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MP63-01 A PROPOSAL FOR A NOVEL PERI-OPERATIVE MORTALITY RISK ASSESSMENT TOOL IN CONTEMPORARY PATIENTS TREATED WITH RADICAL CYSTECTOMY
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
Science, and Technology of Japan (MEXT), Japan; a Medical Research Promotion Grant from Takeda Science Foundation, Japan; and a Research Promotion Grant from the Uehara Memorial Foundation, Japan.
Bladder Cancer: Invasive V Moderated Poster Monday, May 9, 2016
8:00 AM-10:00 AM
MP63-01 A PROPOSAL FOR A NOVEL PERI-OPERATIVE MORTALITY RISK ASSESSMENT TOOL IN CONTEMPORARY PATIENTS TREATED WITH RADICAL CYSTECTOMY Paolo Dell’Oglio, Zhe Tian*, Sami-Ramzi Leyh-Bannurah, Vincent Trudeau, Montreal, Canada; Alessandro Larcher, Umberto Capitanio, Alberto Briganti, Francesco Montorsi, Milan, Italy; Pierre Karakiewicz, Montreal, Canada INTRODUCTION AND OBJECTIVES: The Charlson comorbidity index (CCI) is the most widely used index score in retrospective analyses. However, several comorbid conditions included in this index, such as sever liver disease, AIDS, leukemia/lymphoma, are never seen in patients candidate to radical cystectomy (RC). Some other comorbid conditions, such as diabetes, and chronic pulmonary disease, are very frequently seen. Conversely, other conditions that are not accounted within that CCI index may represent better predictors of perioperative mortality. The purpose of this study was to identify such predictors. METHODS: We relied on 7,076 T1-T4 non-metastatic bladder cancer patients treated with RC between 2000 and 2009 in the SEERMedicare linked database. Of those, 6,076 patients were randomly included within the development cohort and the remaining 1,000 were used for validation. Within the development cohort we relied on simulated annealing on cross-validated c-index to identify the most parsimonious and highly predictive set of conditions (using unique ICD-9 diagnostic code) predicting 90-day mortality after RC, adjusting for T stage, N stage, age, gender and race. The final set of conditions identified was tested within the validation cohort for the ability to predict 90-day mortality. The validated adaptation of CCI by Deyo et al. was also tested in the validation cohort for purpose of comparison after adjusting for T stage, N stage, age, gender and race. RESULTS: Within respectively development and validation cohort, 630 (10.4%) and 131 (13.1%) patients died within 90 days. Within the development cohort, 7 conditions that are based on a single ICD-9 code, were identified and satisfied the parsimony and accuracy criteria: 1. congestive hearth failure, (11.9 % prevalence) 2. urinary tract infection, (60.0% prevalence) 3. anemia, (24.4% prevalence) 4. chronic pulmonary disease, (23.4% prevalence) 5. cardiomegaly, (9.4% prevalence) 6. hematuria (81.3% prevalence) 7. hydronephrosis (22.9% prevalence) Within the validation cohort, the 7 conditions resulted in 71% accuracy in prediction of 90-day mortality relative to 68% for the adapted CCI by Deyo et al. that relied on 17 groupings of comorbid conditions (33 conditions with 187 ICD-9 codes). CONCLUSIONS: In external validation cohort, our new proposed tool for prediction of perioperative mortality after RC was 3% more accurate and relied on 7 instead of 187 ICD-9 codes. In consequence, our method appears to offer a significant advantage compared to the adapted CCI by Deyo et al, based on simplicity and better accuracy. Source of Funding: None
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MP63-02 A PHASE I/II TRIAL OF PREHABILITATION IN PATIENTS UNDERGOING CYSTECTOMY FOR BLADDER CANCER Jeffrey Montgomery*, Todd Morgan, Steven Thelen-Perry, Chang He, Cheryl Lee, Christine Parker, Heidi IglayReger, Khaled Hafez, Brent Hollenbeck, Alon Weizer, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Most cystectomy patients are elderly and frail. As a result, they experience high complication rates, frequent hospital readmissions, poor quality of life (QOL) outcomes and require substantial medical resources. Prehabilitation is the process of fitness training prior to surgery to improve patient outcome. We sought to prospectively study the impact of prehabilitation prior to cystectomy on postoperative readmissions. METHODS: After IRB approval in 2013, patients >60 years old requiring cystectomy for bladder cancer were recruited to participate in this ongoing trial. Planned enrollment is 50 patients, and the present report represents an interim analysis. Patients exercised in a 1:1 supervised setting with a certified personal trainer 3 days a week for 4 weeks before surgery. Fitness and QOL measures were obtained at baseline and after completing the exercise course; QOL was reevaluated 30 and 90 days after surgery. Differences across these time points were compared using The Wilcoxon signed-rank test. RESULTS: 22 patients with mean age 71.8 (6.5) and median Charleson comorbidity index of 6 (range 4-11) were included. 59% were cT2, 41% underwent neoadjuvant chemotherapy, 55% were pT2 and 27% were pN+. Patients attended 77% of the exercise sessions without adverse events. The mean length of stay was 7.1 days (2.6); within 90 days, 36% required hospital readmission and 73% had at least 1 complication (94% Clavien III). Compared to their baseline levels, patients improved their 15 feet walk test by 20 seconds (+6.5%), 6 minute walk distance by 53 feet (+4.7%) and submaximal exercise test VO2 by 1.7 ml/kg/min (+12%). As compared to baseline, normative SF36 scores improved for the physical, general health (GH), vitality, mental health (MH) and physical composite score domains. Physical and vitality domain scores decreased after surgery but improved by day 90; GH and MH scores improved throughout (Figure). (All p<0.05) CONCLUSIONS: We report the first trial of prehabilitation in cystectomy patients, demonstrating that it is feasible, safe, and results in marked improvements in fitness and endurance parameters. Patients report improvements not just in physical but also GH, vitality and MH domains. Surgical complication and readmission rates remain high. Further accrual to this study is ongoing.
Source of Funding: Michigan Institute for Clinical and Health Research
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
Science, and Technology of Japan (MEXT), Japan; a Medical Research Promotion Grant from Takeda Science Foundation, Japan; and a Research Promotion Grant from the Uehara Memorial Foundation, Japan.
Bladder Cancer: Invasive V Moderated Poster Monday, May 9, 2016
8:00 AM-10:00 AM
MP63-01 A PROPOSAL FOR A NOVEL PERI-OPERATIVE MORTALITY RISK ASSESSMENT TOOL IN CONTEMPORARY PATIENTS TREATED WITH RADICAL CYSTECTOMY Paolo Dell’Oglio, Zhe Tian*, Sami-Ramzi Leyh-Bannurah, Vincent Trudeau, Montreal, Canada; Alessandro Larcher, Umberto Capitanio, Alberto Briganti, Francesco Montorsi, Milan, Italy; Pierre Karakiewicz, Montreal, Canada INTRODUCTION AND OBJECTIVES: The Charlson comorbidity index (CCI) is the most widely used index score in retrospective analyses. However, several comorbid conditions included in this index, such as sever liver disease, AIDS, leukemia/lymphoma, are never seen in patients candidate to radical cystectomy (RC). Some other comorbid conditions, such as diabetes, and chronic pulmonary disease, are very frequently seen. Conversely, other conditions that are not accounted within that CCI index may represent better predictors of perioperative mortality. The purpose of this study was to identify such predictors. METHODS: We relied on 7,076 T1-T4 non-metastatic bladder cancer patients treated with RC between 2000 and 2009 in the SEERMedicare linked database. Of those, 6,076 patients were randomly included within the development cohort and the remaining 1,000 were used for validation. Within the development cohort we relied on simulated annealing on cross-validated c-index to identify the most parsimonious and highly predictive set of conditions (using unique ICD-9 diagnostic code) predicting 90-day mortality after RC, adjusting for T stage, N stage, age, gender and race. The final set of conditions identified was tested within the validation cohort for the ability to predict 90-day mortality. The validated adaptation of CCI by Deyo et al. was also tested in the validation cohort for purpose of comparison after adjusting for T stage, N stage, age, gender and race. RESULTS: Within respectively development and validation cohort, 630 (10.4%) and 131 (13.1%) patients died within 90 days. Within the development cohort, 7 conditions that are based on a single ICD-9 code, were identified and satisfied the parsimony and accuracy criteria: 1. congestive hearth failure, (11.9 % prevalence) 2. urinary tract infection, (60.0% prevalence) 3. anemia, (24.4% prevalence) 4. chronic pulmonary disease, (23.4% prevalence) 5. cardiomegaly, (9.4% prevalence) 6. hematuria (81.3% prevalence) 7. hydronephrosis (22.9% prevalence) Within the validation cohort, the 7 conditions resulted in 71% accuracy in prediction of 90-day mortality relative to 68% for the adapted CCI by Deyo et al. that relied on 17 groupings of comorbid conditions (33 conditions with 187 ICD-9 codes). CONCLUSIONS: In external validation cohort, our new proposed tool for prediction of perioperative mortality after RC was 3% more accurate and relied on 7 instead of 187 ICD-9 codes. In consequence, our method appears to offer a significant advantage compared to the adapted CCI by Deyo et al, based on simplicity and better accuracy. Source of Funding: None
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MP63-02 A PHASE I/II TRIAL OF PREHABILITATION IN PATIENTS UNDERGOING CYSTECTOMY FOR BLADDER CANCER Jeffrey Montgomery*, Todd Morgan, Steven Thelen-Perry, Chang He, Cheryl Lee, Christine Parker, Heidi IglayReger, Khaled Hafez, Brent Hollenbeck, Alon Weizer, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Most cystectomy patients are elderly and frail. As a result, they experience high complication rates, frequent hospital readmissions, poor quality of life (QOL) outcomes and require substantial medical resources. Prehabilitation is the process of fitness training prior to surgery to improve patient outcome. We sought to prospectively study the impact of prehabilitation prior to cystectomy on postoperative readmissions. METHODS: After IRB approval in 2013, patients >60 years old requiring cystectomy for bladder cancer were recruited to participate in this ongoing trial. Planned enrollment is 50 patients, and the present report represents an interim analysis. Patients exercised in a 1:1 supervised setting with a certified personal trainer 3 days a week for 4 weeks before surgery. Fitness and QOL measures were obtained at baseline and after completing the exercise course; QOL was reevaluated 30 and 90 days after surgery. Differences across these time points were compared using The Wilcoxon signed-rank test. RESULTS: 22 patients with mean age 71.8 (6.5) and median Charleson comorbidity index of 6 (range 4-11) were included. 59% were cT2, 41% underwent neoadjuvant chemotherapy, 55% were pT2 and 27% were pN+. Patients attended 77% of the exercise sessions without adverse events. The mean length of stay was 7.1 days (2.6); within 90 days, 36% required hospital readmission and 73% had at least 1 complication (94% Clavien III). Compared to their baseline levels, patients improved their 15 feet walk test by 20 seconds (+6.5%), 6 minute walk distance by 53 feet (+4.7%) and submaximal exercise test VO2 by 1.7 ml/kg/min (+12%). As compared to baseline, normative SF36 scores improved for the physical, general health (GH), vitality, mental health (MH) and physical composite score domains. Physical and vitality domain scores decreased after surgery but improved by day 90; GH and MH scores improved throughout (Figure). (All p<0.05) CONCLUSIONS: We report the first trial of prehabilitation in cystectomy patients, demonstrating that it is feasible, safe, and results in marked improvements in fitness and endurance parameters. Patients report improvements not just in physical but also GH, vitality and MH domains. Surgical complication and readmission rates remain high. Further accrual to this study is ongoing.
Source of Funding: Michigan Institute for Clinical and Health Research