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1400 CLINICAL NODAL STAGING SCORES FOR BLADDER CANCER A NEW PREOPERATIVELY NODAL ASSESSMENT TOOL
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THE JOURNAL OF UROLOGY姞
Vol. 187, No. 4S, Supplement, Tuesday, May 22, 2012
ing a laparoscopic exposure and hilar dissection with a robotic extirpation and renorrhaphy provides improved perioperative outcomes compared to a pure robotic approach. We performed a comparison of perioperative outcomes between combined laparoscopic-robotic partial nephrectomy (LRPN) and pure robotic partial nephrectomy (RPN). METHODS: A multi-center retrospective analysis of patients undergoing RPN and LRPN using the Da Vinci S system ® was performed. LRPN consisted of a laparoscopic exposure and hilar dissection, and the robot was docked for extirpation and renorrhaphy. Patient charts were reviewed for perioperative variables. Statistical analysis was performed using R ® statistical program. RESULTS: Thirty-one patients underwent RPN while 81 patients underwent LRPN between 2007-2011. Four patients in the LRPN group were excluded due coversion to total nephrectomy. Preoperative variables were similar between each group, with the exception of lesion size and nephrometry score (Table 1). Length of surgery, estimated blood loss and morphine used were significantly less in the LRPN group, while warm ischemia time (WIT) was significantly longer (Table 2). The difference in WIT disappeared after controlling for nephrometry score. There was no significant difference in perioperative creatinine. CONCLUSIONS: The combined LRPN approach was associated with a shorter operative time, reduced blood loss and lower narcotic usage. This finding may translate into a reduced utilization of hospital resources and cost. Table 1: Preoperative Demographic Information Patient Characteristic Lap-Robotic Pure Robotic Patients 77 81 Age
60
T-Test
60
Male
39 (48%)
22 (70%)
Female
41 (52%)
9 (30%)
BMI
30.2
Lesion Size
3.5
2.6
*p ⬍ 0.05
Nephrometry Score
6.2
4.7
***p ⬍ 0.001
31
Table 2: Perioperative Outcomes Perioperative Variable Lap-Robotic Pure Robotic Warm Ischemia Time (min) 28 18.5
T Test ***p ⬍ 0.001
Length of Surgery (min)
173.8
211.9
***p ⬍ 0.001
Estimated Blood Loss (ml)
139.3
271.9
***p ⬍ 0.001
2.4
2.6
19.7
32.4
1.1
1.2
Length of Stay (days) Mg of IV Morphine Preoperative Creatinine Postoperative Creatinine
1.2
1.2
Clear Cell Renal Cell Carcinoma
37 (48%)
12 (39%)
Papillary Renal Cell Carcinoma
23 (30%)
9 (29%)
Benign Mass
14 (19%)
10 (32%)
2 (3%)
0
Minor Complications
5
3
Major Complications
2
1
Other
*p ⬍ 0.05
Bladder Cancer: Invasive I Moderated Poster Tuesday, May 22, 2012
8:00 AM-10:00 AM
1400 CLINICAL NODAL STAGING SCORES FOR BLADDER CANCER: A NEW PREOPERATIVELY NODAL ASSESSMENT TOOL Michael Rink*, Behfar Ehdaie, Eugene K. Cha, New York, NY; Robert S. Svatek, San Antonio, TX; Thomas Chromecki, Harun Fajkovic, New York, NY; Jens Hansen, Montre´al, Canada; Giacomo Novara, Padua, Italy; Siamak Daneshmand, Los Angeles, CA; Yves Fradet, Que´bec City, Canada; Yair Lotan, Arthur Sagalowsky, Dallas, TX; Derya Tilki, Patrick Bastian, Munich, Germany; Wassim Kassouf, Montre´al, Canada; Hans-Martin Fritsche, Maximilian Burger, Regensburg, Germany; Jonathan I. Izawa, London, Canada; Firas Abdollah, Pierre I. Karakiewicz, Montre´al, Canada; Felix K. Chun, Margit Fisch, Hamburg, Germany; Guru Sonpavde, Houston, TX; Douglas S. Scherr, Mithat Gonen, Shahrokh F. Shariat, New York, NY INTRODUCTION AND OBJECTIVES: Radical cystectomy (RC) with pelvic lymph node dissection (LND) is the standard of care for refractory non-muscle-invasive and muscle-invasive bladder cancer. Although a consensus exists on the need for LND, its extent is still debated. We sought to develop a model that allows preoperative determination of the number of nodes needed to be removed at RC. METHODS: Data from 4,335 patients treated with RC and pelvic LND without neoadjuvant chemotherapy at 12 academic centers were collected. We estimated the sensitivity of pathologic nodal staging using a beta-binomial model and developed clinical (preoperative) nodal staging scores (cNSS), which represent the probability that a patient has tumor metastasis to lymph nodes as a function of the number of examined nodes. RESULTS: Overall, the probability of missing a positive lymph node decreases with an increasing number of nodes examined (52% if three nodes examined, 40 % if five examined, and 26% if ten examined). A cNSS of 90% can be achieved by examining six nodes for clinical Ta-Tis tumors, nine nodes for cT1 tumors, and 25 nodes for cT2 tumors. In contrast, examination of 25 nodes provides only 77% cNSS for cT3-T4 tumors. CONCLUSIONS: The minimum number of examined lymph nodes for adequate staging depends preoperatively on the clinical T stage. Predictive tools can give a preoperative estimation of the likelihood of nodal metastasis and thereby allow tailored decision-making regarding the extent of LND at RC.
Source of Funding: None
Source of Funding: None
THE JOURNAL OF UROLOGY姞
Vol. 187, No. 4S, Supplement, Tuesday, May 22, 2012
ing a laparoscopic exposure and hilar dissection with a robotic extirpation and renorrhaphy provides improved perioperative outcomes compared to a pure robotic approach. We performed a comparison of perioperative outcomes between combined laparoscopic-robotic partial nephrectomy (LRPN) and pure robotic partial nephrectomy (RPN). METHODS: A multi-center retrospective analysis of patients undergoing RPN and LRPN using the Da Vinci S system ® was performed. LRPN consisted of a laparoscopic exposure and hilar dissection, and the robot was docked for extirpation and renorrhaphy. Patient charts were reviewed for perioperative variables. Statistical analysis was performed using R ® statistical program. RESULTS: Thirty-one patients underwent RPN while 81 patients underwent LRPN between 2007-2011. Four patients in the LRPN group were excluded due coversion to total nephrectomy. Preoperative variables were similar between each group, with the exception of lesion size and nephrometry score (Table 1). Length of surgery, estimated blood loss and morphine used were significantly less in the LRPN group, while warm ischemia time (WIT) was significantly longer (Table 2). The difference in WIT disappeared after controlling for nephrometry score. There was no significant difference in perioperative creatinine. CONCLUSIONS: The combined LRPN approach was associated with a shorter operative time, reduced blood loss and lower narcotic usage. This finding may translate into a reduced utilization of hospital resources and cost. Table 1: Preoperative Demographic Information Patient Characteristic Lap-Robotic Pure Robotic Patients 77 81 Age
60
T-Test
60
Male
39 (48%)
22 (70%)
Female
41 (52%)
9 (30%)
BMI
30.2
Lesion Size
3.5
2.6
*p ⬍ 0.05
Nephrometry Score
6.2
4.7
***p ⬍ 0.001
31
Table 2: Perioperative Outcomes Perioperative Variable Lap-Robotic Pure Robotic Warm Ischemia Time (min) 28 18.5
T Test ***p ⬍ 0.001
Length of Surgery (min)
173.8
211.9
***p ⬍ 0.001
Estimated Blood Loss (ml)
139.3
271.9
***p ⬍ 0.001
2.4
2.6
19.7
32.4
1.1
1.2
Length of Stay (days) Mg of IV Morphine Preoperative Creatinine Postoperative Creatinine
1.2
1.2
Clear Cell Renal Cell Carcinoma
37 (48%)
12 (39%)
Papillary Renal Cell Carcinoma
23 (30%)
9 (29%)
Benign Mass
14 (19%)
10 (32%)
2 (3%)
0
Minor Complications
5
3
Major Complications
2
1
Other
*p ⬍ 0.05
Bladder Cancer: Invasive I Moderated Poster Tuesday, May 22, 2012
8:00 AM-10:00 AM
1400 CLINICAL NODAL STAGING SCORES FOR BLADDER CANCER: A NEW PREOPERATIVELY NODAL ASSESSMENT TOOL Michael Rink*, Behfar Ehdaie, Eugene K. Cha, New York, NY; Robert S. Svatek, San Antonio, TX; Thomas Chromecki, Harun Fajkovic, New York, NY; Jens Hansen, Montre´al, Canada; Giacomo Novara, Padua, Italy; Siamak Daneshmand, Los Angeles, CA; Yves Fradet, Que´bec City, Canada; Yair Lotan, Arthur Sagalowsky, Dallas, TX; Derya Tilki, Patrick Bastian, Munich, Germany; Wassim Kassouf, Montre´al, Canada; Hans-Martin Fritsche, Maximilian Burger, Regensburg, Germany; Jonathan I. Izawa, London, Canada; Firas Abdollah, Pierre I. Karakiewicz, Montre´al, Canada; Felix K. Chun, Margit Fisch, Hamburg, Germany; Guru Sonpavde, Houston, TX; Douglas S. Scherr, Mithat Gonen, Shahrokh F. Shariat, New York, NY INTRODUCTION AND OBJECTIVES: Radical cystectomy (RC) with pelvic lymph node dissection (LND) is the standard of care for refractory non-muscle-invasive and muscle-invasive bladder cancer. Although a consensus exists on the need for LND, its extent is still debated. We sought to develop a model that allows preoperative determination of the number of nodes needed to be removed at RC. METHODS: Data from 4,335 patients treated with RC and pelvic LND without neoadjuvant chemotherapy at 12 academic centers were collected. We estimated the sensitivity of pathologic nodal staging using a beta-binomial model and developed clinical (preoperative) nodal staging scores (cNSS), which represent the probability that a patient has tumor metastasis to lymph nodes as a function of the number of examined nodes. RESULTS: Overall, the probability of missing a positive lymph node decreases with an increasing number of nodes examined (52% if three nodes examined, 40 % if five examined, and 26% if ten examined). A cNSS of 90% can be achieved by examining six nodes for clinical Ta-Tis tumors, nine nodes for cT1 tumors, and 25 nodes for cT2 tumors. In contrast, examination of 25 nodes provides only 77% cNSS for cT3-T4 tumors. CONCLUSIONS: The minimum number of examined lymph nodes for adequate staging depends preoperatively on the clinical T stage. Predictive tools can give a preoperative estimation of the likelihood of nodal metastasis and thereby allow tailored decision-making regarding the extent of LND at RC.
Source of Funding: None
Source of Funding: None