1409 PROSPECTIVE EVALUATION OF DEEP VENOUS THROMBOSIS AND PULMONARY EMBOLUS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY

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THE JOURNAL OF UROLOGY姞

1408 A NEW MULTIMODAL ANESTHESIOLOGICAL AND NUTRITIONAL APPROACH IN RADICAL CYSTECTOMY WITH URINARY DIVERSION BASED ON ILEAL SEGMENT: A SINGLECENTRE, PROSPECTIVE, RANDOMIZED STUDY Carmen Maccagnano*, Lorenzo Rocchini, Nazareno Suardi, Federico Pellucchi, Buthaina Ibrahim, Antonella Crescenti, Andrea Salonia, Giuseppe Zanni, Luca Villa, Giorgio Gandaglia, Paolo Capogrosso, Niccolo` Passoni, Nicola Fossati, Stefano Corti, Patrizio Rigatti, Francesco Montorsi, Renzo colombo, Milan, Italy INTRODUCTION AND OBJECTIVES: Evaluating a new multimodal anesthesiological and nutritional approach in patients submitted to radical cystectomy (RC) and urinary diversion with ileal segment (orthotopic bladder substitution or Bricker ileo-cutaneous anastomosis). The main end-points were: 1. evaluating the reliability, tolerability and efficacy of intra-operative analgesia without opium-derivatives 2. describing the peri-operative impact of non administered standard bowel mechanical preparation (BMP) 3. reporting the effects of an early administration of oral nutrition (ON). METHODS: Patients were randomized into 2 groups. Group I (patients with standard treatment): administration of BMP with osmotic laxatives during the day before the operation and antibiotic prophylaxis with erytromicine and paromomicine; use of opium derivatives for the intra-operative analgesia and administration of parenteral nutrition during the 7 days after the operation. Group II (patients with the experimental treatment): administration of a standard enema the day before the operation; intra-operative analgesia without opium derivatives and administration of ON with yoghurts and puddings starting since the third day after the operation. RESULTS: Forty-six patients were included in the study: 27 in the group I and 19 in the group II. The mean age at the time of the operation was 68 years (range 50 – 68). Flatus (used as indicator of restarting of the peristalsis) was described after a mean time of 3.1 days (range 1–7) in the group I and after 2.3 days (range 2– 4) in the group II; canalization was observed after 4.5 days (range 1–15) in the group I and after 6.3 days (range 2–11) in the group II; surgical wound have been considered as repaired after 10.1 days (range 9 –19) in both groups. The ON was well tolerated by 97% (26/27) of patients of group II. Patients in the group 1 were discharged after 22.2 days while patients in the group II after 12.2 days. The complications in the group I were: urinary leakage in 15% of cases (4/27), exitus in 3% (1/27), fever with temperature ⬎ 38.3°C in 26% (7/27). The complications in the group II were: nausea and/or vomiting in 21% of cases (4/19); re-operation in 3% (1/19); sub-occlusion was reported in 10% of patients (2/19); fever was described in 21% of patients (2/19). CONCLUSIONS: The new anesthesiological and nutritional approach in RC with urinary ileal diversion allow a more rapid restarting of the peristalsis; the ON was well tolerated, allowing a better retrieve of the psycho-physical balance of the patients. Source of Funding: None

1409 PROSPECTIVE EVALUATION OF DEEP VENOUS THROMBOSIS AND PULMONARY EMBOLUS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY Heidi Penn*, Marcus Austenfeld, Moben Mirza, Jeffrey Holzbeierlein, Kansas City, KS INTRODUCTION AND OBJECTIVES: Deep venous thrombosis (DVT) is a postoperative complication that carries a significant risk of morbidity, and poses potential fatal sequela in pulmonary embolus (PE). Retrospective studies estimate the risk of DVT without prophylaxis at 10% in urologic surgeries and specifically 3.7% after radical cystectomy. While the use of chemoprophylaxis reduces this risk, the concern for bleeding is a limiting factor. We conducted a prospective evaluation of patients undergoing cystectomy for the incidence of DVT and PE.

Vol. 185, No. 4S, Supplement, Tuesday, May 17, 2011

METHODS: After IRB approval a prospective analysis of all patients undergoing cystectomy beginning July 2008 to present was performed to evaluate for the presence of DVT. Patients received perioperative DVT prophylaxis with sequential compression devices (SCDs) placed prior to induction and ambulation starting post-operative day one. Patients were screened with bilateral lower extremity Duplex ultrasound for the presence of DVT on post-operative day 2 or 3, regardless of symptoms. Pathological stage, presence of metastases, body mass index (BMI), blood pressure at induction, and any neoadjuvant therapy were recorded. Statistical analysis to detect any correlation between the development of a DVT and clinical factors was performed. RESULTS: A total of 133 cystectomies were performed. Mean age and BMI were 64 and 29, respectively. Mean length of operation was 5:47. Majority performed for primary bladder malignancy. Positive Doppler ultrasounds were found in 13 patients (10%), despite negative physical exams. One patient with a negative scan post-op day 3, presented post-operative day 10 with swelling and found to have a DVT. Six patients (4.5%) developed a PE, five of whom had negative ultrasounds. No deaths were attributable to PEs. Out of the 19 total events, 9 (47%) had pT3 disease and 8(42%) had positive nodes. Seven patients (37%) had received neoadjuvant chemotherapy or radiation prior to cystectomy. There was no statistical difference between BMI, length of operation, and induction blood pressure between patients with positive scans and those without (p⫽0.19, p⫽0.15, p⫽0.23). CONCLUSIONS: In the only prospective study performed to date, we found a 10% risk of DVT after radical cystectomy as compared to 4.7% reported in the literature. Including those with PEs, this increased to 14 percent. Patients with high-grade disease, positive nodes, and neoadjuvant treatment are at the greatest risk for developing a DVT and subsequent PE. These patients should receive more aggressive prophylaxis with the use of SCDs and low molecular weight heparin. Source of Funding: None

1410 DEVELOPMENT OF A NEW OUTCOME PREDICTION MODEL FOR PATIENTS WITH INVASIVE BLADDER CANCER BASED ON PREOPERATIVE SERUM CRP AND STANDARD PATHOLOGIC RISK FACTORS: THE TNR-C SCORE Georgios Gakis*, Tilman Todenhoefer, Markus Renninger, David Schilling, Christian Schwentner, Karl-Dietrich Sievert, Arnulf Stenzl, Tuebingen, Germany INTRODUCTION AND OBJECTIVES: To assess the predictive value of preoperative C-reactive protein (CRP) in patients undergoing radical cystectomy (RC) for invasive bladder cancer in light of recent data showing it to be an independent indicator of adverse oncological outcome in other malignancies. METHODS: A contemporary, consecutive cohort of 246 patients undergoing RC and bilateral pelvic lymphadenectomy for bladder cancer between 1999 –2009. Elevated CRP was defined as ⬎0.5 mg/dL. The median follow-up was 30 months (6 –116). Fisher Exact test and Cox-regression analysis were used for uni- and multivariate analysis of risk factors, and Kaplan-Meier analysis for cancer-specific survival (CSS). Furthermore, a new scoring model was developed to predict cancer-specific outcomes. The predictive accuracy of the model was evaluated using the concordance index. RESULTS: Normal (ⱕ0.5mg/dl) and elevated CRP (⬎0.5mg/dl) was present in 120 and 126 patients, respectively. The 3-year-CSS was 74.0% in patients with normal and 44.0% with elevated CRP (p⬍0.001). In univariate analysis, elevated CRP was significantly associated with advanced tumor stage, lymph node density ⱖ0.09, increased tumor size (all p⬍0.001), increased age (p⫽0.003) and positive resection margins (p⫽0.026). No significant differences were found for: gender, multifocality, grade, non-urothelial cancer pathology, preoperative leukocyte count, and postoperative chemotherapy. In multi-