007), and correlated significantly with reduced IQOL scores (R1⁄4-0.531, p<0.001). Surgical approach, catheter size and indwelling time, and intraoperative complications had no significant effect on the analyzed endpoints. CONCLUSIONS: This is the first study to analyze long-term effects of perioperative complications on favorable outcomes after AUS implantation. We show that perioperative morbidity does not lead to less favorable long-term results and therefore reassure both implanting surgeon and patient. Since duration of antibiotic prophylaxis had a negative effect on AUS outcomes, our results advocate a more restrictive use of perioperative antibiotics.

MP25-15 FACTORS ASSOCIATED WITH INFLATABLE PENILE PROSTHESIS (IPP) EXPLANTATION: EVALUATING THE ROLE FOR POSTOPERATIVE ORAL ANTIBIOTICS ADMINISTRATION

initial implanter (26% vs 11%, p1⁄40.004), and when reoperation was performed by a high volume implanter (p<0.001). On multivariate analysis, salvage was less common when the operation for infection was not performed by the original implanter (OR 0.42, p1⁄40.04) or was performed by a low volume implanter ( 2/year vs >20/year, OR 0.21, p1⁄40.01). CONCLUSIONS: Men treated for infected IPPs with salvage procedures are far more likely to end up with a prosthesis than those treated with explant. Despite these favorable functional outcomes, salvage of infected IPPs is an underutilized strategy. We identified surgeon factors that may partially explain this suboptimal practice pattern. Proactive referral of patients with IPP infections to their original surgeons or to experienced implanters could improve functional outcomes for affected patients.

PD17-02 THE IMPACT OF CONCURRENT PROCEDURES ON PERIOPERATIVE OUTCOMES AMONG WOMEN UNDERGOING ABDOMINAL SACROCOLPOPEXY: MIDURETHRAL SLING PLACEMENT IS ASSOCIATED WITH INCREASED RISK OF COMPLICATION

for total vaginal length at least 7 cm. Secondary outcomes included complication rate, operating time, intra-operative blood loss, hospitalstay length, functional results and satisfaction (PGI-I scores). Statistical analysis : The Mann-Whitney, McNemar, X2 test. RESULTS: 121 consecutive women were included in the RCT (60 AS, 61 LS). In this sub-analysis we compared 3 surgical subgroups: Group 1 (28): 14 AS, 14 LS; Group 2 (45): 24 AS, 21 LS; Group 3 (47): 22 AS, 25 LS. The groups were comparable for demographic and clinical characteristics. Mean follow-up was of 45.4 months. There was a statistical functional and anatomical improvement in all subgroups in both groups. The recurrences (stage I or II) in anterior compartment were significantly more common in the LS group (in particular in group3) (p1⁄40.015), while in posterior compartment was more frequently but not significantly present in the AS group (p1⁄40.736). Intra-operative median blood loss(p<0.001), hospital stay (p<0.0001) and median operating time (group 3 p<0.0001 and group 2 p1⁄40.022) were lower in LS in all the 3 subgroups. There were no significant differences in the grade of complications among surgical subgroups in both groups (AS p1⁄40.845, LS p1⁄40.250). The majority of complications were observed in group 2 (16/24 in AS and 9/21 in LS, p1⁄40.193). There were 3 mesh exposure in LS (2 group 2 and 1 group 1) and 1 in AS (group 2). CONCLUSIONS: LS can be considered an excellent option in patients with severe urogenital prolapse,with functional and anatomical outcomes and patient’s satisfaction as good as AS in all the subgroups. The recurrence rate of anterior compartment is higher in LS especially when uterus is preserved. LS had best intraoperative and peri operative results compared to AS group.

PD66-03 SURVIVAL IN PATIENTS WITH END STAGE RENAL DISEASE AS A RESULT OF KIDNEY CANCER

cohort, 4 patients (3%) experienced disease recurrence. A total of 6 patients (4%) died during follow up and 4 patients (3%) were felt to have died of disease. In chromophobe patients who developed disease recurrence, tumors were predominantly larger (mean 12.3cm) with sarcomatoid differentiation in 50%. CONCLUSIONS: Variant tumors with oncocytic features behave more like oncocytoma than renal cell carcinoma. “Atypical features”, when present, are permissible as long as the gross appearance remains compatible with oncocytoma. These tumors require little to no post-operative surveillance as opposed to chromophobe RCC, where follow up is warranted. Whether surgery can be obviated altogether when these tumors are diagnosed on preoperative renal mass biopsy requires further evaluation.

PD24-06 TRENDS IN MANAGEMENT OF BONE HEALTH IN MEN WITH METASTATIC PROSTATE CANCER: ANALYSIS FROM THE SURVEILLANCE, EPIDEMIOLOGY, AND END RESULTS MEDICARE DATABASE

RESULTS: Overall, 42 and 1 out of 43 patients underwent radical prostatectomy and brachytherapy, respectively. Mean and median PSA value at PET/CT scan were 6.7 and 2.9 ng/ml (IQR 1.2-6.1), respectively. Open and laparoscopic sLNDs were performed in 37/49 (76%) and 12/49 (34%), respectively. Histological report was positive for PCa in 36/49 sLND (73%). Five of 36 patients were lost at follow up. Group A consisted of 4 patients and 2 had sTF. Group B and C consisted of 14 and 13 patients and all had sTF. Mean and median PSA value before sLND in Group A, B, C were 1.4 and 1.3 ng/ml (IQR 0.62.2), 9 and 3.5 ng/ml (IQR 1.6-12.9), 9.4 and and 3.5 ng/ml (IQR 2.316.9), respectively. Median PSA nadir in group B and C was 0.67 ng/ml (IQR 0.36-2.6) and 3.14 ng/ml (IQR 0.7-4.4), respectively (p1⁄40.3). Median time to sTF was 11 months (IQR 8-55 months), 5 months (IQR 1.7-13.2) and 4 months (IQR 2.0-10) for group A, B and C. Mean time to sTF in Group A was significantly superior to mean time in Group B and C together (p1⁄40.01). Only 2 of 43 patients were long-term free of recurrence. Limitations of this study are missing PET controls after sLND and PSA persistence, low patient numbers and the retrospective design. CONCLUSIONS: Only pts with positive histological report with a PSA nadir <0.01 ng/ml after sLND seem to have a long-term benefit. Pts with a PSA nadir >0.01ng/ml have a delay of systemic treatment of up to 5 months. Pts without PSA response do not benefit from sLND.

PD53-03 TOTAL LYMPH NODE YIELD IMPACTS OVERALL SURVIVAL FOLLOWING POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR NON-SEMINOMATOUS TESTICULAR CANCER

INTRODUCTION AND OBJECTIVES: The management of testicular cancer requires a complex multimodal therapeutic approach. Despite the availability of regularly updated national and international guidelines on testicular cancer, treatment still differs between the institutions probably affecting the patients’ outcome. Our study aims to investigate frequently occurring errors regarding the diagnosis and therapy of testicular cancer in consideration of the current EAU guidelines. METHODS: We performed a retrospective analysis including 129 patients diagnosed with testicular cancer that were referred to our department between 09/2015 and 10/2016. Patients’ age, histology, clinical stage, IGCCCG risk classification, treatment (surveillance, chemotherapy, radiotherapy, surgery) and follow-up were investigated and compared to the EAU guidelines’ recommendations. RESULTS: Of the eligible 129 patients, 34 (26%) patients displayed a non-guideline concordant care. The most common error was undertreatment (47%), mostly due to missing chemotherapy cycles. Modified treatment and overtreatment occurred in 20% and 16% respectively, while inappropriate treatment (9%) and misdiagnosis (6%) were rarely seen (Table 1). In secondary treated patients, non-guideline concordant therapy was observed more frequently compared to those patients receiving primary therapy (59% vs. 41 %). Almost all patients (93%) receiving a non-guideline concordant therapy suffered a relapse in contrast to 67% of patients that were treated according to the EAU guidelines. CONCLUSIONS: Non-adherence to the current EAU guidelines on testicular cancer appears to be a major problem in various testicular cancer treating institutions. In our study, the most frequent error was undertreatment, followed by modified treatment and overtreatment. Inappropriate therapy leads to a higher relapse rate and morbidity associated with a worse curative outcome.

MP10-02 TEMPORAL TRENDS IN PERIOPERATIVE MORBIDITY FOR RADICAL CYSTECTOMY

INTRODUCTION AND OBJECTIVES: Bladder cancer (BC) continues toexact highmorbidity andmortality in patientswhohaveahistory of tobacco use. Less is knownabout non-tobacco related factors associated with BC-related death which may be targeted to lower the incidence or course of the disease. The mortality-to-incidence ratio (MIR) is a novel measure that has utility as a valid indicator of fatality and burden of disease. Wehypothesized that a pooled county-level, population-based dataset from theUnitedStates, could demonstrate smokingandnon-smoking related risk factors that may be modifiable targets in a prevention strategy. METHODS: SurveillanceEpidemiologyandEndResults (SEER) population-based cancer registry data; state-specific Behavioral Risk Factor Surveillance Study (BRFSS) results; health care manpower, psychosocial, and socio-economic data from the 2014-2015 Area Health Resources File (AHRF) were pooled to establish independent variables associatedwith theMIR of BC by county. Cancer data was suppressed to ensure confidentiality and stability of rate estimates. Independent multivariate stepwise regression models were built for either sex. RESULTS: A total of 3140 counties in theU.S. were included in the dataset, of which 666 and 265 counties had complete data for males and females, respectively.Themean (+/sd)MIRofBCwas0.22 (0.05) and0.26 (0.07) formalesand females, respectively (range: 0.11 0.77). Tobaccowas strongly associated with the MIR of bladder cancer in all counties. On multivariateanalysis, significantnon-tobacco-related factors that predicteda greater MIR of BC in males were: poverty, lack of insurance, low urologist density; in females: poverty, obesity and low urologist density. CONCLUSIONS: There is an independent association with death from bladder cancer due to inadequate access to healthcare, including urologists, and risk factors such as obesity and poverty, especially in women. Our study demonstrates that bladder cancer continues to afflict the poor, especially those who smoke and who have little access to health care (Figure 1). Prevention strategies may be more effective if anti-smoking campaigns target medically (and urologically) underserved, rural, and obese populations. The MIR is a novel indicator of the effectiveness of the health system.

MP21-03 DEFINITIVE TREATMENT OF BLADDER CANCER IN OCTOGENARIANS: BALANCING INCREASED PERIOPERATIVE MORTALITY WITH SUPERIOR OVERALL SURVIVAL

INTRODUCTION AND OBJECTIVES: Around one third of bladder cancers (BCs) are high-grade non-muscle invasive tumors (HGNMI). Current guidelines advocate early re-resection for these cancers, although the benefits are unclear and the uniform need has been questioned. Here we compare the outcomes in patients with and without re-resection using a large single-centre cohort. METHODS: We identified all patients with new HGNMI BC treated between 1994-2009 in Sheffield. We annotated these with hospital, pharmacy and cancer registry records. Primary outcomes were disease specific and overall survival. Secondary outcomes were the findings at re-resection, rates of muscle invasion and radical treatment. Statistical tests were two-tailed and significance defined as p<0.05. RESULTS: We identified 932 eligible patients, including 229 (25%) who underwent re-resection within 12 weeks and 234 (25%) 3-6 months after diagnosis. Patients with and without re-resection were broadly similar for clinicopathological criteria. Re-resection was normal in 91 (20%) and contained BC in 138 (30%) patients. Of these, 15(10.8%) cancers were low grade, 85(61.6%) high-grade NMI and 38 muscle invasive (28%). During follow up, patients with re-resection were more frequently diagnosed with muscle invasion (126 (27%) vs. 49 (11%), Chi sq. p<0.001) and more commonly underwent radical treatment (127 (27%) vs. 35 (8%), p<0.001) than those without re-resection. In total, 528 (57%) patients died during follow up. Patients with reresection had a significantly higher disease-specific (179 (78%) vs. 518 (76%), log rank p1⁄40.05) and overall survival (119 (53%) vs. 251 (37%), log rank p<0.001) than those without re-resection. CONCLUSIONS: We found that patients undergoing early reresection were more likely to be diagnosed with muscle invasion, more likely to undergo radical treatment and had a higher disease-specific and overall survival. The differences were greatest in patients with lamina propria invasion at diagnosis. Limitations of our work include retrospective design and potential selection bias.