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1617 RISK FACTORS OF HOSPITAL READMISSIONS FOLLOWING OPEN RADICAL CYSTECTOMY AND URINARY DIVERSION: ANALYSIS OF 1000 CONSECUTIVE PATIENTS
Vol. 189, No. 4S, Supplement, Tuesday, May 7, 2013
1617 RISK FACTORS OF HOSPITAL READMISSIONS FOLLOWING OPEN RADICAL CYSTECTOMY AND URINARY DIVERSION: ANALYSIS OF 1000 CONSECUTIVE PATIENTS Samer El-Halwagy*, Ahmed. Haraz, Yasser Osman, Mahmoud Laymon, Ahmed Mosbah, Atalla Shaaban, Mansoura, Egypt INTRODUCTION AND OBJECTIVES: To analyze risk factors predicting complications requiring hospital readmissions in a large cohort of patients undergoing open radical cystectomy and urinary diversion. METHODS: We retrospectively analyzed our prospective database for 1000 consecutive patients who underwent open radical cystectomy and urinary diversion between January 2004 and September 2009. Patients’ demographics, perioperative data and postoperative complications were categorized and analyzed. Primary outcome of the study is the development of complications requiring readmission to the hospital. Readmissions were classified as early if occurring within first 3 months of hospital discharge while late as 3 months thereafter. Univariable and multivariable analyses were performed to detect factors predicting the primary outcome of the study. RESULTS: Out of 1000 patients, 172 (17.2%) were readmitted including 78 (7.8%) early readmissions and 94 (9.4%) late readmissions. The main causes of early readmissions were pyelonephritis, ureteral obstruction, metabolic acidosis and intestinal obstruction in 17 (21.8%), 14 (17.9%) and 11 (14.1%), and 7 (9%), respectively. The main causes of late readmissions included ureteral obstruction, intestinal obstruction, metabolic acidosis and pouch stones in 16 (17%), 15 (16%), 8 (8.5%) and 8 (8.5), respectively. Cox regression analysis revealed continent urinary diversion was an independent predictor of complications requiring hospital readmission (HR: 1.67; 95%CI: 1.22.4; p ⫽ 0.005). CONCLUSIONS: Hospital readmission rate after radical cystectomy is considerably high with continent urinary diversion. Source of Funding: None
1618 IMPACT OF URINARY DIVERSION ON CANCER SPECIFIC-SURVIVAL IN PATIENTS WITH BLADDER CANCER AND PATHOLOGIC POSITIVE LYMPH NODES Federico Pellucchi*, Lorenzo Rocchini, Carmen Maccagnano, Giuseppe Zanni, Giovanni La Croce, Marco Moschini, Giorgio Gandaglia, Patrizio Rigatti, Francesco Montorsi, Renzo Colombo, Milan, Italy INTRODUCTION AND OBJECTIVES: To examine the impact of urinary diversion on cancer-specific survival (CSS) in patients with muscle-invasive bladder cancer treated by radical cystectomy (RC) and found with pathologic positive nodes (N⫹) METHODS: Overall, 210 consecutive patients submitted to RC at our institution between 1999 and 2011 for muscle-invasive bladder cancer and positive lymph node metastases were retrospectively evaluated. All patients received either an ileal neobladder or an ileal conduit as the urinary diversion. Complete clinical, pathological data (including T stage, grade, age, gender, diversion type) and follow-up were available for 133 patients (63%). The CSS probability using the KaplanMeier method, was investigated. Univariate and multivariate Cox regression analyses were adopted to assess the effect of urinary diversion on CSS. RESULTS: Overall, mean age was 68.2 yr (median: 68; range: 48-87). Of the 133 patients, 24 (18%) patients were female and 109 (82%) were male. All patients were found with high grade disease. The pathologic stage distribution was pT2, pT3 and pT4 in 21 (15.7%), 69 (52%) and 43 (32.3%) cases, respectively. The pathologic nodal status (according to the Sixth Edition of TNM classification) was defined as pN1 in 43 (32.4%), and pN2 in 90 (67.6%). An ileal conduit and an ileal neobladder was completed in 72 (54.2%) and 61 (45.8%) patients,
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respectively. Mean follow-up time was 71 months (median: 51; range 1-125). The overall 5-year CSS was 55.7%. When analyses were stratified according to urinary diversion, the 5-year CSS was documented to be 56.3%, 54.7% for the ileal conduit and the orthotopic bladder substitution, respectively. At multivariate analyses, both age (HR 1.03, p⫽0.01) and number of positive nodes (HR 1.04, p⫽0.02) were associated with worst CSS. After adjustement for potential confounders, ileal conduit and ileal neobladder showed similar CSS (p⫽0.9). No statistically significant differences could be observed for the remaining variables (all p⬎0.2). CONCLUSIONS: In patients with pathologic positive nodal status submitted to ileal conduit or orthotopic bladder substitution after RC, a similar cancer specific survival may be expected. Source of Funding: None
1619 ACCESS TO CARE PREDICTS ADEQUATE PELVIC LYMPH NODE DISSECTION IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR MUSCLE-INVASIVE BLADDER CANCER C.J. Stimson*, Sanjay G. Patel, Harras B. Zaid, Samuel D. Kaffenberger, Matthew J. Resnick, Daniel A. Barocas, Michael S. Cookson, Sam S. Chang, Nashville, TN INTRODUCTION AND OBJECTIVES: Previous studies demonstrate that pelvic lymph node dissection (PLND) provides more accurate staging during radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). Further, increased node counts have been associated with better long-term recurrence and survival rates. We sought to identify the likelihood of receiving an adequate PLND when undergoing RC. Furthermore, we investigated access-related predictors of adequate PLND in patients undergoing RC for MIBC. METHODS: We analyzed patients with clinical T2 (cT2) or T3 (cT3) BC diagnosed between 1998 and 2010 from the National Cancer Data Base (NCDB) cancer registry. The NCDB captures approximately 70% of all cancer diagnoses from 1400 accredited hospitals in the US. We examined the relationship between clinical and socioeconomic variables and the use of adequate PLND, defined as ⱖ 10 lymph nodes, during RC for MIBC. Inclusion criteria were stage cT2 or cT3/cN0/cM0, histology⫺proven urothelial cell carcinoma, treatment with RC, and complete PLND data. We performed both univariate and multivariate logistic regression analysis to identify independent predictors of adequate PLND at the time of RC. RESULTS: Of the 7843 patients who met the inclusion criteria, 3672 (46.8%) patients had adequate PLND. The median number of nodes was 17 (interquartile range 13-26). Univariate analyses revealed statistically significant associations between adequate PLND and age, year of diagnosis, insurance status, metro/urban/rural, distance from hospital, geographic location, Charlson Comorbidity Index, and clinical stage (p⬍0.05 for each). Multivariate logistic regression modeling identified several access-related predictors of adequate PLND, including median income, distance from hospital, and geographic location. (Table 1) CONCLUSIONS: Most patients (53.2%) undergoing RC for cT2 or cT3 BC did not have an adequate PLND. Several access-related patient characteristics predict which patients are less likely to receive this standard adjunct, including median income, distance from hospital, and geographic location. Given the evidence indicating superior survival in patients with adequate PLND, these data suggest that targeted intervention to improve access to care may improve BC outcomes.
1617 RISK FACTORS OF HOSPITAL READMISSIONS FOLLOWING OPEN RADICAL CYSTECTOMY AND URINARY DIVERSION: ANALYSIS OF 1000 CONSECUTIVE PATIENTS Samer El-Halwagy*, Ahmed. Haraz, Yasser Osman, Mahmoud Laymon, Ahmed Mosbah, Atalla Shaaban, Mansoura, Egypt INTRODUCTION AND OBJECTIVES: To analyze risk factors predicting complications requiring hospital readmissions in a large cohort of patients undergoing open radical cystectomy and urinary diversion. METHODS: We retrospectively analyzed our prospective database for 1000 consecutive patients who underwent open radical cystectomy and urinary diversion between January 2004 and September 2009. Patients’ demographics, perioperative data and postoperative complications were categorized and analyzed. Primary outcome of the study is the development of complications requiring readmission to the hospital. Readmissions were classified as early if occurring within first 3 months of hospital discharge while late as 3 months thereafter. Univariable and multivariable analyses were performed to detect factors predicting the primary outcome of the study. RESULTS: Out of 1000 patients, 172 (17.2%) were readmitted including 78 (7.8%) early readmissions and 94 (9.4%) late readmissions. The main causes of early readmissions were pyelonephritis, ureteral obstruction, metabolic acidosis and intestinal obstruction in 17 (21.8%), 14 (17.9%) and 11 (14.1%), and 7 (9%), respectively. The main causes of late readmissions included ureteral obstruction, intestinal obstruction, metabolic acidosis and pouch stones in 16 (17%), 15 (16%), 8 (8.5%) and 8 (8.5), respectively. Cox regression analysis revealed continent urinary diversion was an independent predictor of complications requiring hospital readmission (HR: 1.67; 95%CI: 1.22.4; p ⫽ 0.005). CONCLUSIONS: Hospital readmission rate after radical cystectomy is considerably high with continent urinary diversion. Source of Funding: None
1618 IMPACT OF URINARY DIVERSION ON CANCER SPECIFIC-SURVIVAL IN PATIENTS WITH BLADDER CANCER AND PATHOLOGIC POSITIVE LYMPH NODES Federico Pellucchi*, Lorenzo Rocchini, Carmen Maccagnano, Giuseppe Zanni, Giovanni La Croce, Marco Moschini, Giorgio Gandaglia, Patrizio Rigatti, Francesco Montorsi, Renzo Colombo, Milan, Italy INTRODUCTION AND OBJECTIVES: To examine the impact of urinary diversion on cancer-specific survival (CSS) in patients with muscle-invasive bladder cancer treated by radical cystectomy (RC) and found with pathologic positive nodes (N⫹) METHODS: Overall, 210 consecutive patients submitted to RC at our institution between 1999 and 2011 for muscle-invasive bladder cancer and positive lymph node metastases were retrospectively evaluated. All patients received either an ileal neobladder or an ileal conduit as the urinary diversion. Complete clinical, pathological data (including T stage, grade, age, gender, diversion type) and follow-up were available for 133 patients (63%). The CSS probability using the KaplanMeier method, was investigated. Univariate and multivariate Cox regression analyses were adopted to assess the effect of urinary diversion on CSS. RESULTS: Overall, mean age was 68.2 yr (median: 68; range: 48-87). Of the 133 patients, 24 (18%) patients were female and 109 (82%) were male. All patients were found with high grade disease. The pathologic stage distribution was pT2, pT3 and pT4 in 21 (15.7%), 69 (52%) and 43 (32.3%) cases, respectively. The pathologic nodal status (according to the Sixth Edition of TNM classification) was defined as pN1 in 43 (32.4%), and pN2 in 90 (67.6%). An ileal conduit and an ileal neobladder was completed in 72 (54.2%) and 61 (45.8%) patients,
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respectively. Mean follow-up time was 71 months (median: 51; range 1-125). The overall 5-year CSS was 55.7%. When analyses were stratified according to urinary diversion, the 5-year CSS was documented to be 56.3%, 54.7% for the ileal conduit and the orthotopic bladder substitution, respectively. At multivariate analyses, both age (HR 1.03, p⫽0.01) and number of positive nodes (HR 1.04, p⫽0.02) were associated with worst CSS. After adjustement for potential confounders, ileal conduit and ileal neobladder showed similar CSS (p⫽0.9). No statistically significant differences could be observed for the remaining variables (all p⬎0.2). CONCLUSIONS: In patients with pathologic positive nodal status submitted to ileal conduit or orthotopic bladder substitution after RC, a similar cancer specific survival may be expected. Source of Funding: None
1619 ACCESS TO CARE PREDICTS ADEQUATE PELVIC LYMPH NODE DISSECTION IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR MUSCLE-INVASIVE BLADDER CANCER C.J. Stimson*, Sanjay G. Patel, Harras B. Zaid, Samuel D. Kaffenberger, Matthew J. Resnick, Daniel A. Barocas, Michael S. Cookson, Sam S. Chang, Nashville, TN INTRODUCTION AND OBJECTIVES: Previous studies demonstrate that pelvic lymph node dissection (PLND) provides more accurate staging during radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). Further, increased node counts have been associated with better long-term recurrence and survival rates. We sought to identify the likelihood of receiving an adequate PLND when undergoing RC. Furthermore, we investigated access-related predictors of adequate PLND in patients undergoing RC for MIBC. METHODS: We analyzed patients with clinical T2 (cT2) or T3 (cT3) BC diagnosed between 1998 and 2010 from the National Cancer Data Base (NCDB) cancer registry. The NCDB captures approximately 70% of all cancer diagnoses from 1400 accredited hospitals in the US. We examined the relationship between clinical and socioeconomic variables and the use of adequate PLND, defined as ⱖ 10 lymph nodes, during RC for MIBC. Inclusion criteria were stage cT2 or cT3/cN0/cM0, histology⫺proven urothelial cell carcinoma, treatment with RC, and complete PLND data. We performed both univariate and multivariate logistic regression analysis to identify independent predictors of adequate PLND at the time of RC. RESULTS: Of the 7843 patients who met the inclusion criteria, 3672 (46.8%) patients had adequate PLND. The median number of nodes was 17 (interquartile range 13-26). Univariate analyses revealed statistically significant associations between adequate PLND and age, year of diagnosis, insurance status, metro/urban/rural, distance from hospital, geographic location, Charlson Comorbidity Index, and clinical stage (p⬍0.05 for each). Multivariate logistic regression modeling identified several access-related predictors of adequate PLND, including median income, distance from hospital, and geographic location. (Table 1) CONCLUSIONS: Most patients (53.2%) undergoing RC for cT2 or cT3 BC did not have an adequate PLND. Several access-related patient characteristics predict which patients are less likely to receive this standard adjunct, including median income, distance from hospital, and geographic location. Given the evidence indicating superior survival in patients with adequate PLND, these data suggest that targeted intervention to improve access to care may improve BC outcomes.