- Email: [email protected]
OUTCOMES IN PATIENTS WITH ADVANCED STAGE RENAL CELL CARCINOMA TREATED WITH NEPHRON SPARING SURGERY
434
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
Table 1. Pathologic Specimen Gleason score and Stage for Non-HD and HD Nerve Sparring RALRP
pT2 pT3
Non-HD RALRP
HD RALRP
23/29 (79.3%)
14/16 (87.5%)
6/29 (20.7%)
2/16 (12.5%)
Source of Funding: None
1218 ANALGESIC USE IN MEN UNDERGOING ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY: A DETAILED ANALYSIS OF DEMOGRAPHIC, CLINICAL, AND OPERATIVE, INFLUENCES Angela Smith*, Matthew Coward, Anjana Lal, Raj Kurpad, Jeff Nix, Matthew Nielsen, Eric M Wallen, Raj S Pruthi, Chapel Hill, NC INTRODUCTION AND OBJECTIVES: A variety of factors may potentially influence post-operative pain and narcotic use after surgery including patient factors (e.g. cultural influences, age, obesity), clinical factors (PSA, stage), and operative outcomes (EBL, OR time). We analyzed the potential influence of demographic, clinical, and operative factors on the use of post-operative analgesics in patients undergoing robotic-assisted radical prostatectomy. METHODS: 200 consecutive men undergoing robotic-assisted radical prostatectomy were evaluated as to their inpatient analgesic use. This included both narcotic and non-narcotic (e.g. ketorolac) usage. Narcotic use was converted to morphine- (MSO4-) equivalents, and ketorolac use reported as mg delivered and also converted to MSO4equivalents by a 3:1 (keteroloac:MSO4) conversion - an often used conversion rate in the anesthesia literature. Analysis and comparisons were made to several demographic (race, age, BMI), clinical (PSA, stage), and operative factors (OR time, EBL) to evaluate the potential influences of these factors on post-operative analgesic usage. RESULTS: Characteristics of this cohort were as follows: mean age = 59.2 years; mean BMI = 29.2; mean PSA 6.4 ng/ml. Mean analgesic usage (MSO4 equiv) was significantly higher in men 65 years (n=37) (50.2 vs. 37.3 vs. 30.8; p < 0.05). Although analgesic usage trended lower with increasing BMI (< 25 vs. 25-29.9 vs. >=30) (44.8 vs. 41.0 vs. 35.5), this did not achieve significance (p=0.130). Analgesic usage was also not different based on race, PSA, stage, OR time, or EBL. In addition, post-op analgesic usage did not correlate with longterm functional outcomes of continence (pad use) or potency. CONCLUSIONS: - In patients undergoing robotic prostatectomy, analgesic usage is higher in younger men and trends higher in patients with lower BMI. No other differences were observed based on demographic, operative, pathologic, or functional outcomes. Source of Funding: None
1219 CARDIORESPIRATORY CHANGES DURING STEEP TRENDELENBURG POSITION WITH AND WITHOUT PNEUMOPERITONEUM DURING ROBOT-ASSISTED RADICAL CYSTECTOMY Khurshid A Guru*, Zubair Butt, Abid Hussain, Rameela Chandrasekhar, Gregory Wilding, Victor Filadora, Kathleen O’leary, Buffalo, NY INTRODUCTION AND OBJECTIVES: Impact of comorbid conditions on physiologic parameters in patients undergoing robotassisted radical cystectomy during different positions has not been studied METHODS: Twenty consecutive patients who underwent robotassisted radical cystectomy over a period of 2 months were included in a prospective study. Age, sex, body mass index, American Society of Anesthesiologists (ASA) score, comorbid conditions and cardiovascular medication history were included. Measured variables included heart rate (HR), stroke volume (SV), cardiac index (CI), mean arterial pressure (MAP), central venous pressure (CVP), systemic vascular
resistance (SVR), respiratory rate (RR), tidal volume (TV), peak airway pressure (PawP), peak end expiratory pressure (PEEP) and end tidal CO2 (ETCO2). Assessments were conducted after induction of general anesthesia in the initial supine position (IS); at 45[[Unsupported Character - ◦]] Trendelenburg (T); Trendelenburg + pneumoperitoneum (TP); Trendelenburg + pneumoperitoneum + ports (TPPo); and at the end of surgery in the supine position (ES). Arterial blood gas (ABG) values were also measured at IS, 3 hours after TPPo and at one hour after ES. RESULTS: Mean cardiac index did not significantly change with position or pneumoperitoneum. Higher age was associated with lower mean cardiac index (p=0.0011). Stroke volume dropped significantly in the TPPo position (p=0.039). Cardiovascular medication use lowered the mean SV (p=0.0373) but tended to raise mean HR (p=0.0186). Cardiac output did not significantly change in any position although it increased with higher BMI (p=0.0449). Higher ASA score (p=0.0002), male gender (p=0.0063) and cardiovascular medication history (p=0.0034) were significantly associated with a higher mean MAP throughout surgery while a lowered mean SVR was associated with increased use of cardiovascular medications (p=0.0057). Ventilatory parameters of mean tidal volume and mean endtidal CO2 did not change significantly with position or pneumoperitoneum or any patient characteristics. Changes in position were significantly associated with changes in mean pH (p<0.0001), mean PCO2 (p=0.0027), mean PaO2 (p=0.0010) and mean HCO3 (p=0.0292). All patients successfully completed the surgery. CONCLUSIONS: Although pneumoperitoneum and steep Trendelenburg position significantly altered cardiovascular parameters during robot assisted radical cystectomy, overall outcomes were unaffected. Source of Funding: None
Kidney Cancer: Localized (III) Moderated Poster 41 Monday, April 27, 2009
3:30 pm - 5:30 pm
1220 OUTCOMES IN PATIENTS WITH ADVANCED STAGE RENAL CELL CARCINOMA TREATED WITH NEPHRON SPARING SURGERY. Rodney H Breau*, Paul L Crispen, Christine M Lohse, Michael L Blute, Bradley C Leibovich, Rochester, MN INTRODUCTION AND OBJECTIVES: The benefit and safety of nephron sparing surgery (NSS) for T1 renal cell carcinoma (RCC) has become clear. As surgical technique evolves, urologists may consider NSS for more complex tumors. We describe the largest reported series of NSS for advanced stage RCC. METHODS: Between 1970 and 2006, 1,807 partial nephrectomies were performed at our institution. Forty-two of these were for sporadic unilateral advanced stage tumors (pT2=22; pT3a=20). We reviewed outcomes of these patients compared to 126 patients treated with radical nephrectomy (RN) matched (3:1) for age, stage, tumor size and baseline renal function. RESULTS: Cancer-specific survival and overall survival were similar between patients treated with NSS or RN (figures 1 and 2). At a median of 6.1 years follow up, 7 (17%) NSS patients and 10 (8%) RN patients developed local recurrence (HR 2.31; 0.88 to 6.11) and 11 (26%) NSS patients and 40 (32%) RN patients developed metastatic disease (HR 0.95; 0.48-1.85). Of the NSS group, 7 (17%) were complicated by urine leak and 1 (2%) by retroperitoneal bleed requiring intervention. The average change in serum creatinine was 9.9% for the NSS group compared to 38.3% for the RN group (p<0.001). CONCLUSIONS: NSS for advanced RCC preserves renal function and appears to achieve similar oncologic outcomes compared to RN. The role of NSS in patients with T2-3a tumors and a normal contralateral kidney deserves further consideration and study.
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
435
Source of Funding: None
1221 LONG-TERM OUTCOMES AFTER NEPHRON-SPARING SURGERY FOR THE TREATMENT OF RENAL CELL CARCINOMAS LARGER THAN 4 CM Morgan Roupret*, Matthieu Peycelon, Vincent Hupertan, Eva Comperat, Raphaele Renard-Penna, Christophe Vaessen, Vincent Misrai, Pierre Conort, Emmanuel Chartier-Kastler, Marc-Olivier Bitker, François Richard, Paris, France INTRODUCTION AND OBJECTIVES: To determine the cancer control afforded by nephron-sparing surgery (NSS) in renal cell carcinomas (RCC) over 4 cm. METHODS: We performed a retrospective review of data for patients treated between 1980 and 2005. The following case characteristics were analyzed: age, surgical procedure, intraoperative parameters, complications, tumor size, Fuhrman grade, TNM stage, pathological data, and outcome. Kaplan-Meier survival curves were generated. RESULTS: The median age of the 61 patients included was 64 years (40-83). Mean intraoperative blood loss was 622 ml ± 691 (504800) and mean operative time was 155.7 ± 82 mins (52-360). Mean preoperative and immediate postoperative creatinine was 1.16 and 1.25 mg/dL, respectively. Mean RCC size was 56.3 ±18 mm (41-100). Margin status was positive in 11 cases (18%). Median follow-up time was 70.7 months. Five and ten-year cancer specific survival rates were 81% and 78%, respectively. Tumor-free survival rate was 92% at five years and 88% at ten years. By univariate analysis, tumor size >7 cm (p=0.002), pathological stage (p=0.001), and Fuhrman grade (p=0.004) were associated with survival. In the multivariate analysis, only pathological stage (p<0.0001) and Fuhrman grade (p=0.007) were significant. CONCLUSIONS: Our results support the fact that NSS is a useful and acceptable approach for RCC greater than 4 cm in size. When technically possible, NSS provides acceptable long-term cancer-specific survival rates. Oncological safety, however, is less evident in cases of RCCs greater than 7 cm. In such cases, NSS should only be considered for absolute indications so far.
Source of Funding: None
1222 AGE AT DIAGNOSIS IS AN INDEPENDENT PREDICTOR OF RECURRENCE-FREE SURVIVAL IN PATIENTS WITH SMALL RENAL CELL CARCINOMA Dalsan You*, Junsoo Park, Changhee Yoo, Seoul, Republic of Korea; Kyung Hyun Moon, Ulsan, Republic of Korea; In Gab Jeong, Jun Hyuk Hong, Hanjong Ahn, Choung-Soo Kim, Seoul, Republic of Korea INTRODUCTION AND OBJECTIVES: The incidence of incidentally detected small renal cell carcinoma (RCC) has been increased with a stage migration. This study investigated the relationship between age at diagnosis and disease recurrence after surgery in patients with small RCC. METHODS: Of the 1,196 patients who underwent curative surgery for RCC between 1989 and 2005 at our institution, 490 patients with small RCC (tumors of 4cm or less in diameter on pathological evaluation) were included in our study. Patients were stratified into three subgroups according to age at diagnosis [a40 years (n=93), 41 to 60 years (n=253), >60 years (n=144)]. Clinical and pathological variables at diagnosis were compared and a survival analysis was performed. RESULTS: Mean age at diagnosis was 52.7 years (median 54, range 10 to 80). Mean postoperative follow-up was 60.3 months (median 53, range 2 to 185). Pathologic T stages consisted of pT1a in 469 (95.7%), pT3a in 19 (3.9%) and pT3b in 2 (0.4%) patients. Fuhrman grades consisted of 1 in 35 (7.2%), 2 in 272 (55.5%), 3 in 174 (35.5%) and 4 in 9 (1.8%), respectively. Seventeen patients (3.5%) experienced disease recurrence and nine patients (1.8%) died of metastatic RCC during follow-up. Higher Fuhrman nuclear grades were associated with older age at diagnosis (p=0.001). Overall, patient recurrence-free survival (RFS) rates were 97.2% and 92.4% at 5 and 10 years, respectively. Ten year RFS rates were 100% for patients aged a40 years, 95.7% for patients aged 40 to 59 years, and 79.0% for patients aged > 60 years (p=0.002). The 5-year RFS rates for patients with pT1a and pT3a/T3b
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
Table 1. Pathologic Specimen Gleason score and Stage for Non-HD and HD Nerve Sparring RALRP
pT2 pT3
Non-HD RALRP
HD RALRP
23/29 (79.3%)
14/16 (87.5%)
6/29 (20.7%)
2/16 (12.5%)
Source of Funding: None
1218 ANALGESIC USE IN MEN UNDERGOING ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY: A DETAILED ANALYSIS OF DEMOGRAPHIC, CLINICAL, AND OPERATIVE, INFLUENCES Angela Smith*, Matthew Coward, Anjana Lal, Raj Kurpad, Jeff Nix, Matthew Nielsen, Eric M Wallen, Raj S Pruthi, Chapel Hill, NC INTRODUCTION AND OBJECTIVES: A variety of factors may potentially influence post-operative pain and narcotic use after surgery including patient factors (e.g. cultural influences, age, obesity), clinical factors (PSA, stage), and operative outcomes (EBL, OR time). We analyzed the potential influence of demographic, clinical, and operative factors on the use of post-operative analgesics in patients undergoing robotic-assisted radical prostatectomy. METHODS: 200 consecutive men undergoing robotic-assisted radical prostatectomy were evaluated as to their inpatient analgesic use. This included both narcotic and non-narcotic (e.g. ketorolac) usage. Narcotic use was converted to morphine- (MSO4-) equivalents, and ketorolac use reported as mg delivered and also converted to MSO4equivalents by a 3:1 (keteroloac:MSO4) conversion - an often used conversion rate in the anesthesia literature. Analysis and comparisons were made to several demographic (race, age, BMI), clinical (PSA, stage), and operative factors (OR time, EBL) to evaluate the potential influences of these factors on post-operative analgesic usage. RESULTS: Characteristics of this cohort were as follows: mean age = 59.2 years; mean BMI = 29.2; mean PSA 6.4 ng/ml. Mean analgesic usage (MSO4 equiv) was significantly higher in men 65 years (n=37) (50.2 vs. 37.3 vs. 30.8; p < 0.05). Although analgesic usage trended lower with increasing BMI (< 25 vs. 25-29.9 vs. >=30) (44.8 vs. 41.0 vs. 35.5), this did not achieve significance (p=0.130). Analgesic usage was also not different based on race, PSA, stage, OR time, or EBL. In addition, post-op analgesic usage did not correlate with longterm functional outcomes of continence (pad use) or potency. CONCLUSIONS: - In patients undergoing robotic prostatectomy, analgesic usage is higher in younger men and trends higher in patients with lower BMI. No other differences were observed based on demographic, operative, pathologic, or functional outcomes. Source of Funding: None
1219 CARDIORESPIRATORY CHANGES DURING STEEP TRENDELENBURG POSITION WITH AND WITHOUT PNEUMOPERITONEUM DURING ROBOT-ASSISTED RADICAL CYSTECTOMY Khurshid A Guru*, Zubair Butt, Abid Hussain, Rameela Chandrasekhar, Gregory Wilding, Victor Filadora, Kathleen O’leary, Buffalo, NY INTRODUCTION AND OBJECTIVES: Impact of comorbid conditions on physiologic parameters in patients undergoing robotassisted radical cystectomy during different positions has not been studied METHODS: Twenty consecutive patients who underwent robotassisted radical cystectomy over a period of 2 months were included in a prospective study. Age, sex, body mass index, American Society of Anesthesiologists (ASA) score, comorbid conditions and cardiovascular medication history were included. Measured variables included heart rate (HR), stroke volume (SV), cardiac index (CI), mean arterial pressure (MAP), central venous pressure (CVP), systemic vascular
resistance (SVR), respiratory rate (RR), tidal volume (TV), peak airway pressure (PawP), peak end expiratory pressure (PEEP) and end tidal CO2 (ETCO2). Assessments were conducted after induction of general anesthesia in the initial supine position (IS); at 45[[Unsupported Character - ◦]] Trendelenburg (T); Trendelenburg + pneumoperitoneum (TP); Trendelenburg + pneumoperitoneum + ports (TPPo); and at the end of surgery in the supine position (ES). Arterial blood gas (ABG) values were also measured at IS, 3 hours after TPPo and at one hour after ES. RESULTS: Mean cardiac index did not significantly change with position or pneumoperitoneum. Higher age was associated with lower mean cardiac index (p=0.0011). Stroke volume dropped significantly in the TPPo position (p=0.039). Cardiovascular medication use lowered the mean SV (p=0.0373) but tended to raise mean HR (p=0.0186). Cardiac output did not significantly change in any position although it increased with higher BMI (p=0.0449). Higher ASA score (p=0.0002), male gender (p=0.0063) and cardiovascular medication history (p=0.0034) were significantly associated with a higher mean MAP throughout surgery while a lowered mean SVR was associated with increased use of cardiovascular medications (p=0.0057). Ventilatory parameters of mean tidal volume and mean endtidal CO2 did not change significantly with position or pneumoperitoneum or any patient characteristics. Changes in position were significantly associated with changes in mean pH (p<0.0001), mean PCO2 (p=0.0027), mean PaO2 (p=0.0010) and mean HCO3 (p=0.0292). All patients successfully completed the surgery. CONCLUSIONS: Although pneumoperitoneum and steep Trendelenburg position significantly altered cardiovascular parameters during robot assisted radical cystectomy, overall outcomes were unaffected. Source of Funding: None
Kidney Cancer: Localized (III) Moderated Poster 41 Monday, April 27, 2009
3:30 pm - 5:30 pm
1220 OUTCOMES IN PATIENTS WITH ADVANCED STAGE RENAL CELL CARCINOMA TREATED WITH NEPHRON SPARING SURGERY. Rodney H Breau*, Paul L Crispen, Christine M Lohse, Michael L Blute, Bradley C Leibovich, Rochester, MN INTRODUCTION AND OBJECTIVES: The benefit and safety of nephron sparing surgery (NSS) for T1 renal cell carcinoma (RCC) has become clear. As surgical technique evolves, urologists may consider NSS for more complex tumors. We describe the largest reported series of NSS for advanced stage RCC. METHODS: Between 1970 and 2006, 1,807 partial nephrectomies were performed at our institution. Forty-two of these were for sporadic unilateral advanced stage tumors (pT2=22; pT3a=20). We reviewed outcomes of these patients compared to 126 patients treated with radical nephrectomy (RN) matched (3:1) for age, stage, tumor size and baseline renal function. RESULTS: Cancer-specific survival and overall survival were similar between patients treated with NSS or RN (figures 1 and 2). At a median of 6.1 years follow up, 7 (17%) NSS patients and 10 (8%) RN patients developed local recurrence (HR 2.31; 0.88 to 6.11) and 11 (26%) NSS patients and 40 (32%) RN patients developed metastatic disease (HR 0.95; 0.48-1.85). Of the NSS group, 7 (17%) were complicated by urine leak and 1 (2%) by retroperitoneal bleed requiring intervention. The average change in serum creatinine was 9.9% for the NSS group compared to 38.3% for the RN group (p<0.001). CONCLUSIONS: NSS for advanced RCC preserves renal function and appears to achieve similar oncologic outcomes compared to RN. The role of NSS in patients with T2-3a tumors and a normal contralateral kidney deserves further consideration and study.
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
435
Source of Funding: None
1221 LONG-TERM OUTCOMES AFTER NEPHRON-SPARING SURGERY FOR THE TREATMENT OF RENAL CELL CARCINOMAS LARGER THAN 4 CM Morgan Roupret*, Matthieu Peycelon, Vincent Hupertan, Eva Comperat, Raphaele Renard-Penna, Christophe Vaessen, Vincent Misrai, Pierre Conort, Emmanuel Chartier-Kastler, Marc-Olivier Bitker, François Richard, Paris, France INTRODUCTION AND OBJECTIVES: To determine the cancer control afforded by nephron-sparing surgery (NSS) in renal cell carcinomas (RCC) over 4 cm. METHODS: We performed a retrospective review of data for patients treated between 1980 and 2005. The following case characteristics were analyzed: age, surgical procedure, intraoperative parameters, complications, tumor size, Fuhrman grade, TNM stage, pathological data, and outcome. Kaplan-Meier survival curves were generated. RESULTS: The median age of the 61 patients included was 64 years (40-83). Mean intraoperative blood loss was 622 ml ± 691 (504800) and mean operative time was 155.7 ± 82 mins (52-360). Mean preoperative and immediate postoperative creatinine was 1.16 and 1.25 mg/dL, respectively. Mean RCC size was 56.3 ±18 mm (41-100). Margin status was positive in 11 cases (18%). Median follow-up time was 70.7 months. Five and ten-year cancer specific survival rates were 81% and 78%, respectively. Tumor-free survival rate was 92% at five years and 88% at ten years. By univariate analysis, tumor size >7 cm (p=0.002), pathological stage (p=0.001), and Fuhrman grade (p=0.004) were associated with survival. In the multivariate analysis, only pathological stage (p<0.0001) and Fuhrman grade (p=0.007) were significant. CONCLUSIONS: Our results support the fact that NSS is a useful and acceptable approach for RCC greater than 4 cm in size. When technically possible, NSS provides acceptable long-term cancer-specific survival rates. Oncological safety, however, is less evident in cases of RCCs greater than 7 cm. In such cases, NSS should only be considered for absolute indications so far.
Source of Funding: None
1222 AGE AT DIAGNOSIS IS AN INDEPENDENT PREDICTOR OF RECURRENCE-FREE SURVIVAL IN PATIENTS WITH SMALL RENAL CELL CARCINOMA Dalsan You*, Junsoo Park, Changhee Yoo, Seoul, Republic of Korea; Kyung Hyun Moon, Ulsan, Republic of Korea; In Gab Jeong, Jun Hyuk Hong, Hanjong Ahn, Choung-Soo Kim, Seoul, Republic of Korea INTRODUCTION AND OBJECTIVES: The incidence of incidentally detected small renal cell carcinoma (RCC) has been increased with a stage migration. This study investigated the relationship between age at diagnosis and disease recurrence after surgery in patients with small RCC. METHODS: Of the 1,196 patients who underwent curative surgery for RCC between 1989 and 2005 at our institution, 490 patients with small RCC (tumors of 4cm or less in diameter on pathological evaluation) were included in our study. Patients were stratified into three subgroups according to age at diagnosis [a40 years (n=93), 41 to 60 years (n=253), >60 years (n=144)]. Clinical and pathological variables at diagnosis were compared and a survival analysis was performed. RESULTS: Mean age at diagnosis was 52.7 years (median 54, range 10 to 80). Mean postoperative follow-up was 60.3 months (median 53, range 2 to 185). Pathologic T stages consisted of pT1a in 469 (95.7%), pT3a in 19 (3.9%) and pT3b in 2 (0.4%) patients. Fuhrman grades consisted of 1 in 35 (7.2%), 2 in 272 (55.5%), 3 in 174 (35.5%) and 4 in 9 (1.8%), respectively. Seventeen patients (3.5%) experienced disease recurrence and nine patients (1.8%) died of metastatic RCC during follow-up. Higher Fuhrman nuclear grades were associated with older age at diagnosis (p=0.001). Overall, patient recurrence-free survival (RFS) rates were 97.2% and 92.4% at 5 and 10 years, respectively. Ten year RFS rates were 100% for patients aged a40 years, 95.7% for patients aged 40 to 59 years, and 79.0% for patients aged > 60 years (p=0.002). The 5-year RFS rates for patients with pT1a and pT3a/T3b