Philip J. Cheng

Clinical Use of Expanded Prostate Cancer Index Composite for Clinical Practice to Assess Patient Reported Prostate Cancer Quality of Life Following Robot-Assisted Radical Prostatectomy

Purpose: EPIC‐CP (Expanded Prostate Cancer Index Composite for Clinical Practice) is a short questionnaire that comprehensively measures patient reported health related quality of life at the point of care. We evaluated the feasibility of using EPIC‐CP in the routine clinical care of patients with prostate cancer without research infrastructure. We compared longitudinal patient and practitioner reported prostate cancer outcomes. Materials and Methods: We reviewed health related quality of life outcomes in 482 patients who underwent radical prostatectomy at our institution from 2010 to 2014. EPIC‐CP was administered and interpreted in routine clinical practice without research personnel. We compared practitioner documented rates of incontinence pad use and functional erections to patient reported rates using EPIC‐CP. Results: A total of 708 EPIC‐CP questionnaires were completed. Mean urinary incontinence domain scores were significantly higher (worse) than baseline (mean ± SD 0.6 ± 0.2) 3 and 6 months after treatment (mean 3.1 ± 2.3 and 2.2 ± 2.1, respectively, each p <0.05) but they returned to baseline at 12 months (mean 1.6 ± 1.7, p >0.05). Mean sexual domain scores were significantly worse than baseline (mean 2.4 ± 2.8) at all posttreatment time points (each p <0.05). Practitioners significantly overestimated incontinence pad‐free rates at 3 months (48% vs 39%) and functional erection rates at 3 months (18% vs 12%), 6 months (38% vs 23%) and 12 months (45% vs 23%, each p <0.05). Conclusions: EPIC‐CP is feasible to use in the routine clinical care of patients with prostate cancer without requiring a research infrastructure. Using EPIC‐CP in clinical practice may help practitioners objectively assess and appropriately manage posttreatment side effects in patients with prostate cancer.

The Effect of Resident Involvement on Surgical Outcomes for Common Urologic Procedures: A Case Study of Uni- and Bilateral Hydrocele Repair.

OBJECTIVE Previous studies have investigated the effect of resident involvement (RI) on surgical complications in minimally invasive and complex surgical cases. This study evaluates the effect of surgical education on outcomes in a simple general urologic procedure, unilateral and bilateral hydrocele repair, in a large prospectively collected multi-institutional database. METHODS Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User files (2005-2013), we extracted patients who underwent unilateral or bilateral hydrocele repair using Current Procedural Terminology codes 55040, 55041, and 55060. Cases with missing information on RI were excluded. Descriptive and logistic regression analyses were performed to assess the impact of RI on perioperative outcomes. A prolonged operative time (pOT) was defined as operative time >75th percentile. RESULTS Overall, 1378 cases were available for final analyses. The overall complication, readmission, and reoperation rates were 2.3% (32/1378), 0.5% (7/1378), and 1.4% (19/1378), respectively. A pOT was more frequently observed in bilateral procedures (35.2% vs 21.3%, P < .0001) and with RI (33.8% vs 19.0%, P < .0001). Procedures with RI had a 2.2-fold higher odds of pOT (95% confidence interval 1.7-2.8, P < .0001). Overall complications (odds ratio 1.1, 95% confidence interval 0.5-2.3) were not associated with RI (P = .789). In sensitivity analyses, all postgraduate years of training were associated with a pOT (P < .0001). CONCLUSION Although the involvement of a resident in hydrocele repairs leads to higher odds of pOT, it does not affect patient safety, as evidenced by similar complication rates.

Clinical Use of EPIC for Clinical Practice (EPIC-CP) to Assess Patient-Reported Prostate Cancer Quality-of-Life Following Robot-Assisted Radical Prostatectomy.

Purpose: EPIC‐CP (Expanded Prostate Cancer Index Composite for Clinical Practice) is a short questionnaire that comprehensively measures patient reported health related quality of life at the point of care. We evaluated the feasibility of using EPIC‐CP in the routine clinical care of patients with prostate cancer without research infrastructure. We compared longitudinal patient and practitioner reported prostate cancer outcomes. Materials and Methods: We reviewed health related quality of life outcomes in 482 patients who underwent radical prostatectomy at our institution from 2010 to 2014. EPIC‐CP was administered and interpreted in routine clinical practice without research personnel. We compared practitioner documented rates of incontinence pad use and functional erections to patient reported rates using EPIC‐CP. Results: A total of 708 EPIC‐CP questionnaires were completed. Mean urinary incontinence domain scores were significantly higher (worse) than baseline (mean ± SD 0.6 ± 0.2) 3 and 6 months after treatment (mean 3.1 ± 2.3 and 2.2 ± 2.1, respectively, each p <0.05) but they returned to baseline at 12 months (mean 1.6 ± 1.7, p >0.05). Mean sexual domain scores were significantly worse than baseline (mean 2.4 ± 2.8) at all posttreatment time points (each p <0.05). Practitioners significantly overestimated incontinence pad‐free rates at 3 months (48% vs 39%) and functional erection rates at 3 months (18% vs 12%), 6 months (38% vs 23%) and 12 months (45% vs 23%, each p <0.05). Conclusions: EPIC‐CP is feasible to use in the routine clinical care of patients with prostate cancer without requiring a research infrastructure. Using EPIC‐CP in clinical practice may help practitioners objectively assess and appropriately manage posttreatment side effects in patients with prostate cancer.

Moving Towards Widespread Implementation of Enhanced Recovery Protocols for Radical Cystectomy

Enhanced recovery after surgery (ERAS) protocols were initiated in the 1990s to reduce the surgical stress response and achieve early postoperative recovery [1]. Since then, an increasing number of fast-track programs have been established with the primary goals of reducing length of stay (LOS) and improving perioperative outcomes. In addition, given that most health care systems are overburdened and under financial constraints, another goal of these protocols is to reduce costs. The majority of evidence supporting ERAS pathways among radical cystectomy (RC) patients has been extrapolated from colorectal surgery. A meta-analysis of six randomized controlled trials (RCTs) involving 452 patients undergoing colorectal surgery showed that patients in the ERAS arm of the trials had significantly shorter LOS (mean difference 2.6 d; 95% confidence interval 3.2 to 1.9) and lower complication rates [2]. Certain individual components of ERAS for colorectal surgery, such as preoperative carbohydrate solution, avoidance of bowel preparation, early enteral feeding, and goal-directed fluid therapy, are supported by RCTs that have evaluated their effects [2,3]. While many of these components have been adapted to RC ERAS protocols, it is prudent to note some key differences between colorectal surgery and RC, such as small bowel anastomoses, urine in the peritoneum, both extraperitoneal and intraperitoneal access, longer operative times, and greater blood loss [4]. Unlike the situation for colorectal surgery, there is a lack of RCTs for urology. One RCT has been published, but the investigators used very few ERAS components. The ERAS pathway included the absence of mechanical bowel

Implementation of a Perioperative Venous Thromboembolism Prophylaxis Program for Patients Undergoing Radical Cystectomy on an Enhanced Recovery After Surgery Protocol

BACKGROUND Novel venous thromboembolism (VTE) prophylaxis programs, including postdischarge pharmacologic prophylaxis, have been associated with decreased VTE rates. Such practices have not been widely adopted in managing radical cystectomy (RC) patients. OBJECTIVE To evaluate the effect of a perioperative VTE prophylaxis program on VTE rates after RC. DESIGN, SETTING, AND PARTICIPANTS Single-institution, nonrandomized, pre- and post-intervention analysis of 319 patients undergoing RC at Brigham and Womens Hospital between July 2011 and April 2017. Patient and outcome data were prospectively collected as part of the American College of Surgeons National Surgical Quality Improvement Program. INTERVENTION Before June 2015, patients only received postoperative pharmacologic and mechanical VTE prophylaxis in the inpatient setting. Starting June 2015, a perioperative VTE prophylaxis program was implemented as part of an enhanced recovery after surgery (ERAS) protocol, including a 28-d course of postdischarge enoxaparin. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary outcome was 30-d postoperative VTE rate. Secondary outcomes were perioperative bleeding rates, 30-d complication, readmission, and mortality rates, and length of stay. Univariate analysis was performed comparing outcomes between pre- and post-intervention cohorts. RESULTS AND LIMITATIONS Of the 319 patients who underwent RC, 210 (66%) were in the pre- and 109 (34%) in the post-intervention cohort. VTE rate was significantly lower in the post-intervention cohort (n=1, 0.9% vs n=13, 6.2%; p=0.04). Rates of perioperative bleeding (35% vs 33%; p=0.80) and 30-d readmissions related to bleeding (1% vs 3.7%; p=0.19) did not differ significantly. Single-institution data limits generalizability, and patient compliance with postdischarge enoxaparin was unknown. CONCLUSIONS Implementation of a perioperative VTE prophylaxis program as part of an ERAS protocol that includes extended postdischarge pharmacologic prophylaxis was associated with decreased rate of VTE events after RC. Perioperative bleeding and readmissions related to bleeding did not increase with this intervention. PATIENT SUMMARY This study evaluated whether clotting complication rates after radical cystectomy (RC) for bladder cancer can be reduced by implementing a new postoperative care pathway. This pathway reduced rates of clotting complications without increasing bleeding rates and should be considered for all patients undergoing RC.

Resident Involvement in Radical Inguinal Orchiectomy for Testicular Cancer Does Not Adversely Impact Perioperative Outcomes - A Retrospective Study

Introduction: To evaluate perioperative outcomes related to resident involvement (RI) in a large and prospectively collected multi-institutional database of patients undergoing orchiectomy for testicular cancer. Materials and Methods: Using current procedural terminology and ICD-9 codes, information about patients with testicular cancer were abstracted from the American College of Surgeons National Surgical Quality Improvement Program database (2006-2013). Multivariable analyses evaluated the impact of RI on outcomes after orchiectomy. Prolonged operative time (pOT) and prolonged length of stay were defined by the 75th percentile (59 min) and postoperative inpatient stay ≥2 days, respectively. Results: Overall, 267 patients underwent orchiectomy either with (38.6%) or without (61.4%) RI. In all, 89.1% of patients underwent an outpatient procedure. The median body mass index was 26.8 and baseline characteristics between the 2 groups were similar. Overall complications, re-intervention, and bleeding-related complication rates were 2.6, 0.7, and 0.4%, respectively. Although there was no difference in terms of overall complications between the groups (3.9 vs. 1.8%; p = 0.44), RI resulted in pOT (32 vs. 19.5%; p = 0.028). In multivariable analyses, RI predicted pOT (OR 1.89, 95% CI 1.06-3.37; p = 0.031), without association with prolonged length of stay and overall complications. Conclusions: RI during orchiectomy for testicular cancer does not undermine patient safety at the cost of pOT.

MP22-04 RACIAL DISPARITIES IN THE TREATMENT AND SURVIVAL OF METASTATIC RENAL CELL CARCINOMA

morphometric measures have been suggested to be predictive for prognosis. We investigated the impact of a novel combination of preoperative tumor morphology (RENAL score) and a laboratory based inflammatory marker (DeRitis Ratio, AST/ALT) on survival outcomes in localized RCC. METHODS: Single center, retrospective analysis of 524 patients with RCC (312 PN, 212 RN, mean follow up 35.8 months) from 2003-2015. A priori, we assigned a positive marker score of 1 if RENAL >8 or DeRitis >1.5. Patients were stratified by increasing positive markers (01⁄4RENAL 8 and DeRitis 1.5, 11⁄4RENAL >8 or DeRitis >1.5, 21⁄4RENAL >8 and DeRitis>1.5). Primary outcome was overall survival (OS). Cox models and Kaplan-Meier curves were utilized. RESULTS: 524 patients, 68% male, mean age 64.8 12.6 years, mean BMI 29.1 6.5, mean DeRitis 1.1 0.4. With regards to tumor characteristics, mean clinical tumor size was 4.8 3.3cm and median RENAL score was 8 (IQR 6-10). For clinical staging, 74% were cT1, 19% cT2, and 6% were >T2. On Cox model for OS, RENAL >8 (HR 1.95, p1⁄40.003) and DeRitis >1.5 (HR 3.74, p<0.001) were significantly associated with worsened survival. On Cox model output for OS and marker score, we found 1 marker (HR 1.83, p1⁄40.011) and 2 markers (HR 7.68, p<0.001) were significantly associated with worsened survival (figure). CONCLUSIONS: Novel combination of a morphological score (RENAL) and an inflammatory marker (DeRitis ratio) was associated with worsened OS in RCC after surgical treatment. Our findings point towards development and validation of a prognostic index to assist in risk stratification and follow up protocols for RCC.

Adult UrologyOncology: Prostate/Testis/Penis/UrethraClinical Use of Expanded Prostate Cancer Index Composite for Clinical Practice to Assess Patient Reported Prostate Cancer Quality of Life Following Robot-Assisted Radical Prostatectomy

Purpose: EPIC‐CP (Expanded Prostate Cancer Index Composite for Clinical Practice) is a short questionnaire that comprehensively measures patient reported health related quality of life at the point of care. We evaluated the feasibility of using EPIC‐CP in the routine clinical care of patients with prostate cancer without research infrastructure. We compared longitudinal patient and practitioner reported prostate cancer outcomes. Materials and Methods: We reviewed health related quality of life outcomes in 482 patients who underwent radical prostatectomy at our institution from 2010 to 2014. EPIC‐CP was administered and interpreted in routine clinical practice without research personnel. We compared practitioner documented rates of incontinence pad use and functional erections to patient reported rates using EPIC‐CP. Results: A total of 708 EPIC‐CP questionnaires were completed. Mean urinary incontinence domain scores were significantly higher (worse) than baseline (mean ± SD 0.6 ± 0.2) 3 and 6 months after treatment (mean 3.1 ± 2.3 and 2.2 ± 2.1, respectively, each p <0.05) but they returned to baseline at 12 months (mean 1.6 ± 1.7, p >0.05). Mean sexual domain scores were significantly worse than baseline (mean 2.4 ± 2.8) at all posttreatment time points (each p <0.05). Practitioners significantly overestimated incontinence pad‐free rates at 3 months (48% vs 39%) and functional erection rates at 3 months (18% vs 12%), 6 months (38% vs 23%) and 12 months (45% vs 23%, each p <0.05). Conclusions: EPIC‐CP is feasible to use in the routine clinical care of patients with prostate cancer without requiring a research infrastructure. Using EPIC‐CP in clinical practice may help practitioners objectively assess and appropriately manage posttreatment side effects in patients with prostate cancer.