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MP64-11 EVALUATION OF SURGICAL COMPLICATIONS IN A CONTEMPORARY SERIES OF PARTIAL NEPHRECTOMY PATIENTS
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
e833
MP64-09
MP64-10
MULTIPLE TUMOR EXCISIONS INCREASE COMPLICATIONS AFTER PARTIAL NEPHRECTOMY
PERIOPERATIVE ASPIRIN DOES NOT HAVE SIGNIFICANT IMPACT ON BLEEDING COMPLICATIONS FOLLOWING ROBOTIC PARTIAL NEPHRECTOMY
Matthew J. Maurice*, Daniel Ramirez, Peter A. Caputo, Onder Kara, Jihad H. Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: The association between ipsilateral multifocal disease and postoperative complications following partial nephrectomy is poorly characterized. We sought to assess the impact of ipsilateral tumor multifocality on complications after robotic partial nephrectomy (RPN). METHODS: Using our retrospective RPN database, we abstracted data on patients who were treated between 2006 and 2015. Multifocal disease was characterized by >1 masses seen on preoperative imaging or >1 separate excisions performed during RPN. The primary outcome was the overall rate of postoperative complications. The association between ipsilateral tumor multifocality and complications was evaluated using univariate analysis and multivariate logistic regression. RESULTS: Of 1123 cases, 59 (5.3%) had >1 ipsilateral renal masses and 35 (3.1%) had >1 separate ipsilateral excisions. The overall complication rate for the entire cohort was 22.2% (249/1123). Increasing number of ipsilateral renal masses was associated with a higher complication rate, 21.7% (231/1064) for 1 mass, 25.0% (9/36) for 2 masses, and 39.1% (9/14) for >2 masses, but this difference was not significant (p¼.127). However, performing >2 excisions during RPN was significantly associated with overall complications (p¼.006). Other variables significantly associated with overall complications on univariate analysis were age, race, Charlson score, body mass index, tumor size, and RENAL score. After adjusting for these factors on multivariate analysis, number of excisions remained a significant predictor of overall complications (OR 5.6, 95%CI 1.7-18.4, p¼.003). Other independent predictors of overall complications on multivariate analysis included race, Charlson score, body mass index, and RENAL score. Major complications were higher (16.7% vs. 5.8%) for patients having >2 vs. 1 excision(s) as well, but this difference was not significant (p¼.268). CONCLUSIONS: Patients with ipsilateral multifocal disease requiring 2 or more excisions are at increased risk for complications following RPN. Pending prospective validation, this information may facilitate clinical decision-making and patient counseling.
Vignesh T. Packiam*, Charles U. Nottingham, Andrew J. Cohen, Shane M. Pearce, Arieh L. Shalhav, Scott E. Eggener, Chicago, IL INTRODUCTION AND OBJECTIVES: There is controversy regarding perioperative administration of aspirin for urologic procedures with increased bleeding risk. We evaluated whether continuation of perioperative aspirin alters bleeding and other complications in patients who undergo robotic partial nephrectomy. METHODS: Retrospective review identified 214 consecutive patients who underwent robotic partial nephrectomy at our institution from May 2012 to March 2015. Patients were stratified by perioperative aspirin administration status: 49 (23%) patients continued aspirin (81 mg), 34 (16%) patients held aspirin for at least 7 days prior to surgery, and 131 (61%) patients had never taken aspirin. Primary outcomes were bleeding complications including post-operative hemoglobin drop of > 3g/dL during admission, post-operative blood transfusion, or necessity for urgent selective angiographic embolization. RESULTS: Patients continuing aspirin were older (median age 68 vs 68 vs 55 years, p<0.01) and had higher Charlson Comorbidity Index (median 5 vs 4 vs 2, p<0.01) compared to patients who held or never took aspirin. Overall mean BMI was 30.7 7.4 kg/m2 and mean tumor size was 3.4 1.8 cm, which were not different between groups (all p>0.6). There was no difference in estimated blood loss, operating room time, or length of stay between groups (all p>0.1). Compared to those who held or never took aspirin, patients continuing aspirin had similar rates of overall bleeding complications (27% vs 15% vs 14%, p¼0.13), hemoglobin drop > 3g/dL (24% vs 15% vs 14%, p¼0.24), and post-operative blood transfusion (4% vs 3% vs 2%, p¼0.43), although they did trend to more frequent need for embolization (6% vs 3% vs 1%, p¼0.07). Two of 3 cases of embolization for those who continued aspirin occurred > 3 days after discharge, while both cases in other groups occurred during initial admission. Continuation of aspirin was associated with higher overall 30-day complications compared to the two other groups (24% vs 12% vs 8%, p¼0.03). There were no reoperations for bleeding or 30-day thromboembolic events. One cardiac complication occurred for a patient who held aspirin: bradycardia requiring pacemaker placement. CONCLUSIONS: Continuation of perioperative aspirin for patients undergoing robotic partial nephrectomy was not associated with higher overall bleeding complications although there was a trend toward more frequent need for embolization. Our data suggests continuing perioperative aspirin is safe and may minimize thromboembolic risk. Source of Funding: none
MP64-11 EVALUATION OF SURGICAL COMPLICATIONS IN A CONTEMPORARY SERIES OF PARTIAL NEPHRECTOMY PATIENTS Harras Zaid*, R. Houston Thompson, William Parker, Christine Lohse, John Cheville, Stephen Boorjian, Bradley Leibovich, Rochester, MN
Source of Funding: none
INTRODUCTION AND OBJECTIVES: Partial nephrectomy (PN) has become the treatment of choice for small renal masses. Over the past decade, practice patterns have changed, with increased utilization of PN and minimally invasive technologies. A comprehensive institutional review during this time period remains understudied, especially with regards to predictors of post-operative complications. We thus reviewed our experience with PN in a contemporary cohort. METHODS: We performed a single institution retrospective study evaluating all adult patients undergoing PN between 2001-2012 for non-hereditary renal masses at the Mayo Clinic. Univariable and multivariable logistic regression models were evaluated to assess clinicopathologic predictors of post-operative complications within 30 days.
THE JOURNAL OF UROLOGYâ
e834
RESULTS: We identified 1763 patients who underwent 1773 PNs between 2001-2012. Clinicopathologic feature are summarized in the Table for early (2001-2006) and late (2007-2012) cohorts. In the early cohort, 766 partial nephrectomies were performed (85% open, 15% laparoscopic, <1% robotic); in contrast, during the late cohort, 1007 partial nephrectomies were performed (75% open, 8% laparoscopic, 17% robotic); p < 0001. Between 2001-2012, there were 241 (14%) PNs that resulted in an early surgical complication (see Table), with the majority (51%) being Clavien 1-2. In a multivariable model, the following features predicted increased risk of complication: male gender (OR 1.40, p ¼ 0.036); solitary kidney (OR 1.71, p ¼ 0.021); eGFR < 30 (OR 2.89, p ¼ 0.002); and Charlson score 3 (OR 1.97, p < 0.001). Compared to open surgery, laparoscopic and robotic approaches were 2.12 and 2.38 times less likely to result in a complication on multivariable analysis (OR 0.47, p ¼ 0.017 and OR 0.42, p ¼ 0.016, respectively). CONCLUSIONS: Over the past decade, there has been a significant increase in the number of PNs performed, especially robotic. Patient-level factors associated with higher rates of early complication include male gender, solitary kidney, renal insufficiency, and higher Charlson score, regardless of approach. These data may help inform patient counseling prior to PN, and selection of high-risk candidates for percutaneous ablative approaches.
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
nephrectomy (PN, n¼194), radical nephrectomy (RN, n¼25), or radiofrequency ablation (RFA, n¼52), and had surveillance follow up at our institution. Standard surveillance protocol coincides with AUA guideline recommendations. Retrospective chart review was performed to identify demographics, pathologic findings, and surveillance records. The primary outcome was the incidence of asymptomatic pulmonary recurrences diagnosed by CXR in pT1a disease, and our secondary outcome compared diagnoses by treatment modality (PN, RN, or RFA). RESULTS: Baseline demographics and pathologic diagnosis are shown in table 1. Median follow up for the entire cohort was 36 months (range 1-152 months), and 193/271 patients (71%) had greater than 24 months of follow-up. A mean of 3.2 surveillance CXR were completed per patient. A total of 3/271 patients developed pulmonary metastases (1.1%), but only 1 patient was diagnosed with standard CXR surveillance (0.4%). The other two patients were diagnosed based on symptoms after prior negative CXR, and computed tomography (CT) of the chest with a negative CXR, respectively. When assessed by treatment type, there was not a significant difference in recurrence rates for PN (0/194), RN (0/25), or RFA (1.9%, 1/ 52) (p¼0.1). CONCLUSIONS: CXR are a low-yield diagnostic tool for the detection of asymptomatic pulmonary metastasis in patients with pT1a RCC. Mode of treatment does not appear to influence the need for CXR surveillance. Alternative screening recommendations including periodic chest CT and means to identify late recurrences (>5 years post-surgery) remains to be determined.
Source of Funding: None.
MP64-12 THE UTILITY OF CHEST X-RAYS FOR PATHOLOGIC T1A RENAL CELL CARCINOMA SURVEILLANCE Noah Canvasser*, Kylee Stouder, Aaron Lay, Jeffrey Gahan, Yair Lotan, Vitaly Margulis, Ganesh Raj, Arthur Sagalowsky, Jeffrey Cadeddu, Dallas, TX INTRODUCTION AND OBJECTIVES: The past two decades have brought much change to post-operative imaging surveillance for renal cell carcinoma (RCC). While chest x-ray (CXR) is the most commonly ordered surveillance study for all stages of RCC, the overall incidence of pulmonary metastasis for pathologic T1 disease is less than 5%. Our goal was to evaluate the utility of CXR in pT1a RCC surveillance. METHODS: Between 2006 and 2012, 271 patients had pathologically confirmed T1a RCC, were treated with partial
Source of Funding: none
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
e833
MP64-09
MP64-10
MULTIPLE TUMOR EXCISIONS INCREASE COMPLICATIONS AFTER PARTIAL NEPHRECTOMY
PERIOPERATIVE ASPIRIN DOES NOT HAVE SIGNIFICANT IMPACT ON BLEEDING COMPLICATIONS FOLLOWING ROBOTIC PARTIAL NEPHRECTOMY
Matthew J. Maurice*, Daniel Ramirez, Peter A. Caputo, Onder Kara, Jihad H. Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: The association between ipsilateral multifocal disease and postoperative complications following partial nephrectomy is poorly characterized. We sought to assess the impact of ipsilateral tumor multifocality on complications after robotic partial nephrectomy (RPN). METHODS: Using our retrospective RPN database, we abstracted data on patients who were treated between 2006 and 2015. Multifocal disease was characterized by >1 masses seen on preoperative imaging or >1 separate excisions performed during RPN. The primary outcome was the overall rate of postoperative complications. The association between ipsilateral tumor multifocality and complications was evaluated using univariate analysis and multivariate logistic regression. RESULTS: Of 1123 cases, 59 (5.3%) had >1 ipsilateral renal masses and 35 (3.1%) had >1 separate ipsilateral excisions. The overall complication rate for the entire cohort was 22.2% (249/1123). Increasing number of ipsilateral renal masses was associated with a higher complication rate, 21.7% (231/1064) for 1 mass, 25.0% (9/36) for 2 masses, and 39.1% (9/14) for >2 masses, but this difference was not significant (p¼.127). However, performing >2 excisions during RPN was significantly associated with overall complications (p¼.006). Other variables significantly associated with overall complications on univariate analysis were age, race, Charlson score, body mass index, tumor size, and RENAL score. After adjusting for these factors on multivariate analysis, number of excisions remained a significant predictor of overall complications (OR 5.6, 95%CI 1.7-18.4, p¼.003). Other independent predictors of overall complications on multivariate analysis included race, Charlson score, body mass index, and RENAL score. Major complications were higher (16.7% vs. 5.8%) for patients having >2 vs. 1 excision(s) as well, but this difference was not significant (p¼.268). CONCLUSIONS: Patients with ipsilateral multifocal disease requiring 2 or more excisions are at increased risk for complications following RPN. Pending prospective validation, this information may facilitate clinical decision-making and patient counseling.
Vignesh T. Packiam*, Charles U. Nottingham, Andrew J. Cohen, Shane M. Pearce, Arieh L. Shalhav, Scott E. Eggener, Chicago, IL INTRODUCTION AND OBJECTIVES: There is controversy regarding perioperative administration of aspirin for urologic procedures with increased bleeding risk. We evaluated whether continuation of perioperative aspirin alters bleeding and other complications in patients who undergo robotic partial nephrectomy. METHODS: Retrospective review identified 214 consecutive patients who underwent robotic partial nephrectomy at our institution from May 2012 to March 2015. Patients were stratified by perioperative aspirin administration status: 49 (23%) patients continued aspirin (81 mg), 34 (16%) patients held aspirin for at least 7 days prior to surgery, and 131 (61%) patients had never taken aspirin. Primary outcomes were bleeding complications including post-operative hemoglobin drop of > 3g/dL during admission, post-operative blood transfusion, or necessity for urgent selective angiographic embolization. RESULTS: Patients continuing aspirin were older (median age 68 vs 68 vs 55 years, p<0.01) and had higher Charlson Comorbidity Index (median 5 vs 4 vs 2, p<0.01) compared to patients who held or never took aspirin. Overall mean BMI was 30.7 7.4 kg/m2 and mean tumor size was 3.4 1.8 cm, which were not different between groups (all p>0.6). There was no difference in estimated blood loss, operating room time, or length of stay between groups (all p>0.1). Compared to those who held or never took aspirin, patients continuing aspirin had similar rates of overall bleeding complications (27% vs 15% vs 14%, p¼0.13), hemoglobin drop > 3g/dL (24% vs 15% vs 14%, p¼0.24), and post-operative blood transfusion (4% vs 3% vs 2%, p¼0.43), although they did trend to more frequent need for embolization (6% vs 3% vs 1%, p¼0.07). Two of 3 cases of embolization for those who continued aspirin occurred > 3 days after discharge, while both cases in other groups occurred during initial admission. Continuation of aspirin was associated with higher overall 30-day complications compared to the two other groups (24% vs 12% vs 8%, p¼0.03). There were no reoperations for bleeding or 30-day thromboembolic events. One cardiac complication occurred for a patient who held aspirin: bradycardia requiring pacemaker placement. CONCLUSIONS: Continuation of perioperative aspirin for patients undergoing robotic partial nephrectomy was not associated with higher overall bleeding complications although there was a trend toward more frequent need for embolization. Our data suggests continuing perioperative aspirin is safe and may minimize thromboembolic risk. Source of Funding: none
MP64-11 EVALUATION OF SURGICAL COMPLICATIONS IN A CONTEMPORARY SERIES OF PARTIAL NEPHRECTOMY PATIENTS Harras Zaid*, R. Houston Thompson, William Parker, Christine Lohse, John Cheville, Stephen Boorjian, Bradley Leibovich, Rochester, MN
Source of Funding: none
INTRODUCTION AND OBJECTIVES: Partial nephrectomy (PN) has become the treatment of choice for small renal masses. Over the past decade, practice patterns have changed, with increased utilization of PN and minimally invasive technologies. A comprehensive institutional review during this time period remains understudied, especially with regards to predictors of post-operative complications. We thus reviewed our experience with PN in a contemporary cohort. METHODS: We performed a single institution retrospective study evaluating all adult patients undergoing PN between 2001-2012 for non-hereditary renal masses at the Mayo Clinic. Univariable and multivariable logistic regression models were evaluated to assess clinicopathologic predictors of post-operative complications within 30 days.
THE JOURNAL OF UROLOGYâ
e834
RESULTS: We identified 1763 patients who underwent 1773 PNs between 2001-2012. Clinicopathologic feature are summarized in the Table for early (2001-2006) and late (2007-2012) cohorts. In the early cohort, 766 partial nephrectomies were performed (85% open, 15% laparoscopic, <1% robotic); in contrast, during the late cohort, 1007 partial nephrectomies were performed (75% open, 8% laparoscopic, 17% robotic); p < 0001. Between 2001-2012, there were 241 (14%) PNs that resulted in an early surgical complication (see Table), with the majority (51%) being Clavien 1-2. In a multivariable model, the following features predicted increased risk of complication: male gender (OR 1.40, p ¼ 0.036); solitary kidney (OR 1.71, p ¼ 0.021); eGFR < 30 (OR 2.89, p ¼ 0.002); and Charlson score 3 (OR 1.97, p < 0.001). Compared to open surgery, laparoscopic and robotic approaches were 2.12 and 2.38 times less likely to result in a complication on multivariable analysis (OR 0.47, p ¼ 0.017 and OR 0.42, p ¼ 0.016, respectively). CONCLUSIONS: Over the past decade, there has been a significant increase in the number of PNs performed, especially robotic. Patient-level factors associated with higher rates of early complication include male gender, solitary kidney, renal insufficiency, and higher Charlson score, regardless of approach. These data may help inform patient counseling prior to PN, and selection of high-risk candidates for percutaneous ablative approaches.
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
nephrectomy (PN, n¼194), radical nephrectomy (RN, n¼25), or radiofrequency ablation (RFA, n¼52), and had surveillance follow up at our institution. Standard surveillance protocol coincides with AUA guideline recommendations. Retrospective chart review was performed to identify demographics, pathologic findings, and surveillance records. The primary outcome was the incidence of asymptomatic pulmonary recurrences diagnosed by CXR in pT1a disease, and our secondary outcome compared diagnoses by treatment modality (PN, RN, or RFA). RESULTS: Baseline demographics and pathologic diagnosis are shown in table 1. Median follow up for the entire cohort was 36 months (range 1-152 months), and 193/271 patients (71%) had greater than 24 months of follow-up. A mean of 3.2 surveillance CXR were completed per patient. A total of 3/271 patients developed pulmonary metastases (1.1%), but only 1 patient was diagnosed with standard CXR surveillance (0.4%). The other two patients were diagnosed based on symptoms after prior negative CXR, and computed tomography (CT) of the chest with a negative CXR, respectively. When assessed by treatment type, there was not a significant difference in recurrence rates for PN (0/194), RN (0/25), or RFA (1.9%, 1/ 52) (p¼0.1). CONCLUSIONS: CXR are a low-yield diagnostic tool for the detection of asymptomatic pulmonary metastasis in patients with pT1a RCC. Mode of treatment does not appear to influence the need for CXR surveillance. Alternative screening recommendations including periodic chest CT and means to identify late recurrences (>5 years post-surgery) remains to be determined.
Source of Funding: None.
MP64-12 THE UTILITY OF CHEST X-RAYS FOR PATHOLOGIC T1A RENAL CELL CARCINOMA SURVEILLANCE Noah Canvasser*, Kylee Stouder, Aaron Lay, Jeffrey Gahan, Yair Lotan, Vitaly Margulis, Ganesh Raj, Arthur Sagalowsky, Jeffrey Cadeddu, Dallas, TX INTRODUCTION AND OBJECTIVES: The past two decades have brought much change to post-operative imaging surveillance for renal cell carcinoma (RCC). While chest x-ray (CXR) is the most commonly ordered surveillance study for all stages of RCC, the overall incidence of pulmonary metastasis for pathologic T1 disease is less than 5%. Our goal was to evaluate the utility of CXR in pT1a RCC surveillance. METHODS: Between 2006 and 2012, 271 patients had pathologically confirmed T1a RCC, were treated with partial
Source of Funding: none