947 THE PROBABILITY OF RENAL FUNCTION DECLINE AND NEW ONSET CHRONIC KIDNEY DISEASE IN URINARY DIVERSION – A RETROSPECTIVE COHORT STUDY COMPARING ILEAL CONDUIT AND ILEAL ORTHOTOPIC NEOBLADDER

Vol. 183, No. 4, Supplement, Monday, May 31, 2010

946 LONG-TERM OUTCOME OF RENAL FUNCTION IN BLADDER CANCER PATIENTS AFTER RADICAL CYSTECTOMY Takahiro Osawa*, Satoru Maruyama, Takashige Abe, Shintaro Maru, Toshiki Aoyagi, Ataru Sazawa, Nobuo Shinohara, Katsuya Nonomura, Sapporo, Japan INTRODUCTION AND OBJECTIVES: There have been few publications describing the long-term outcome of renal function in bladder cancer patients who have undergone radical cystectomy (RC). In the present study, we evaluated postoperative renal function and risk factors for the loss of renal function in patients who had undergone RC. METHODS: One hundred forty nine patients who had undergone RC between 1988 and 2008 were identified. After excluding the patients with resection of the entire urinary tract (n⫽1), preexisting renal disease (n⫽4), simultaneous nephrectomy or nephroureterectomy (n⫽22) or less than 12 months follow-up (n⫽52), 70 patients were included in this study [male/female⫽53/17, median follow up time: 47 months (range 12-243), median serum creatinine before surgery 0.8mg/dl (range 0.4-2.5)]. In this cohort, four types of urinary diversions were performed, respectively [ileal neobladder (n⫽24), ileocecal reservoir (n⫽12), ileal conduit (n⫽25) and cutaneous ureterostomy (n⫽9)]. Postoperative change of renal function was reviewed and eGFR was calculated using the standard Japanese formula (eGFR⫽194xAge-0.287xCr-1.094 ml/min/1.73m2 [x0.739 if female]). Renal deterioration (RD) was defined as more than 25% decrease in eGFR compared to that shown preoperatively. The variables analyzed were age (75⬎ vs. 75⬍), type of urinary diversion, a prior history of hypertension (HTN) or diabetes mellitus (DM), preoperative renal function (eGFR: 60⬎ vs. 60⬍), postoperative episode of acute pyelonephritis (APN), management for ureteral obstruction (yes vs. no), presence of chemotherapy (yes or no). The RD-free interval was estimated by the Kaplan-Meier method and distributions were compared by log-rank test. Cox proportional hazards model was applied for multivariate analyses. RESULTS: The total eGFR was 74.6(range 15.2-155.1) ml/min/ 1.73m2 before surgery and 63.6(range 8.7-111.5) ml/min/1.73m2 at the last follow-up. Of these patients, 25(35.7%) developed RD at a median interval of 21.5 (range 12-228) months. Univariate analysis showed that APN (p⫽0.01) and presence of chemotherapy (p⫽0.02) were adverse factors and both of these factors remained significant on multivariate analysis (APN; HR 3.2, 95% CI 1.28-8.05, p⫽0.01, Presence of chemotherapy; HR 2.8, 95% CI 1.18-6.67, p⫽ 0.02). The type of urinary diversion did not affect renal functional outcome. CONCLUSIONS: Twenty-five (35.7%) patients who underwent RC demonstrated deterioration of renal function during the follow-up period. APN and presence of chemotherapy were significant adverse factors. Source of Funding: None

947 THE PROBABILITY OF RENAL FUNCTION DECLINE AND NEW ONSET CHRONIC KIDNEY DISEASE IN URINARY DIVERSION – A RETROSPECTIVE COHORT STUDY COMPARING ILEAL CONDUIT AND ILEAL ORTHOTOPIC NEOBLADDER Thomas Hofner*, Axel Haferkamp, Sdrjan Milakovic, Jesco Pfitzenmaier, Sascha Pahernik, Nenad Djakovic, Nina Wagener, Boris Hadaschik, Markus Hohenfellner, Heidelberg, Germany INTRODUCTION AND OBJECTIVES: Comparative studies in reference to renal function after urinary diversion are up to now rarely reported. METHODS: We did a retrospective cohort study of 225 patients with two healthy kidneys undergoing urinary diversion with either ileal conduit (131) or ileal orthotopic neobladder (94) between 1990 and 2009. Glomerular filtration rate (GFR) was estimated using the Cockcroft-Gould formula and the abbreviated Modification in Diet and Renal Disease Study equation (MDRD). Two time-to-event analyses (Kaplan-Meier curves) were used for the probability of a new onset of overall decline in renal function and a new onset of GFR lower than 60 ml/min. Multivariable Cox proportional hazard regression analysis was used to identify prognostic factors for renal function decline including the Charlson-Romano weighted

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index of comorbidity. Additional analyzed factors were age, type of urinary diversion, hypertension and preoperative baseline GFR. RESULTS: After surgery, the 5-year probability of freedom from a new onset of overall decline in renal function was 47.8 % after ileal conduit and 44.8% after ileal orthotopic neobladder (p⫽0.73), corresponding values for freedom from a new onset of GFR lower than 60 ml/min were 79,4% after ileal conduit and 87,1% after ileal orthotopic neobladder (p⫽0.16). Multivariable analysis demonstrated preoperative baseline GFR as independent factor for a new onset of overall decline in renal function [HR 5.60 (95%CI 2.73 to 11.50, p⬍0.001)]. Age was identified as independent factor for a new onset of GFR lower than 60 ml/min [HR 2.81 (95%CI 1.39 to 5.70, p⫽0.004)]. Charlson Comorbidity Index of patients (range 0 to 11) and type of urinary diversion had no significant influence on hazard of overall renal function decline and developing a GFR lower than 60ml/min. CONCLUSIONS: The probability of renal function decline and new onset chronic kidney disease is not dependent on the choice of ileal conduit or ileal orthotopic neobladder as urinary diversion of patients. It is also independent of comorbidity. The hazard of an overall decline in renal function rises with an increase of baseline GFR and the hazard of a new onset of chronic kidney disease rises with increasing age at the time of urinary diversion with either ileal conduit or ileal orthotopic neobladder. Source of Funding: None

948 PERITONEUM PRESERVING RETROGRADE RADICAL CYSTECTOMY FOR ELDERLY AND HIGH RISK BLADDER CANCER PATIENTS Senji Hoshi*, Taku Yamamuro, Yukihiko Ogata, Kenji Numahata, Osamu Sugano, Yamagata, Japan INTRODUCTION AND OBJECTIVES: Radical cystectomy is gold standard of treatment of invasive bladder cancer. However, for elderly patients more than 70 yeas old, mortality rate of perioperative time is reported 8.8% (AUA06-Abstract No. 31). The most common postoperative complication is prolonged ileus. For elderly and high risk patients, we are selecting completely extraperitoneal cystectomy, and single stoma bilateral ureterocutaneostomy with Toyoda Method (J Urol, 117, 276). We established easy technique of complete peritoneum preserving retrograde radical cystectomy. At first, prostatic deep vein complex and urethra are dissected. Prostate and seminal vesicle were dissected retrogradely. Bilateral ureters are dissected at the distal end and retrograde cystectomy is done. Peritoneum detachment from bladder is easily done because peritoneum is rising like as a tent and peritoneum bladder adhesion line is easily detected. Operation time is short and no peritoneal defect. Then we compared the time of peritoneum detachment from bladder up to now ante-grade procedure and new technique of retrograde procedure. METHODS: Twenty patients of old age male bladder cancer, mean age 75, range 73-83, candidate for radical cystectomy and ureterocutaneostomy were divided randomly. And 10 were performed ante-grade peritoneum detachment (AD) from bladder and 10 were performed retrograde peritoneum detachment (RD). Informed consent was obtained. From the operation video of each patient, operation time of AD and RD was calculated. In all patients, the double barreled single ureterocutaneostomy stoma was created with Toyoda Method (J Urol, 117, 276). Operative time of ureterocutaneostomy was also compared with neoblader diversion (15) or ilial conduit diversion (30). The operations were performed by single surgeon (SH). RESULTS: Mean time and range of AD and RD was 25 minutes, 20-38 minutes and 15 minutes, 10-20 minutes, respectively (p⬍0.01). Operation time requiring peritoneum detachment from bladder with RD was clearly shorter than that with AD. Mean operation time of ureterocutaneostomy was clearly shorter than those of neoblader diversion or ilial conduit diversion(p⬍0.01). All patients ureterocutaneostomy diversion could drink and eat the next day of the operation and the median length of hospital stay was shorter than those of neoblader diversion or ilial conduit diversion (p⬍0.01). CONCLUSIONS: We established easy and time saving technique of complete peritoneum preserving retrograde radical cystectomy. Source of Funding: None