Melanie Adamsky

National Surgical Quality Improvement Program surgical risk calculator poorly predicts complications in patients undergoing radical cystectomy with urinary diversion

PURPOSE To evaluate the accuracy of the American College of Surgeons National Surgical Quality Improvement Programs (ACS-NSQIP) surgical risk calculator in patients undergoing radical cystectomy (RC) with urinary diversion. MATERIALS AND METHODS Preoperative characteristics of patients who underwent RC with ileal conduit or orthotropic neobladder (ONB) between 2007 and 2016 were entered into the proprietary online ACS-NSQIP calculator to generate 30-day predicted risk profiles. Predicted and observed outcomes were compared by measuring Brier score (BS) and area under the receiver operating characteristic curve (AUC). RESULTS Of 954 patients undergoing RC, 609 (64%) received ileal conduit and 345 (36%) received ONB. The calculator underestimated most risks by 10%-81%. The BSs exceeded the acceptable threshold of 0.01 and AUC were less than 0.8 for all outcomes in the overall cohort. The mean (standard deviation) predicted vs. observed length of stay was 9 (1.5) vs. 10.6 (7.4) days (Pearsons r = 0.09). Among patients who received ONB, adequate BS (<0.01) was observed for pneumonia, cardiac complications, and death. The receiver operating characteristic curve analysis revealed moderate accuracy of calculator for cardiac complications (AUC = 0.69) and discharge to rehab center (AUC = 0.75) among patients who underwent RC with ONB. CONCLUSIONS The universal ACS-NSQIP calculator poorly predicts most postoperative complications among patients undergoing RC with urinary diversion. A procedure-specific risk calculator is required to better counsel patients in the preoperative setting and generate realistic quality measures.

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.

Evaluating the Role of Postoperative Oral Antibiotic Administration in Artificial Urinary Sphincter and Inflatable Penile Prosthesis Explantation: A Nationwide Analysis

OBJECTIVE To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown. MATERIALS AND METHODS We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates. RESULTS We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation. CONCLUSION Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.

MP19-18 VARIABILITY IN RENAL PAPILLARY PITTING SCORES EXCEEDS THAT OF RANDALL′S PLAQUE: EVIDENCE FOR THE PATHOGENESIS OF CALCIUM STONE FORMATION

using a retrograde pyelogram to confirm the location of each papilla. A single investigator (NLM) reviewed the video to quantify RP and other papillary abnormalities such as pitting and Bellini duct plugs. Each papilla was graded as having mild (<10%), moderate (10-50%), or severe (>50%) amount of RP. Patient history was recorded. RESULTS: An average of 9 papillae were mapped per patient. RP was present in 100% of patients and in 88.8% (64/72) of all papillae examined. When present, RP was uniformly distributed throughout the kidney without preferential distribution to a region or pole. The amount of RP on the papillae was graded as mild in 60%, moderate in 20.8%, and severe in 8.3% (Table 1). Other papillary abnormalities were rare in pediatric SF with Bellini duct plugging in 9.7% and pitting in 15.2% papillae. No correlation was found between the amount of plaque and age at first stone or number of prior stones (p1⁄4 0.84). Attached stones were rare (1/8 patients). The two patients with severe RP had a small amount of calcium phosphate in their stone analysis. CONCLUSIONS: RP is common in pediatric CaOx SF, while pitting and Bellini duct plugging are not. Compared to adult CaOx SF where up to 75% of stones are found attached to RP, attached stones were rare. The significance of these findings in pediatric stone pathogenesis remains uncertain in this early report, however ongoing research to include correlation with 24 hr urine data and stone recurrence is currently underway.

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.

MP20-11 ACCURACY OF MULTI-PARAMETRIC MAGNETIC RESONANCE IMAGING FOR DETECTION OF PROSTATE CANCER EXTRACAPSULAR EXTENSION AND RELATION TO ITS HISTOLOGIC EXTENT

for overall detection rate of PCa and histological analysis of each Likert group (5,4,3), TB, SB and RARP samples according to Gleason score. Results determined diagnostic accuracy of biopsy samples in comparison to definitive histological diagnosis. RESULTS: 67/79 (84.1%) patients had TB positive for PCa, with a second lesion positive in 17/79 cases. Gleason score of TB and SB was equivalent in 29 (36.7%). Gleason score was higher in TB and SB in 15 (19%) and 35 (44%) cases, respectively. TB was benign in 14 patients. Gleason score at biopsy and RARP were equivalent in 49 (52.7%) cases but higher in RARP and biopsy in 10 and 34 cases, respectively. TB was PCa positive in 38/41 (92.7%) Likert 5 lesions. 2/3 remaining patients had PCa positive SB in an identical region to TB. 21/ 27 (77.8%) Likert 4 lesions had TB positive PCa, 3/6 remaining cases had PCa positive SB in an identical region to TB. TB was positive in 9/ 11 (81.8%) of Likert 3 lesions with SB negative in the remaining 2 patients. The correlation between mpMRI-TPFB-RARP was positive for 97.6% Likert 5, 88.9% Likert 4 and 85.7% Likert 3 lesions. mpMRI identified a suspicious lesion confirmed on RARP in 74 patients (93.7%). 2/5 patients with a negative correlation had a second MRI lesion that corresponded to RARP. CONCLUSIONS: The results of our analysis demonstrate the accuracy of mpMRI and the reliability of TB taken during TPFB in confirming PCa when compared to SB and definitive histological diagnosis.

PD57-09 NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM SURGICAL RISK CALCULATOR POORLY PREDICTS COMPLICATIONS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY WITH URINARY DIVERSION: THE CASE FOR A PROCEDURE-SPECIFIC RISK CALCULATOR

and diagnosis of bladder cancer controlling for age, smoking history and race. RESULTS: We identified 42,774 patients with BPH. The median follow-up was 87 months. There were 11,864 (27.7%) African Americans (AA), 11,863 (27.7%) Caucasians, and 6,340 (14.8%) Hispanics in this population. 5,698 (13.3%) patients were prescribed Finasteride. Bladder cancer was diagnosed in 84 of 5,698 (1.5%) patients who were prescribed Finasteride compared with 863 of 37,076 (2.3%), who were not prescribed Finasteride (p<0.001). Multivariate logistic regression analysis showed that Finasteride use was protective of bladder cancer (OR: 0.57, CI: 0.45-0.71, p<0.001). When we stratified the data based on race, Finasteride use was protective of bladder cancer in Caucasians (2.1% vs. 3.8%, p1⁄40.001) and Hispanics (0.8% vs. 1.6%, p1⁄40.042), but not in AA (1.7% vs. 1.7%, p1⁄40.854). CONCLUSIONS: Our study confirms previous findings from the PLCO study that men who are on Finasteride have lower incidence of bladder cancer but only in Caucasians and Hispanics. Future research and randomized controlled studies may be needed to confirm these findings.

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.