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COMPLICATIONS AND OUTCOMES OF CYSTECTOMY IN HIGH RISK PATIENTS
Vol. 179, No. 4, Supplement, Monday, May 19, 2008
850 INTERNATIONAL ROBOT-ASSISTED CYSTECTOMY CONSORTIUM (IRCC): IMMEDIATE ONCOLOGIC RESULTS AFTER ONE HUNDRED AND SIXTY TWO CASES Khurshid A Guru*, Raj S Pruthi, Zubair M Butt, Eric Wallen, Fred Muhletaler, James L Mohler, Hans Stricker, Hyung L Kim, Peter N Wiklund, James O Peabody, Mani Menon. Buffalo, NY, Chapel Hill, NC, Detroit, MI, and Stockholm, Sweden.. INTRODUCTION AND OBJECTIVE: Radical cystectomy UHPDLQVRQHRIWKHPRVWHIIHFWLYHWUHDWPHQWVIRUSDWLHQWVZLWKORFDOL]HG invasive bladder cancer. Interest in robot assisted surgery for bladder cancer has increased over last several years. Several institutions worldwide have attempted to evaluate and incorporate robot assisted radical cystectomy (RARC) into their practices. We report combined immediate oncologic results after robot assisted radical cystectomy from the consortium. METHODS: The International Robot-assisted Cystectomy Consortium (IRCC) is an international cooperative effort by multiple academic institutions across the globe. Between April 2002 and October 2007, 162 patients underwent RARC with urinary diversion for invasive bladder cancer at 4 academic institutions: Roswell Park Cancer Institute (67), University of North Carolina Chapel Hill (43), Henry Ford Health System (37) & Karolinska Institute Sweden (15). RESULTS: Total of 162 patients underwent robot assisted radical cystectomy (Male: 133, Female: 29). Mean age of the cohort was 64 years (range 36-90). Final pathological stage showed 91 patients KDGRUJDQFRQ¿QHGGLVHDVHSDWLHQWV KDGS7DQG patients (13%) had pT4 disease. The overall rate of positive margins was 8 %. The mean lymph node yield was 18 (1-43). Pathological Stage 7 T3 T4
Number 91 50 21
Positive nodes (%) 5 (5) 21 (42) 10 (48)
Positive Margins (%) 1 (1) 4 (8) 8 (38)
CONCLUSIONS: IRCC is a multi-institutional consortium effort with the largest series of robot assisted radical cystectomy. Our immediate oncologic results appear to be comparable to open radical F\VWHFWRP\ GDWD /RQJ WHUP RQFRORJLF UHVXOWV ZLOO GH¿QH LWV UROH LQ urologic oncology. Source of Funding: None
851 COMPLICATIONS AND OUTCOMES OF CYSTECTOMY IN HIGH RISK PATIENTS James S McIntosh*, Felipe Rosso, Mitra Tabidian, Jeffrey M Holzbeierlein. Kansas City, KS. INTRODUCTION AND OBJECTIVE: To investigate the complications and outcomes in high risk patients undergoing radical cystectomy. METHODS: A detailed database of 272 consecutive patients who underwent radical cystectomy at our institution from 1997 to 2006 ZDVDFFHVVHG+LJKULVNSDWLHQWVZHUHGH¿QHGDVWKRVHSDWLHQWVZLWK an American Society of Anesthesiologists (ASA) score greater than or equal to 3, a body mass index (BMI) greater than or equal to 30, or prior chemotherapy, radiation or partial cystectomy. 210 high risk patients ZHUH LGHQWL¿HG 7KHLU FRPSOLFDWLRQV DQG RXWFRPHV ZHUH FRPSDUHG to 62 radical cystectomy patients who were not considered high risk. Early complications included ileus, wound infection, need for parenteral nutrition, DVT, return to operating room, pneumonia, pulmonary embolus, myocardial infarction, stroke, dehiscence, pulmonary failure, sepsis, bowel leak, urine leak, and small bowel obstruction. Long-term FRPSOLFDWLRQVLQFOXGHGKHUQLDUHQDOLQVXI¿FLHQF\XUHWHURHQWHULFVWULFWXUH VPDOOERZHOREVWUXFWLRQ¿VWXODVWURNHEODGGHUQHFNFRQWUDFWXUHDQG infection. Outcomes included type of diversion and disease status. 5(68/76 )LIW\¿YHSDWLHQWVXQGHUZHQWDVDOYDJHF\VWHFWRP\ DQGSDWLHQWVKDGDQ$6$%0,¶VZHUHDYDLODEOHRQSDWLHQWV RIZKLFKKDGD%0,2YHUDOOFRPSOLFDWLRQUDWHZDVKRZHYHU when excluding ileus it was 37%. Recent series from 2003 to 2006 UHYHDOHGFRPSOLFDWLRQUDWHRI1RVLJQL¿FDQWGLIIHUHQFHZDVIRXQG in complication rates or disease outcomes in the three groups. Length of intensive care unit and hospital stay was longer in patients with an ASA
THE JOURNAL OF UROLOGY®
295
1RVLJQL¿FDQWGLIIHUHQFHLQFRPSOLFDWLRQUDWHZDVIRXQGEHWZHHQ conduit or continent diversions. BMI did not affect type of diversion, however, patients with ASA > 3 and patients undergoing a salvage cystectomy were more likely to receive a conduit. CONCLUSIONS: Given no difference in complication rates between conduits and continent diversions, we suggest that ASA score, BMI, or previous therapy should not exclude a patient from a cystectomy with continent diversion. Source of Funding: None
Pediatrics: Myelodysplasia, Neuropathic Bladder, Dysfunctional Voiding and Enuresis Podium Session 20 Monday, May 19, 2008
10:30 am - 12:30 pm
852 SIX MONTH EVALUATION OF THE BEAUMONT EXPERIENCE WITH THE XIAO “SKIN-CNS-BLADDER” REFLEX IN SPINA BIFIDA Benjamin Girdler*, Cynthia Turzewski, Kevin Feber, Ananias Diokno, William Nantau, Jose A Gonzalez, Gary Trock, Brian Bush, Kenneth Peters. Royal Oak, MI. INTRODUCTION AND OBJECTIVE: The concept of restoring EODGGHUIXQFWLRQLQVSLQDEL¿GDE\WKHFUHDWLRQRIDVNLQ&16EODGGHU UHÀH[DUFE\DQLQWUDGXUDOOXPEDUWRVDFUDOPRWRUURRWPLFURDQDVWRPRVLV was introduced by Xiao. Despite a reported success rate as high as 87% at one year, the procedure has not gained widespread acceptance outside of China. We report our early experience and outcomes with the novel procedure. METHODS: Nine patients (3 males, 6 females) with median DJH RI UDQJH WR \HDUV TXDOL¿HG IRU WKH SURFHGXUH IROORZLQJ detailed preoperative spine MRI, neurophysiologic and urodynamic evaluation. Of the 9 patients, 5 patients had prior defect closure within 24 hours of birth, 3 underwent intrauterine closure and 1 had no prior surgery. The Xiao procedure was then performed with intraoperative neurophysiologic monitoring. Postoperative evaluation included neurological examination at 1 month, follow-up questionnaires and XURG\QDPLFWHVWLQJLQFOXGLQJDWWHPSWHGVWLPXODWLRQRIWKHUHÀH[DUFDW 3 and 6 months, and repeat imaging and labs at 6 months. Ongoing patient follow-up will continue for three years. RESULTS: Mean operative time was 183 (range 127-278) minutes. Donor motor roots were L2 in 1 patient, L3 in 3, L5 in 3 and S1 in 2. Mean EBL was 57 (range 10-100) mL. No patients required a transfusion and no intraoperative complications occurred. Length of stay averaged 3.4 (range 2-7) days. Perioperative complications included foot-drop in 1 patient, wound drainage in 3 patients, and prolonged inability to bear weight in 1 patient. At 1 month, neurological examination revealed major changes in gait in 2/9. 8/9 displayed variable weakness of one or more lower extremity muscle groups. 7 of 9 patients returned to baseline at 6 months with physical therapy and time. Intrauterine closure was associated with longer operative times, worse intraoperative scar tissue and worse weakness postoperatively. Several months postop, 3 patients reported sudden worsening of urinary and/or fecal incontinence and/or increased sensation, improved continence and then the ability to initiate voiding. During 6 months UDTs, 3 children were able to voluntarily YRLGDPHDQRI UDQJH FFVZLWKDQLQWHUPLWWHQWÀRZSDWWHUQ 6WLPXODWLRQRIWKHDSSURSULDWHGHUPDWRPHFDXVHGDVLJQL¿FDQWULVHLQ pDet in 3 patients. At 6 months, 78% of patients reported that they would undergo the procedure again. CONCLUSIONS: The Xiao Procedure enables patients with VSLQDEL¿GDWRYROXQWDULO\YRLGDVHDUO\DVPRQWKVSRVWRSHUDWLYHO\ Source of Funding: Ministrelli Program for Urologic Research and Education (MPURE).
850 INTERNATIONAL ROBOT-ASSISTED CYSTECTOMY CONSORTIUM (IRCC): IMMEDIATE ONCOLOGIC RESULTS AFTER ONE HUNDRED AND SIXTY TWO CASES Khurshid A Guru*, Raj S Pruthi, Zubair M Butt, Eric Wallen, Fred Muhletaler, James L Mohler, Hans Stricker, Hyung L Kim, Peter N Wiklund, James O Peabody, Mani Menon. Buffalo, NY, Chapel Hill, NC, Detroit, MI, and Stockholm, Sweden.. INTRODUCTION AND OBJECTIVE: Radical cystectomy UHPDLQVRQHRIWKHPRVWHIIHFWLYHWUHDWPHQWVIRUSDWLHQWVZLWKORFDOL]HG invasive bladder cancer. Interest in robot assisted surgery for bladder cancer has increased over last several years. Several institutions worldwide have attempted to evaluate and incorporate robot assisted radical cystectomy (RARC) into their practices. We report combined immediate oncologic results after robot assisted radical cystectomy from the consortium. METHODS: The International Robot-assisted Cystectomy Consortium (IRCC) is an international cooperative effort by multiple academic institutions across the globe. Between April 2002 and October 2007, 162 patients underwent RARC with urinary diversion for invasive bladder cancer at 4 academic institutions: Roswell Park Cancer Institute (67), University of North Carolina Chapel Hill (43), Henry Ford Health System (37) & Karolinska Institute Sweden (15). RESULTS: Total of 162 patients underwent robot assisted radical cystectomy (Male: 133, Female: 29). Mean age of the cohort was 64 years (range 36-90). Final pathological stage showed 91 patients KDGRUJDQFRQ¿QHGGLVHDVHSDWLHQWV KDGS7DQG patients (13%) had pT4 disease. The overall rate of positive margins was 8 %. The mean lymph node yield was 18 (1-43). Pathological Stage 7 T3 T4
Number 91 50 21
Positive nodes (%) 5 (5) 21 (42) 10 (48)
Positive Margins (%) 1 (1) 4 (8) 8 (38)
CONCLUSIONS: IRCC is a multi-institutional consortium effort with the largest series of robot assisted radical cystectomy. Our immediate oncologic results appear to be comparable to open radical F\VWHFWRP\ GDWD /RQJ WHUP RQFRORJLF UHVXOWV ZLOO GH¿QH LWV UROH LQ urologic oncology. Source of Funding: None
851 COMPLICATIONS AND OUTCOMES OF CYSTECTOMY IN HIGH RISK PATIENTS James S McIntosh*, Felipe Rosso, Mitra Tabidian, Jeffrey M Holzbeierlein. Kansas City, KS. INTRODUCTION AND OBJECTIVE: To investigate the complications and outcomes in high risk patients undergoing radical cystectomy. METHODS: A detailed database of 272 consecutive patients who underwent radical cystectomy at our institution from 1997 to 2006 ZDVDFFHVVHG+LJKULVNSDWLHQWVZHUHGH¿QHGDVWKRVHSDWLHQWVZLWK an American Society of Anesthesiologists (ASA) score greater than or equal to 3, a body mass index (BMI) greater than or equal to 30, or prior chemotherapy, radiation or partial cystectomy. 210 high risk patients ZHUH LGHQWL¿HG 7KHLU FRPSOLFDWLRQV DQG RXWFRPHV ZHUH FRPSDUHG to 62 radical cystectomy patients who were not considered high risk. Early complications included ileus, wound infection, need for parenteral nutrition, DVT, return to operating room, pneumonia, pulmonary embolus, myocardial infarction, stroke, dehiscence, pulmonary failure, sepsis, bowel leak, urine leak, and small bowel obstruction. Long-term FRPSOLFDWLRQVLQFOXGHGKHUQLDUHQDOLQVXI¿FLHQF\XUHWHURHQWHULFVWULFWXUH VPDOOERZHOREVWUXFWLRQ¿VWXODVWURNHEODGGHUQHFNFRQWUDFWXUHDQG infection. Outcomes included type of diversion and disease status. 5(68/76 )LIW\¿YHSDWLHQWVXQGHUZHQWDVDOYDJHF\VWHFWRP\ DQGSDWLHQWVKDGDQ$6$%0,¶VZHUHDYDLODEOHRQSDWLHQWV RIZKLFKKDGD%0,2YHUDOOFRPSOLFDWLRQUDWHZDVKRZHYHU when excluding ileus it was 37%. Recent series from 2003 to 2006 UHYHDOHGFRPSOLFDWLRQUDWHRI1RVLJQL¿FDQWGLIIHUHQFHZDVIRXQG in complication rates or disease outcomes in the three groups. Length of intensive care unit and hospital stay was longer in patients with an ASA
THE JOURNAL OF UROLOGY®
295
1RVLJQL¿FDQWGLIIHUHQFHLQFRPSOLFDWLRQUDWHZDVIRXQGEHWZHHQ conduit or continent diversions. BMI did not affect type of diversion, however, patients with ASA > 3 and patients undergoing a salvage cystectomy were more likely to receive a conduit. CONCLUSIONS: Given no difference in complication rates between conduits and continent diversions, we suggest that ASA score, BMI, or previous therapy should not exclude a patient from a cystectomy with continent diversion. Source of Funding: None
Pediatrics: Myelodysplasia, Neuropathic Bladder, Dysfunctional Voiding and Enuresis Podium Session 20 Monday, May 19, 2008
10:30 am - 12:30 pm
852 SIX MONTH EVALUATION OF THE BEAUMONT EXPERIENCE WITH THE XIAO “SKIN-CNS-BLADDER” REFLEX IN SPINA BIFIDA Benjamin Girdler*, Cynthia Turzewski, Kevin Feber, Ananias Diokno, William Nantau, Jose A Gonzalez, Gary Trock, Brian Bush, Kenneth Peters. Royal Oak, MI. INTRODUCTION AND OBJECTIVE: The concept of restoring EODGGHUIXQFWLRQLQVSLQDEL¿GDE\WKHFUHDWLRQRIDVNLQ&16EODGGHU UHÀH[DUFE\DQLQWUDGXUDOOXPEDUWRVDFUDOPRWRUURRWPLFURDQDVWRPRVLV was introduced by Xiao. Despite a reported success rate as high as 87% at one year, the procedure has not gained widespread acceptance outside of China. We report our early experience and outcomes with the novel procedure. METHODS: Nine patients (3 males, 6 females) with median DJH RI UDQJH WR \HDUV TXDOL¿HG IRU WKH SURFHGXUH IROORZLQJ detailed preoperative spine MRI, neurophysiologic and urodynamic evaluation. Of the 9 patients, 5 patients had prior defect closure within 24 hours of birth, 3 underwent intrauterine closure and 1 had no prior surgery. The Xiao procedure was then performed with intraoperative neurophysiologic monitoring. Postoperative evaluation included neurological examination at 1 month, follow-up questionnaires and XURG\QDPLFWHVWLQJLQFOXGLQJDWWHPSWHGVWLPXODWLRQRIWKHUHÀH[DUFDW 3 and 6 months, and repeat imaging and labs at 6 months. Ongoing patient follow-up will continue for three years. RESULTS: Mean operative time was 183 (range 127-278) minutes. Donor motor roots were L2 in 1 patient, L3 in 3, L5 in 3 and S1 in 2. Mean EBL was 57 (range 10-100) mL. No patients required a transfusion and no intraoperative complications occurred. Length of stay averaged 3.4 (range 2-7) days. Perioperative complications included foot-drop in 1 patient, wound drainage in 3 patients, and prolonged inability to bear weight in 1 patient. At 1 month, neurological examination revealed major changes in gait in 2/9. 8/9 displayed variable weakness of one or more lower extremity muscle groups. 7 of 9 patients returned to baseline at 6 months with physical therapy and time. Intrauterine closure was associated with longer operative times, worse intraoperative scar tissue and worse weakness postoperatively. Several months postop, 3 patients reported sudden worsening of urinary and/or fecal incontinence and/or increased sensation, improved continence and then the ability to initiate voiding. During 6 months UDTs, 3 children were able to voluntarily YRLGDPHDQRI UDQJH FFVZLWKDQLQWHUPLWWHQWÀRZSDWWHUQ 6WLPXODWLRQRIWKHDSSURSULDWHGHUPDWRPHFDXVHGDVLJQL¿FDQWULVHLQ pDet in 3 patients. At 6 months, 78% of patients reported that they would undergo the procedure again. CONCLUSIONS: The Xiao Procedure enables patients with VSLQDEL¿GDWRYROXQWDULO\YRLGDVHDUO\DVPRQWKVSRVWRSHUDWLYHO\ Source of Funding: Ministrelli Program for Urologic Research and Education (MPURE).