Sangtae Park

Neoadjuvant and adjuvant chemotherapy use in upper tract urothelial carcinoma

OBJECTIVE To determine trends in neoadjuvant and adjuvant chemotherapy use for upper tract urothelial cancer and assess its effects on survival. MATERIALS AND METHODS We identified all patients diagnosed with upper tract urothelial cancer who underwent surgical treatment in the SEER-Medicare database from 2002 to 2011. We collected and analyzed patient demographic, clinical, and pathologic characteristics. We strictly defined neoadjuvant and adjuvant chemotherapy and studied patients who met such criteria. Multivariable Cox proportional hazards models identified were used to identify independent predictors of overall and cancer-specific survival. RESULTS A total of 3,432 patients met inclusion criteria, and their median age was 77 years. Overall, 86.4% of patients underwent surgery alone, 1.8% received neoadjuvant chemotherapy plus surgery, and 11.8% underwent surgery and adjuvant chemotherapy. Neoadjuvant chemotherapy use increased during the study period. Gemcitabine, carboplatin, cisplatin, and paclitaxel were the most commonly used agents. Cancer-specific survival at 5 years was 65.0% (95% CI: 63.2%-66.8%). Cox proportional hazards modeling controlling for sex, race, year of diagnosis, location, and pathologic stage revealed that higher pathologic nodal stage, tumor size>3cm, increased age, and carcinoma in situ predicted for worse survival. CONCLUSION Age, nodal stage, and tumor size>3cm predict for worse cancer-specific survival. Neoajduvant chemotherapy is underused.

PD39-04 COMBINED PLACEMENT OF ARTIFICIAL URINARY SPHINCTER AND INFLATABLE PENILE PROSTHESIS DOES NOT INCREASE RISK OF PERIOPERATIVE COMPLICATIONS OR IMPACT LONG-TERM DEVICE SURVIVAL

OBJECTIVE To determine the impact of concurrent inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) implantation on perioperative complications and long-term device survival, among men with postprostatectomy erectile dysfunction and urinary incontinence. METHODS We identified men older than 65 treated with radical prostatectomy in the Surveillance, Epidemiology, and End Results Medicare database between 2002 and 2016. IPP or AUS placement was determined by current procedural terminology (CPT) code, with dual implantation (DI) defined as IPP and AUS placement on the same date. Device survival was assessed using CPT codes for device removal, replacement, and/or repair. Complications were assessed within 90 days using ICD-9 codes. Statistical analysis was performed using SAS v9.3 (Cary, NC). RESULTS A total of 37,599 men underwent radical prostatectomy, with AUS placed in 793 (2.1%), IPP placed in 644 (1.7%), and DI in 62 (0.2%). Relative to AUS placement alone, men undergoing DI were younger (68.8 vs 70.2 years, P = 0.03), but had equivalent Charlson comorbidity index, tumor grades, and rates of prior radiotherapy. Relative to IPP placement alone, men were more likely to undergo DI if treated with adjuvant or salvage radiotherapy. The incidence of complications within 30 and 90 days of prosthetic implantation did not differ between groups. Long-term device survival on Kaplan-Meier analysis was not impacted by DI relative to single device implantation with median follow-up of 61 months. CONCLUSION Combined AUS and IPP placement does not adversely affect perioperative complications or device survival relative to placement of either device alone.

Facility-level analysis of robot utilization across disciplines in the National Cancer Database

To evaluate trends in contemporary robotic surgery across multiple organ sites as they relate to robotic prostatectomy volume. We queried the National Cancer Database for patients who underwent surgery from 2010 to 2013 for prostate, kidney, bladder, corpus uteri, uterus, cervix, colon, sigmoid, rectum, lung and bronchus. The trend between volumes of robotic surgery for each organ site was analyzed using the Cochran–Armitage test. Multivariable models were then created to determine independent predictors of robotic surgery within each organ site by calculating the odds ratio with 95% CI. Among the 566,399 surgical cases analyzed, 35.1% were performed using robot assistance. Institutions whose robotic prostatectomy volume was in the top 75 percentile compared to the bottom 25 percentile performed a larger percentage of robotic surgery on the following sites: kidney 32.6 vs. 28.8%, bladder 23.6 vs. 18.6%, uterus 52.5 vs. 47.7%, cervix 43.5 vs. 39.2%, colon 3.2 vs. 2.9%, rectum 10.7 vs. 8.9%, and lung 7.3 vs. 6.8% (all p < 0.0001). It appears that increased trends toward robotic surgery in urology have lead to increased robotic utilization within other surgical fields. Future analysis in benign utilizations of robotic surgery as well as outcome data comparing robotic to open approaches are needed to better understand the ever-evolving nature of minimally invasive surgery within the United States.

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.

MP54-14 BLADDER CANCERS ARE NOT ALL THE SAME: DE NOVO MUSCLE INVASIVE DISEASE HAS IMPROVED SURVIVAL COMPARED TO INVASIVE DISEASE PROGRESSING AFTER INTRAVESICAL THERAPY

INTRODUCTION AND OBJECTIVES: Underdiagnosing malnutrition in high-risk surgical patients is problematic. Rapid skeletal muscle wasting is a serious and common complication following radical cystectomy (RC) to treat muscle-invasive bladder cancer. Specialized immunonutrition (SIM) intake before and after RC may help counteract muscle wasting in the post-operative period. METHODS: Men with muscle-invasive cancer scheduled for radical cystectomy were randomly assigned to oral SIM providing supplemental L-arginine, fish oil, vitamin A, and nucleotides (n 1⁄4 14) or a calorieand nitrogen-matched oral nutrition supplement [ONS (n 1⁄4 15)] for 5 days before and 5 days after RC. Malnutrition was assessed by a trained research team using the Patient-Generated Subjective Global Assessment (PG-SGA) tool. Dual Energy X-Ray Absorptiometry scans were obtained at baseline, 14 days, and 30 days after surgery to calculate relative skeletal muscle index (RSMI). Discrepancies between the malnutrition diagnoses using the PG-SGA tool and the UHC Billing database on the same patients were compared. RESULTS: Using the PG-SGA tool, 21% of patients were identified as well nourished, 66% were moderately malnourished, and 14% were severely malnourished prior to RC. Billed and coded data showed 86% of patients were well nourished, 7% were moderately malnourished, and 7% were severely malnourished prior to RC. Relative Skeletal Muscle Index (RSMI) was better preserved in the SIM group at 14 days (7% vs. 17% in the ONS group). CONCLUSIONS: The large discrepancy between patients identified as malnourished using the PG-SGA as compared to the billing data suggests a problem of underdiagnosing malnutrition in this population. Improving nutrition status through specialized immunonutrition could be a low risk, high-impact means of counteracting muscle wasting after RC for bladder cancer.

MP36-18 PATTERNS AND TIMING OF ARTIFICIAL URINARY SPHINCTER FAILURE

INTRODUCTION AND OBJECTIVES: The gold standard treatment for severe post-prostatectomy incontinence is implantation of an artificial urinary sphincter (AUS). There is a paucity of data regarding the timing of AUS placement after prostatectomy and other factors which predict device failure. METHODS: We identified all patients who underwent prostatectomy and subsequent AUS placement in SEER-Medicare from 2002-2011. These patients’ demographic, clinical and pathologic characteristics were included in multivariable cox proportional hazard models, to identify predictors for device survival. We also analyzed factors impacting the time to revision or explantation from initial AUS implantation and prostatectomy. RESULTS: 841 men underwent AUS placement at a median 23 months (IQR:15-40.6) after prostatectomy. 236 (28%) men ultimately required revision or explantation. There were no differences in age, race or hospital setting for those undergoing reoperation vs. not (p 0.2). Patients who underwent reoperation were more likely to have had higher clinical stage cancer, undergone open prostatectomy, or had prior sling placement (p<0.01). There were no differences in rates of diabetes, smoking status, prior radiation therapy, or Charlson Comorbidity Index scores between those requiring reoperation vs. not (all p >0.15). Patients with delayed AUS placement (29%), defined as >3 years after prostatectomy, experienced prolonged device survival (Figure). Delayed patients were significantly more likely to have received radiation therapy [36.5% vs. 10.5% (p<0.001)]. Nonetheless, delayed repair was confirmed to be protective on multivariate analysis, after controlling for patient and disease characteristics including radiation history [HR:0.44 (95% CI: 0.32-0.62); p<0.01]. Factors independently associated with a shorter interval time until reoperation included history of radiation [HR: 1.69 (95% CI: 1.16-2.44);p<0.01] and history of prior sling [HR:1.88 (95% CI: 1.19-2.97); p<0.01]. CONCLUSIONS: Delayed AUS implantation in the Medicare population is associated with prolonged device survival, while radiation exposure and prior urethral sling surgery predict for early reoperation. Further work is required to identify patient specific factors which may explain variability in timing for AUS after prostatectomy and how such factors contribute to device longevity.