Q-D. Trinh

573 Prediction of intravesical recurrence after radical nephroureterectomy: Development of a clinical decision-making tool

Background: Intravesical recurrence after radical nephroureterectomy (RNU) is a frequent event requiring intense cystoscopic surveillance. Recently, a prospective randomized clinical trial has shown that a single intravesical postoperative dose of mitomycin C (MMC) reduces the absolute risk of intravesical recurrence after RNU. Objective: The aim of the current study was to identify predictors of intravesical recurrence and to develop a tool to allow a risk-stratified approach supporting patient counseling for cystoscopic surveillance and postoperative intravesical MMC administration. Design, setting, and participants: We performed a retrospective analysis of 1839 patients with upper tract urothelial carcinoma (UTUC). The data set was split into a development cohort of 1261 patients from North America and a validation cohort of 578 patients from Europe. Interventions: RNU with bladder cuff excision was performed. The surgical approach was open in 1424 patients (77.4%) and laparoscopic in 415 patients (22.6%).

Minimally invasive surgery and its impact on 30-day postoperative complications, unplanned readmissions and mortality

A critical appraisal of the benefits of minimally invasive surgery (MIS) is needed, but is lacking. This study examined the associations between MIS and 30‐day postoperative outcomes including complications graded according to the Clavien–Dindo classification, unplanned readmissions, hospital stay and mortality for five common surgical procedures.

93 A nationwide survey of prostate specific antigen based screening and counseling for prostate cancer

Abstract Introduction Controversy surrounds prostate specific antigen screening following the 2012 U.S. Preventive Services Task Force grade D recommendation. There is limited evidence evaluating patterns of prostate specific antigen counseling and patient perceptions of the prostate specific antigen test since 2012. We evaluated the association between prostate cancer screening counseling and patient sociodemographic factors in a nationally representative sample. Methods Using data from the 2013 Health Information National Trends Survey we identified 768 male respondents age 40 to 75 years without a prior prostate cancer diagnosis. Using logistical regression we assessed trends in prostate cancer screening, counseling and prostate specific antigen use. Results Overall 54.1% of respondents reported ever having a prostate specific antigen test. Men undergoing prostate specific antigen testing were more likely to have had a prior cancer diagnosis other than prostate cancer (OR 3.93, 95% CI 1.19–12.94) and to have had at least some college education (OR 11.35, 95% CI 3.29–39.04). Men 40 to 49 years old had decreased odds of undergoing prostate specific antigen testing compared to men 50 to 69 years old (OR 0.20, 95% CI 0.10–0.39). History of cancer (OR 2.50, 95% CI 1.19–5.26) was associated with greater odds of being counseled on the potential adverse effects of prostate cancer treatment. Younger men (age 40 to 49 years) had decreased odds of discussing the prostate specific antigen test with a health care professional (OR 0.32, 95% CI 0.16–0.62) and being informed of the controversy surrounding prostate specific antigen screening (OR 0.35, 95% CI 0.13–0.95). Conclusions We show that certain men receive substantially different prostate specific antigen screening counseling, which may impact shared patient-provider decision making before prostate specific antigen counseling.

436 Predictors of wound dehiscence in a prospective dataset of 2,586 cystectomies

INTRODUCTION AND OBJECTIVES: Wound dehiscence is major complication following radical cystectomy. It is a significant cause of readmission, reopearation and potentially delays lifesaving adjuvant therapies. We sought to investigate the incidence and predictors of wound dehiscence in patients undergoing radical cystectomy. METHODS: 2556 patient records with Current Procedural Terminology (CPT) codes for cystectomy between 2005 and 2012 were extracted from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP). Stratification was made on the basis of the occurrence of postoperative wound dehiscence. This was defined as full disintegrity of the skin and fascial layer. Outcomes of interest included overall complication, mortality, prolonged length of stay and prolonged operative time, the latter two defined as measures above the 75th percentile. Descriptive and logistic regression models were performed to identify predictors of postoperative wound dehiscence. RESULTS: Of 2556 patients analyzed, 74 (2.9%) had a documented wound dehiscence. In multivariable analyses, smoking (OR 2.2 p1⁄4.002), prolonged operative time (OR 1.6;p1⁄40.05) and BMI were associated with increased odds of postoperative wound dehiscences. Female gender was associated with decreased odds of dehiscence (OR 0.4; p1⁄40.022). Elevated preoperative creatinine (>1.2 mg/dl), chronic steroid use and diabetes were not independent predictors. CONCLUSIONS: Our study is the first to identify predictors of wound dehiscence following radical cystectomy in a large multi-institutional prospective cohort. Identifying patients at risk for postoperative wound complications may guide the use preventative measures at the time of surgery. Source of Funding: none

641 Racial disparities in the surgical care of localized prostate cancer

INTRODUCTION AND OBJECTIVES: The Cancer of the Prostate Risk Assessment Postsurgical (CAPRA-S) score predicts prostate cancer (PCa) recurrence based on pathologic information from radical prostatectomy (RP). We independently validated the CAPRA-S in a European, single-institution database. METHODS: The study cohort comprised of 14532 patients treated with radical prostatectomy between January 1992 and August 2012. Prediction of biochemical recurrence (BCR), metastasis and cancer-specific mortality (CSM) by CAPRA-S was assessed by Kaplan-Meier analysis and the c-index. Performance of CAPRA-S in predicting BCR was assessed by calibration plot and decision curve analysis. RESULTS: Median follow up was 48.8 months (IQR 24.6 e 95.9). Biochemical recurrence occurred in 20.3% of men at a median time of 21.2 mo (interquartile range [IQR]: 7.7e44.9). When stratifying patients by CAPRA-S risk groups, biochemical recurrence-free survival estimates at 5 years were 91.4%, 70.4%, and 29.3% for the low, intermediate and high-risk group, respectively. The c-index for CAPRA-S in predicting BCR was 0.80. The cindices for CAPRA-S in predicting metastasis and CSM were 0.85 and 0.88, respectively. 374 men developed metastasis, and 184 men died from PCa. CONCLUSIONS: The postoperative CAPRA-S score was accurate when applied in a European study cohort and predicted biochemical recurrence, metastasis and CSM after RP with c-indices> 0.80. The score can be valuable for decision-making for adjuvant therapy.

18 The influence of physican recommendation on PSA screening

INTRODUCTION AND OBJECTIVES: PSA screening for prostate cancer is a controversial topic, and little is known regarding a physician’s impact on a patient’s decision to undergo screening. The study’s objective was to evaluate the impact of a patient’s understanding of the risks and benefits of PSA screening compared to the final recommendation of the health care provider on the patient’s decision to undergo PSA screening. METHODS: Using the 2012 BRFSS, males aged 55 years who did not have a prior history of prostate cancer/prostate “problem” and who reported a PSA test within the preceding 12 months were considered to have undergone PSA screening. The percentage of men informed and not informed of the risks and benefits of PSA screening and the percentage men receiving recommendations for PSA screening from their HCP was reported. Multivariable complex-samples logistic regression calculated the odds ratio of undergoing screening in men informed of PSA screening benefits, screening risks, and for those receiving a recommendation to undergo screening. RESULTS: Seventy-five percent of men were informed of screening benefits, however 32% were informed of screening risks. After being informed of both, 55.6% of men opted for PSA screening if the HCP recommended it, compared to only 20.6% when not recommended. Men receiving a recommendation to undergo PSA testing had higher odds of undergoing screening (OR 4.98, 95% CI: 4.53-5.48) compared to those who were only informed about screening benefits (OR 2.40, 95% CI: 2.18-2.65) or risks (OR 0.92, 95% CI: 0.86-0.98). Significant limitations of our study include recall and non-response bias. CONCLUSIONS: Physicians have a tendency to report the favorable aspects of screening while under informing patients of the possible risks of screening. A patient’s decision to undergo or forgo PSA screening is heavily influenced by the recommendation of their physician, and thus it is imperative that physicians are cognizant of their biases and facilitate an unbiased shared decision making process.

235 Morbidity and mortality after benign prostatic hyperplasia surgery: Data from the national surgical quality improvement program

RESULTS: 484 patients had open or laparoscopic UOS, with 200 (41%) classified as high risk for VTE by CRSs. The rates of VTEs and median times to VTE were 6% and 74 days in Group 1, 13% and 44 days in Group 2, 15% and 40 days in Group 3, and 23% and 11 days in Group 4. Adjusted hazard ratios for VTE are shown in Table 1. Group 1 had no VTE’s or fatal pulmonary embolisms in the first 30 days after UOS. Bleeding and lymphocele rates were 0% and 2% in Group 1, 0% and 4% in Group 2, 3% and 3% in Group 3, 0% and 0% in Group 4. Complications were considered Clavien grades II-IIIa. CONCLUSIONS: VTE risk is lowest in patients who receive clinical protocol prophylaxis with EDP. Risk of VTE remains elevated for at least 90 days following UOS. A clinical VTE prevention protocol using perioperative prophylaxis and EDP is effective and safe in reducing VTE risk in UOS patients.

625 Predictors of admission in patients presenting to the emergency department with urinary tract infection

Purpose Previous studies examining the management of urinary tract infections (UTI) showed marked variability in the economical burden of care, with a tenfold increase in costs when patients require admission to the hospital. We sought to examine the patient and emergency department (ED) characteristics associated with hospitalization in patients presenting to the ED with UTI.

V13 ROBOTIC INFERIOR VENA CAVA THROMBECTOMY

Renal cell carcinoma (RCC) has a natural tendency of progression from the kidney along its route of venous drainage, into the inferior vena cava (IVC) in 4–10% of patients. Radical nephrectomy (RN) with tumor thrombectomy is the standard of care for these difficult cases. Even such complex operative procedures were conducted in an open fashion, potential fatal complications caused by bleeding or embolism may occur. Open surgery requires a big abdomen incision associated with slow recovery. With the development of laparoscopy and robotic technology in recent years, several centers had reported successful experience in laparoscopic IVC thrombectomy (IVCTE). However, laparoscopic IVCTE is extremely challenging and technically demanding, even for experienced laparoscopic surgeons. Surgical robotic equipment has been increasingly used in intricate laparoscopic procedures and might facilitate application of minimally invasive surgical techniques in such challenging surgeries. We performed robotic IVC thrombectomy (R-IVCTE) since 2013. Detailed techniques for R-IVCTE of different sides (left or right RCC) are compared and described below.