Padraic O'Malley

Changes in Renal Function Following Nephroureterectomy May Affect the Use of Perioperative Chemotherapy

BACKGROUND Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function. OBJECTIVE Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function. DESIGN, SETTINGS, AND PARTICIPANTS We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included. INTERVENTION All patients underwent nephroureterectomy. MEASUREMENTS All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2-52 wk). Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease study equation. eGFR values before and after surgery were compared using the paired t test. We chose an eGFR of 45 and 60 ml/min per 1.73 m(2) as possible cut-offs for chemotherapy eligibility and compared eligibility before and after surgery using the chi-square test. RESULTS AND LIMITATIONS Our cohort of 388 patients included 233 men (60%) with a median age of 70 yr. Mean eGFR decreased by 24% after surgery. Using a cut-off of 60 ml/min per 1.73 m(2), 49% of patients were eligible for chemotherapy before surgery, but only 19% of patients remained eligible postoperatively. Using a cut-off of 45 ml/min per 1.73 m(2), 80% of patients were eligible preoperatively, but only 55% remained eligible after surgery. This distribution persisted when we limited the analysis to patients with advanced pathologic stage (T3 or higher). Patients older than the median age of 70 yr were more likely to be ineligible for chemotherapy both pre- and postoperatively by either definition, and they were significantly more likely to have an eGFR <45 ml/min per 1.73 m(2) postoperatively, regardless of their starting eGFR. This study is limited by its retrospective nature, and there was some variability in the timing of postoperative serum creatinine measurements. CONCLUSIONS eGFR is significantly diminished after nephroureterectomy, particularly in elderly patients. These changes in renal function likely affect eligibility for adjuvant cisplatin-based therapy. Accordingly, we suggest strong consideration of neoadjuvant regimens.

Re: Changes in Renal Function Following Nephroureterectomy may Affect the Use of Perioperative Chemotherapy

Background—Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function. Objective—Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function. Design, settings, and participants—We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included. Intervention—All patients underwent nephroureterectomy. Measurements—All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2[en]52 wk).

MP54-06 IMPACT OF SURGICAL VOLUME ON SURVIVAL FOLLOWING RARC IN A LARGE, NATIONAL COHORT

physical capacity (86%), followed by improvement of incontinence (81%) and reduction of mental distress (31%). During FT 25.9% of patients had a urinary tract infection requiring antibiotics and 8.6% had a symptomatic metabolic acidosis. Only 18.1% were under antithrombotic medication at the beginning of FT. Antibiotic use decreased from 19.8% to 17.3%. Incontinence pad use increased from 2.14 to 2.55 pads per day on average. At the end of FT, patients indicated improvement of incontinence, physical capacity and mental distress in 60.5%, 74.1% and 30.86%. CONCLUSIONS: Compared to the preand perioperative management of BC, there is a scarcity of studies investigating FT of BC. A multitude of significantly different FT models have been implemented in different countries. Both from the economic as well as medical point of view high-quality FT must be strived for. Our study gives insights into the current state of FT in Germany and shows both benefits as well as unsolved challenges.

MP54-20 DO MEN WITH A HISTORY OF PROSTATE CANCER HAVE WORSE BLADDER CANCER OUTCOMES?

cancer is a controversial issue with contradictory findings concerning ureteral FS and very few data concerning urethral FS. Moreover, previous reports aimed to assess the impact of positive FS on oncological outcomes but none have compared the impact of FS vs. no FS on oncological ouctomes. The objective of this study was to evaluate the impact of urethral and ureteral FS use on oncological outcomes after radical cystectomy for bladder cancer. METHODS: All patients who underwent a radical cystectomy for bladder cancer between 1995 and 2015 were included in a singlecenter retrospective study. The use of ureteral and urethral FS varied according to surgeons preference (routine for some, never for others) but not according to the tumors’ characteristics. Patients were divided into different groups according to the use of ureteral and/or urethral FS (FS vs. no FS). Preoperative data and the rate of positive margins were compared between groups. The prognostic factors for cancer-specific survival (CSS) and recurrence-free survival (RFS) were sought in univariate analysis using the log-rank test and in multivariate analysis using a cox regression model. RESULTS: Out of 329 patients included in this study, ureteral FS were performed in 132 (40%) and urethral FS in 183 (56%) respectivley respectively. Thirteen urethral FS were positive (7.1%) resulting in 10 additional urethrectomy. Fourteen ureteral FS (10.6%) were invaded resulting in 8 additional ureteral resections and 1 nephroureterectomy. The use of urethral FS was associated with a decrease in positive margins rate (6% vs. 23%; RR 1⁄4 0.27; p <0.0001). Conversely, the use of ureteral FS had no impact on the rate of positive margins (12% vs.14%; RR 1⁄4 0.85; p 1⁄4 0.58). The use of ureteral FS had no impact on survival whereas the routine use of urethral FS was a prognostic factor for RFS and CSS in univariate (5-years RFS: 51.5% vs. 32%; p <0.0001 and 5-year CSS: 65.1% vs. 50.5%) and multivariate analysis (HR 1⁄4 1.7; p1⁄4 0.003 and HR1⁄41.4; p1⁄40.04 respectively). CONCLUSIONS: This study is the first to asses the impact of urethral and ureteral FS use on oncological outcomes after radical cystectomy. The routine use of urethral FS was associated with adecreased rate of positive surgical margins and improved recurrence-free survival and cancer-specific survival. Conversely, the use of ureteral frozen section had no impact on oncological outcomes.

PD20-09 SURGICAL APPROACH DOES NOT IMPACT POSITIVE MARGIN RATE IN PARTIAL NEPHRECTOMY FOR LARGE RENAL MASSES

INTRODUCTION AND OBJECTIVES: Utilization of partial nephrectomy (PNx) has expanded to include treatment of an increasing number of renal masses 4cm by various surgical approaches. Recent evidence has suggested risk of recurrence with positive surgical margin (PSM) is increased in the presence of high-risk features, including stage T2. While surgical approach has been associated with PSM in PNx for small renal masses (<4 cm), its impact on margin status for large renal masses is unclear. METHODS: Using the National Cancer Data Base (NCDB), we identified patients undergoing PNx for clinical T1b and T2a renal cell carcinoma (RCC) from 2011 to 2013. Primary outcome was surgical margin status. Multivariable regression modeling was performed to identify patient, facility, and surgical factors, including surgical approach (open, laparoscopic, or robotic) on PSM in patients undergoing PNx. RESULTS: Of 7495 undergoing PNx for cT1b and T2a renal masses from 2011 to 2013, 504 (6.72%) had PSM. On multivariable analysis, age > 60 years (OR 1.57 [95% CI 1.01-2.44] p1⁄40.048), African American race (OR1.52 [95%CI 1.06-2.17] p1⁄40.023), education level (OR 1.48 [95% CI 1.03-2.14] p1⁄40.034), rural setting (OR 4.82 [95% CI 2.459.46] p<0.01), mixed histology (OR 1.84 [95% CI 1.04-3.24] p1⁄40.035), undifferentiated tumor grade (OR2.42 [95%CI 1.26-4.65] p<0.01), aswell as having surgery performed at a non-academic facility (OR 1.57 [95% CI 1.15-2.15] p<0.01) were associated with PSM. Surgical approach (laparoscopic and robotic vs. open) (p1⁄40.119 and p1⁄40.437, respectively) and stage (T2a vs. T1b) (p1⁄40.182) were not associated with PSM. CONCLUSIONS: Surgical approach is not independently associated with increased risk of PSM for large renal masses, which is contrary to previous reports pertaining to cT1a lesions. Surgery at an academic facility was protective against having a positive margin. These data are important given the unclear oncologic significance of margin status in these tumors.

MP96-16 ASSOCIATION OF TRAVEL DISTANCE, SOCIOECONOMIC STATUS, AND REFERRAL INSTITUTION ON DELAY TO DEFINITIVE SURGERY IN PATIENTS WITH BLADDER CANCER

INTRODUCTION AND OBJECTIVES: Hospital acquired conditions are a significant source of patient morbidity and mortality and have been targeted by recent legislation as achievable target for quality improvement. Here, we aim to define the rates of 3 most of the most common hospital acquired conditions (HACs); surgical site infection (SSI) , urinary tract infection (UTI) , and venous thromboembolism (VTE) in patients who undergo major urologic surgery over a period of time encompassing the implementation of the Hospital Acquired Condition Reduction program. METHODS: Using American College of Surgeons National Surgical Quality Improvement Program data, we determined rates of HACs in patients undergoing major inpatient urologic surgery from 2005 to 2012. Rates were stratified by procedure type and approach (open vs. laparoscopic/robotic). Multivariable logistic regression was used to determine the association between [insert independent variable of interest] and HACs. RESULTS: We identified 39,257 patients undergoing major urologic surgery, of whom 2300 (5.8%) had at least one hospital acquired condition. UTI (2.58%) was the most common, followed by SSI (2.46%) and VTE (0.68%). Multivariable logistic regression analysis demonstrated that open surgical approach, diabetes, obesity, hypertension, congestive heart failure, BMI>30, and length of stay were associated with higher likelihood of HAC. When controlling for surgical approach, patients undergoing prostatectomy had the lowest predicted probability of HAC (PP 0.04, p<0.05) compared to patients undergoing upper tract surgery (PP 0.06) or cystectomy and retroperitoneal lymph node dissection (PP 0.02) We observed a non-significant secular trend of decreasing rates of HAC from 7.4% to 5.8% HAC’s during the study period, which encompassed the implementation of the CMS Hospital Acquired Condition Reduction Program. CONCLUSIONS: HACs occurred at a rate of 5.8% during major urologic surgery, and are significantly affected by procedure type and patient health status. The rate of HAC appeared unaffected by national reduction program in this cohort. Better understanding of the nonmodifiable factors associated with HACs is critical in developing effective reduction programs.

PD10-09 HEALTH CARE DISPARITIES AND POST DISCHARGE COMPLICATIONS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY

were stratified into groups based on their distance from UNMH. Fisher tests and odds ratios were used to compare groups. RESULTS: One hundred fifty seven were compliant with follow up while 68 were not. Patients were more likely to be compliant who lived within 40 miles (OR: 4.45, CI: 2.03 e 9.61, P 1⁄4 0.0002), 30 miles (OR: 3.83, CI: 2.05 e 7.16, P < 0.0001), and 20 miles (OR: 3.83 CI: 2.09 e 7.02, P < 0.0001) of our institution. In contrast, those living within 15 miles of UNMH were not statistically different than all other patients living farther away (OR: 0.66, CI: 0.37-1.19, P1⁄40.17). CONCLUSIONS: Urolithiasis is a common problem in the southwest United States, and the need for comprehensive follow up care is crucial for treatment. To our knowledge, this is the first study of its kind to show how distance from point of care relates to compliance in stone disease. Patients living greater than 20 miles from our center demonstrated significantly decreased compliance. Stone disease is distressing to patients and economically costly, and our study highlights the need for further research in strategies to improve compliance.

MP21-12 PCA3 AND T2:ERG ADD FURTHER PREDICTIVE AND CLINICAL BENEFIT TO THE DETECTION OF PROSTATE CANCER IN MEN OF VARIOUS AGES IN THE EARLY DETECTION RESEARCH NETWORK (EDRN)

underwent PSA screening decreased from 52.2% to 46.9% (p1⁄40.01). Survey year 2013 vs. 2010 was associated with decreased odds of screening (OR 0.74, 95% CI 0.66-0.83); the interaction term for age and survey year was not significant. Men with higher self reported health status were no more likely to undergo screening than their less healthy counterparts. CONCLUSIONS: Our results suggest a nationwide impact of the 2012 USPSTF statement on discouraging PSA screening despite their physician’s recommendation for screening, although this was restricted to men aged 50-64. Widespread media coverage and greater awareness of the implications of PSA screening may underlie this phenomenon.

1680 ENDOSCOPIC-GUIDED PERCUTANEOUS NEPHROLITHOTOMY: A TECHNIQUE TO REDUCE RADIATION DOSAGE

tients (10 male). Eleven cases (11/19, 58%) were right sided. Mean BMI was 28.7 (SD 6). PCNL fluoro time for UARN was mean 2 min 1 s (n 16, SD 63.2 s) and mean* PCNL fluoro time in literature for antegrade access by urologist was 7 min 16s (SD** 9 min 24 s) (n 821 cases in 8 papers, p 001). Fluoro time for IR obtained antegrade nephrostomy for stone surgery at DMC was 16 min 42s (SD 19 min 45 s; n 12: 6 with hydro, 2 with stone in calyx, 4 with no hydro). UARN nephrostomy creation fluoro time for cases #3 and #9 was mean 3 min 36 s. Our UARN technique was developed during cases #1-9 (Figure 1) for which separate fluoro time for nephrostomy creation was not recorded. In cases #3 and #9, the access tracts were not dilated due to concern re: adjacent organs, after which pre-op CT scan review was initiated. After the UARN procedure was defined (after case #9), fluoro time for nephrostomy creation was mean 29.6 s (n 7, SD 29.8 s). UARN case data: Average stone size 11.4 cm2 (SD 9), mean 1.5 stones. Twelve cases (12/17, 71%) had no or min. hydronephrosis. Nephrostomy exit: 4 (24%) upper pole, 9 (53%) mid-pole, 4 (24%) lower pole. In 15 cases the nephrostomy exited a stone-bearing calyx; laser was employed to access calyx in 6 cases. Total PCNL time was mean 170 minutes (n 16). All cases were successful with no nephrostomyrelated complications. * Weighted average of the reported means ** Square root of the weighted sum of the literature variances CONCLUSIONS: Ureteroscopy-assisted retrograde nephrostomy offers a significant reduction in radiation exposure in the setting of PCNL compared to antegrade nephrostomy access obtained by urologist or interventional radiologist.