74 CONTEMPORARY PERIOPERATIVE OUTCOMES AND USAGE TRENDS IN PARTIAL AND RADICAL NEPHRECTOMY USING THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) DATABASE

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mediate post-operative information (construct 3, tau⫽0.40, P⬍0.0001). Conversely, there was lower correlation with the questions regarding preoperative communication (construct 2, tau⫽0.25, P⬍0.0001). CONCLUSIONS: The response rate of approximately 33% is consistent with other CAHPS studies which have utilized similar survey methods. Survey results suggest that patients’ satisfaction with their surgeon is more influenced by post-operative communications than by preoperative counseling and decision-making processes. This underscores the importance of attention to continued post-operative care and utilization of good communication skills. We are now exploring different methods of survey administration to attempt to improve the response rate. Source of Funding: None

72 LONGITUDINAL TRENDS IN VOIDING PARAMETERS IN THE ELDERLY MALE Rachel C Esler*, Manchester, United Kingdom; Lewis W. Chan, Melisa J. Litchfield, Vincent W. Tse, Vasi Naganathan, Robert G. Cumming, Sydney, Australia INTRODUCTION AND OBJECTIVES: Lower urinary tract symptoms (LUTS) are common in elderly men. We sought to assess both symptom scores and voiding parameters in a group of communitydwelling elderly men and to determine whether there was any change in either at two years. METHODS: 1705 men aged 70 years and over were enrolled to participate in the Concord Health and Ageing in Men Project (CHAMP), a population based study of men living in a defined geographical area in metropolitan Sydney, Australia. Men were required to complete a survey including International Prostate Symptom Score (IPSS) and medical, medication and urological history, then attend a clinical assessment where uroflowmetry and post void residual volume were measured with a bladder scanner. Subjects were re-assessed after two years and five years with repeat survey and clinical assessment. We report results at baseline and two year follow-up. RESULTS: 1705 men aged between 70 and 97 years participated in initial evaluation. 1366 men presented for follow-up assessment two years later. At baseline median IPSS was 5 (mild 63%, moderate 30%, severe 7%), this was unchanged at two year analysis. Median peak flow rate at baseline was 13ml/sec, which declined to 10.5ml/sec at two year analysis. Peak flow rate was lower in the older men (⬎85 years) within the cohort compared to younger men (70-74 years) both at baseline and two year review (p⫽⬍0.001). Median post void residual volume was 38ml at baseline and 52ml at two years, with a statistically significant difference only in the ⬎85 years group. The majority of men (75%) had a post void residual volume of ⬍100ml, with 19% retaining 101-200ml and 6% ⬎301ml. Increased total IPSS correlated with reduced peak flow and increased post void residual, but not age. 63 (4.6%) men had surgery for lower urinary tract symptoms between baseline and two year review. Only ten men were using a catheter at each assessment. CONCLUSIONS: Both urinary symptom scores and voiding parameters of uroflowmetry and post void residual volume remain remarkably stable over a two year period in elderly, community-dwelling men. The number of men requiring surgical intervention for lower urinary tract symptoms was low. Source of Funding: National Health and Medical Research Council (Australian Government).

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73 PATIENT COMORBIDITY STRATIFIED BY CHARLSON INDEX IS PREDICTIVE OF MEDICAL COMPLICATIONS FOLLOWING PARTIAL NEPHRECTOMY Jay Simhan, Marc Smaldone, Kevin Tsai, Tianyu Li, Philadelphia, PA; Daniel Canter, , ; Anthony Corcoran, Serge Ginzburg, Steven Sterious, Zachary Piotrowski*, Rosalia Viterbo, David Chen, Richard Greenberg, Alexander Kutikov, Robert Uzzo, Philadelphia, PA INTRODUCTION AND OBJECTIVES: The impact of comorbidity on adverse events following partial nephrectomy (PN) is poorly characterized. Our objective was to assess the association between patient comorbidity stratified by Charlson Comorbidity Index (CCI) and complication rates following PN. METHODS: We queried our prospectively maintained institutional kidney cancer database for all patients undergoing PN from 2007-2011. Postoperative complications within 30 days of PN, determined using the Clavien-Dindo classification system (CCS), were classified as medical or surgical in type and further stratified by minor (CCS I-II) and major (III-V) severity. Patient and tumor characteristics were compared between complication groups using Wilcoxon and Chisquare tests. The relationship between CCI and any complication, medical/surgical complications, and medical/surgical complications stratified by severity were assessed using logistic regression analyses controlling for age, race, gender, CCI, body mass index, estimated blood loss (EBL), ECOG score, ASA score, nephrometry score (NS), operative time, and surgical approach. RESULTS: 512 patients (median age 59yrs, 64.3% male) underwent PN (median NS 8.0, median tumor size 3.0cm) with median follow-up of 23 months (range 5-48mo). All patients were stratified into cohorts developing any complication (35.2%), any medical (18.4%)/ surgical (23.4%) complication, and patients sustaining major/minor medical (2.5%/16.8%) or surgical (8.8%/17.6%) complications after surgery. Compared to patients with no complications, those who incurred any complication tended to have greater NS (p⬍0.001), ASA score (p⬍0.005), EBL (p⬍0.001), operative time (p⬍0.001), and preoperative tumor size (p⬍0.001). Controlling for patient and clinical characteristics, increasing CCI was associated with the development of any complication (OR 1.11, CI 1.01-1.21), any medical complication (OR 1.14, CI 1.01-1.28), and any major medical complication (OR 1.66, CI 1.25-2.21) following PN. In contrast, no associations between CCI and surgical complications (in aggregate or stratified by severity) were demonstrated. CONCLUSIONS: In our cohort, increasing Charlson Comorbidity Index is an independent predictor of the development of any Clavien graded medical complication and any major medical complication following PN. This association should be objectified in published reports and integrated into the decision-making and counseling of patients with competing medical risks that present with localized renal tumors. Source of Funding: Kidney Cancer Keystone Program.

74 CONTEMPORARY PERIOPERATIVE OUTCOMES AND USAGE TRENDS IN PARTIAL AND RADICAL NEPHRECTOMY USING THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) DATABASE Jen-Jane Liu*, Bryan Maxwell, Stanford, CA; Seung Jeon, Seoul, Korea, Democratic People’s Republic of; John Leppert, Perikilis Panousis, Benjamin Chung, Stanford, CA INTRODUCTION AND OBJECTIVES: When feasible, nephron sparing surgery is recommended to preserve renal function. We examined contemporary outcomes of partial and radical nephrectomy (PN and RN) and practice patterns of minimally invasive techniques using a national, prospective perioperative database reflecting diverse practice settings. METHODS: The NSQIP database was queried from 2005 to 2010 and nephrectomies were grouped by CPT code as laparoscopic/

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robotic PN, open PN, laparoscopic/robotic RN, and open RN. We examined 30-day perioperative outcomes including surgical and total operation duration, transfusion rate, length of stay, major morbidity (cardiovascular, pulmonary, renal and infectious) and mortality. RESULTS: A total of 1,320 PN and 2,968 RN were identified. Baseline age, BMI, ASA status, and race were similar between groups, although the RN group had more baseline renal insufficiency and medical comorbidities. Minimally invasive RN increased over time. For PN, virtually all laparoscopic/robotic cases were done after 2007, and accounted for ⬃40% of all PN in 2010. For both PN and RN, length of stay, transfusion rate, organ space infections, major morbidity and mortality rates were significantly higher for the open approach (Table). On multivariate analysis, resident involvement and open approach were independent predictors of major complications for both PN and RN. Additionally, the presence of a medical comorbidity was also a risk factor for complications after RN. CONCLUSIONS: Adoption of minimally invasive PN and RN increased during the 5-year study period with favorable outcomes (transfusion rate and length of stay) and low morbidity and mortality compared to the open approach. Although identification of important criteria for selection of operative approach is limited, NSQIP identifies complications up to 30 days postoperatively, providing detailed characterization of postoperative complications compared to administrative databases that only capture inpatient complications using billing codes. These results suggest that minimally invasive PN and RN can be performed with low perioperative morbidity and mortality.

VARIABLE Operative time

OPEN ROB/LAP PN PN N⫽789 N⫽531 (%) (%) 210 min 195 min

ROB/LAP OPEN RN RN N⫽1,480 N⫽1,488 (%) (%) 183 min 209 min

Length of stay

3.2 d

5.6 d

4.0 d

7.5 d

⬍ 0.001

2.26%

6.72%

3.36%

11.35%

⬍ 0.0001

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RESULTS: Over half (8,986) of our cohort (15,536) presented with stage T1 tumors. Remarkably, 26.3% of patients were Hispanic, and 7.7% Asian. Hispanics, Asians, and low SES patients presented less commonly with T1 tumors, though there was a steady increase in the proportion of patients with T1 tumors over time, most prominently among Hispanics (8.7% increase over 5 years vs 4.3% for Whites) and low SES patients (8% vs 4% for high SES) (Fig 1). The use of PN has continued to increase, from 24.7% of T1 cases in 2005 to 36.0% in 2009, paralleling the rise of T1 tumors. White and Black patients also underwent PN more commonly (19.5%, 21.3%) than Hispanics and Asians, consistent with earlier stage of presentation. Low SES patients underwent PN less frequently than high SES patients (16.6 vs 21.2%). SES tertile predicted OS, with mid SES (HR⫽1.13) and low SES patients (HR⫽1.21, 95% CI 1.12-1.31) having increased risk of mortality. After adjusting for tumor stage, Hispanics had a lower risk of mortality (HR⫽0.82, 95% CI 0.82-0.96). There was a trend towards lower risk among Asians as well (HR⫽0.86). CONCLUSIONS: We describe the epidemiology of RCC in 2 understudied minorities, Hispanics and Asians. California Hispanics, Asians, and low SES patients present with higher stage tumors, and have lower rates of PN. This suggests the potential for improvement in access and care for RCC for these populations.

P-VALUE 0.001

COMPLICATION Blood transfusion Cardiac arrest

0 (0%)

Respiratory (pneumonia, ventilator ⬎ 48 h, reintubation)

8 (1.5%)

Organ space infection Composite Death

0 (0%)

1 (0.07%)

6 (0.4%)

Source of Funding: Supported by a Stanford Cancer Institute 2012 Developmental Cancer Research Award Grant.

0.04

76 26 (3.3%)

34 (2.3%)

115 (7.8%)

⬍ 0.0001

SURVIVAL IMPACT OF FOLLOW-UP CARE AFTER RADICAL AND PARTIAL CYSTECTOMY FOR BLADDER CANCER Seth Strope*, Su-Hsin Chang, Ling Chen, Gudarshan Sandhu, Jay Piccirillo, Mario Schootman, Saint Louis, MO

6 (0.4%)

35 (2.4%)

⬍ 0.0001

31 (5.8%)

78 (9.9%)

95 (6.4%)

257 (17.4%)

⬍ 0.0001

2 (0.4%)

6 (0.8%)

11 (0.7%)

43 (2.9%)

⬍ 0.0001

2 (0.38%) 15 (1.9%)

Source of Funding: None

75 TRENDS IN RENAL CELL CARCINOMA IN CALIFORNIA BY RACE AND SOCIOECONOMIC STATUS J Joy Lee*, Stanford, CA; Kari M. Fish, Sacramento, CA; John T. Leppert, Kim F. Rhoads, Stanford, CA INTRODUCTION AND OBJECTIVES: Renal cell carcinoma (RCC) has shown a continued steady rise in incidence over the last 30 years across all racial and ethnic groups. US SEER data shows certain minorities having higher incidence and mortality, but studies have been limited by homogeneous and largely White/Black populations. We sought to define the disparities in presentation and treatment for RCC in an ethnically diverse population in California. METHODS: We queried the California Cancer Registry for all incident cases of RCC between 2005-2009, and performed descriptive statistics for patient and tumor characteristics, stratified by race and SES. Temporal trends of treatment were examined by comparing unadjusted annual incidence rates of radical and partial nephrectomy (PN). Product-limit Kaplan-Meier curves were constructed to indicate overall survival (OS) over time. A Cox proportional hazard model was used to identify race and SES factors independently associated with mortality.

INTRODUCTION AND OBJECTIVES: With substantial variation in follow-up for patients after partial and radical cystectomy, we sought to understand the use and value of urine tests, laboratory tests, physician visits, and imaging relating to overall survival. METHODS: We analyzed a cohort of patients treated in the fee-for-service Medicare population from 1992 through 2007 using Surveillance Epidemiology and End Results - Medicare data. Using propensity score analysis, we assessed the relationship between time and geography standardized expenditures on follow-up care (doctor visits and imaging, laboratory, and urine tests) and overall survival in three time periods after surgery, peri-operative (0-3 months), early follow-up (4-6 months), and late follow-up (6-24 months). Patients were defined in tertiles of expenditures for analysis, and results were adjusted for patient, hospital, surgeon, and geographic factors. Differences in types of care were assessed across the tertiles. We used instrumental variables analysis to assess the impact of the quantity of each type of follow-up care on overall survival. RESULTS: We found no improvement in survival from follow-up care in the peri-operative and early follow-up periods. Receipt of follow-up care in the late follow-up period was associated with improved survival (HRs 0.36, 0.42, 0.59 and 95% CIs 0.28 to 0.45, 0.33 to 0.53, 0.47 to 0.75 for low, middle, and high tertile of expenditures; respectively). Imaging tests accounted for the majority of expenditures in each follow up care tertile (Figure). Instrumental variables analysis suggested that doctor visits and urine testing (HRs: 0.91, 0.86; 95% CIs: 0.84-0.99, 0.79-0.93; respectively) decreased the risk of death.