Monty Aghazadeh

Effect of Preoperative Nutritional Deficiency on Mortality After Radical Cystectomy for Bladder Cancer

PURPOSE Poor preoperative nutritional status is a risk factor for adverse outcomes after major surgery. We evaluated the effect of preoperative nutritional deficiency on perioperative mortality and overall survival in patients undergoing radical cystectomy for bladder cancer. MATERIALS AND METHODS A total of 538 patients underwent radical cystectomy for urothelial carcinoma between January 2000 and June 2008, and had nutritional parameters documented. Patients with preoperative albumin less than 3.5 gm/dl, body mass index less than 18.5 kg/m(2) or preoperative weight loss greater than 5% of body weight were considered to have nutritional deficiency. Primary outcomes were 90-day mortality and overall survival. Survival was estimated using Kaplan-Meier analysis and compared using the log rank test. Cox proportional hazards models were used for multivariate survival analysis. RESULTS Of 538 patients 103 (19%) met the criteria for nutritional deficiency. The 90-day mortality rate was 7.3% overall (39 deaths), with 16.5% in patients with nutritional deficiency and 5.1% in the others (p < 0.01). Nutritional deficiency was a strong predictor of death within 90 days on multivariate analysis (HR 2.91; 95% CI 1.36, 6.23; p < 0.01). Overall survival at 3 years was 44.5% (33.5, 54.9) for nutritionally deficient patients and 67.6% (62.4, 72.2) for those who were nutritionally normal (p < 0.01). On multivariate analysis nutritional deficiency cases had a significantly higher risk of all cause mortality (HR 1.82; 95% CI 1.25, 2.65; p < 0.01). CONCLUSIONS Nutritional deficiency, as measured by preoperative weight loss, body mass index and serum albumin, is a strong predictor of 90-day mortality and poor overall survival. Prospective studies are needed to demonstrate the best indices of preoperative nutritional status and whether nutritional intervention can alter the poor prognosis for patients treated with radical cystectomy who have nutritional deficiencies.

Determining factors for hospital discharge status after radical cystectomy in a large contemporary cohort

PURPOSE We describe hospital discharge status in patients after radical cystectomy for bladder cancer. We determined factors affecting discharge status. MATERIALS AND METHODS The 445 patients underwent radical cystectomy for urothelial carcinoma from January 2004 to December 2007. Patients were grouped by hospital discharge status into 1 of 4 groups, including home under self-care without services, home with home health services, subacute, rehabilitation or skilled nursing facility, or hospice/in-hospital mortality. We compared clinical, perioperative and pathological variables in these groups. We also examined the association of discharge status with the hospital readmission rate and 90-day mortality. RESULTS Of the 440 patients 250 (56.8%), 145 (32.9%), 39 (8.9%) and 6 (1.4%) were in the home without services, home with services, facility and mortality groups, respectively. On multivariate analysis older age, lower preoperative albumin, unmarried status and higher Charlson comorbidity index were predictors of discharge home with services while older age, poor preoperative exercise tolerance and longer hospital stay predicted discharge to a facility. Patients in the facility group were more likely to die within 90 days of surgery than those who returned home independently or with services. There was no difference in the likelihood of rehospitalization. CONCLUSIONS Sociodemographic factors, preoperative performance status, and comorbidities and perioperative factors contribute to the discharge decision after radical cystectomy. Some subgroups can be predicted to have increased postoperative care needs and may be appropriate targets for disposition planning preoperatively.

Validation of a Simulation-training Model for Robotic Intracorporeal Bowel Anastomosis Using a Step-by-step Technique

OBJECTIVE To develop and validate a training model for the robotic intracorporeal bowel anastomosis. METHODS For simulation, surgeons with varying levels of experience were instructed about bowel anastomosis robotic surgical simulation in a short educational video. All participants performed the required steps for the intracorporeal bowel anastomosis under standardized conditions. The procedure consists of the following steps: division of the bowel with a stapler (1), incision and opening of the bowel limbs at the antimesenteric angle (2), insertion of the stapler into the 2 bowel limbs for the side-to-side anastomosis (3), and transverse closure of the anastomosis with the stapler (4). All simulations were performed using the daVinci SI robotic system. Face and content validity were assessed using a standardized questionnaire. Construct validity was evaluated using the Global Evaluative Assessment of Robotic Skills, a validated global performance rating scale. RESULTS Twenty-two surgeons participated including 6 robotic experts and 16 trainees. The expert participants rated the bowel anastomosis model highly for face validity (median 4/5; 64% agree or strongly agree), and all participants rated the content as a training model very highly (median 4.5/5; 100% agree or strongly agree). Discrimination between experts and trainees using Global Evaluative Assessment of Robotic Skills demonstrated construct validity (novice 17.6 vs expert 24.7, P = .03). CONCLUSION We demonstrate that the bowel anastomosis robotic surgical simulator is a reproducible and realistic simulation that allows for an objective skills assessment. We establish face, content, and construct validity for this model. This step-by-step technique may be utilized in training surgeons desiring to acquire skills in robotic intracorporeal urinary diversion.

PD55-10 ONCOLOGIC OUTCOMES AFTER RADICAL PROSTATECTOMY IN FAVORABLE INTERMEDIATE RISK GROUP ACTIVE SURVEILLANCE CANDIDATES

INTRODUCTION AND OBJECTIVES: Active surveillance (AS) of localized prostate cancer (PCa) in the UK involved protocol-driven (P) transrectal repeat biopsies (RB) plus serial digital rectal examination & PSA-testing, until NICE 2014 guidelines recommended multi-parametric magnetic resonance imaging (mpMRI) should drive RB where needed or replace P-RB. Interrogating our AS follow-up (F/U) data, we hypothesized that mpMRI reduces the number of RB required to drive therapeutic intervention (TI). METHODS: 445/461 (97%) AS patients had complete F/U data. Cohort features at diagnosis include median age 68.9 years (interquartile range IQR 63.7-74.8), median PSA 7.2ng/mL (IQR 5.6-9.6), median PSAD 0.11 (IQR 0.08-0.18), cT1c in 80%, 54% unilateral Gleason 3+3, 23% unilateral 3+4, 2% unilateral 4+3, 18% bilateral 3+3, and median Charlson Comorbidity score 3.1 (IQR 2.5-4.2). We examined the drivers for TI and compared the utility of mpMRI prior to potential RB in AS. RESULTS: 132/445 (30%) patients underwent TI (59% external beam radiotherapy/brachytherapy, 22% radical surgery, 19% other) over a medianAS (inter-quartile range IQR) F/U of 2.4 (1.2-3.73) years (maximum F/U 11.3 years). Median (IQR) time to TI was 1.55 (0.71-2.4) years. Reasons for TI included rising PSA, patient choice, mpMRI abnormality alone and/or RB Gleason upgrading. Where TI was driven by RB, 43/71 (61%) had undergone mpMRI, and 39% had P-RB without mpMRI. 49/97 (51%) demonstrated upgrading on RB following mpMRI versus 38/115 (33%) for P-RB without mpMRI. Time to TI was similar for those undergoing RB following mpMRI versus P-RB without mpMRI (P1⁄40.877). Of those upgraded at RB, the number of RB procedures needed to upgrade one patient was 1.9 if prior mpMRI was used versus 3.3 for P-RB alone. CONCLUSIONS: In this UK cancer centre AS cohort, replacement of P-RB with mpMRI RB where indicated, benefitted patients by reducing the number of invasive interventions needed to identify disease progression (characterized by Gleason upgrade), leading to treatment intervention.