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An evaluation of adjuvant chemotherapy eligibility rates among patients undergoing radical cystectomy
S146
Surgical Forum Abstracts
IR-GM rats, a chronic kidney injury model. However, hPKC (F⫹) have more pronounced effects on renal inflammation and oxidative stress. These data support the possibility of using EPO-producing human kidney cells as components of cell-based therapies for degenerative kidney diseases.
Trends in regionalization of adrenalectomy to higher volume surgical centers Jay Simhan MD, Marc C Smaldone MD, Daniel J Canter MD, Fang Zhu PhD, Russell B Starkey MBA, Karyn B Stitzenberg MD, MPH, Robert G Uzzo MD, FACS, Alexander Kutikov MD Fox Chase Cancer Center, Philadelphia, PA and University of North Carolina, Chapel Hill INTRODUCTION: Although centralization of surgical procedures to high volume centers has been described previously, patterns of care for adrenal surgery are unknown. We investigated trends in regionalization of care for patients undergoing adrenalectomy using hospital discharge data from 3 Northeastern states. METHODS: Using 1996-2009 hospital discharge data from NY, NJ and PA, all patients ⱖ 18 years undergoing adrenalectomy were identified. Hospital volume status was assigned by quintiles based on number of procedures performed on a per hospital basis in 1996 and divided as very low volume hospital (VLVH), low (LVH), moderate (MVH), high (HVH) and very high (VHVH). Outcome variables were examined by hospital volume status over time using logistic regression models. RESULTS: From 1996 to 2009, 8,338 patients underwent adrenalectomy with a significant shift towards regionalization to VHVHs (17 to 42%, p⬍0.001). For each successive year, odds of having surgery performed at a VLVH decreased by 14% (OR 0.86 [CI 0.84–0.89]). There were significant differences in patient age, race, geographic location, and payer group (p⬍0.0001) comparing VLVHs to VHVHs. Patients at VHVHs were less likely to be ⱖ55 years (OR 0.91 [CI 0.86–0.96]), insured through Medicaid (OR 0.58 [CI 0.41-0.83]), or be uninsured (OR 0.29 [CI 0.20–0.44]). Controlling for year treated, patients were less likely to die in the hospital if treated at a VHVH (OR 0.38 [CI 0.19–0.75]). CONCLUSIONS: These data demonstrates centralization of adrenalectomy to VHVHs since 1996 with improved clinical outcomes. Inequities in access to care to higher volume centers appear to exist and require further investigation.
Patterns of utilization of urine-based markers in nonmuscle-invasive bladder cancer: Results from the BCAN/ SUO/AUA/LUGPA electronic survey Patrick Selph MD, Joshua Langston MD, Gilad Amiel MD, Tom Guzzo MD, Yair Lotan MD, Neal Shore MD, Angela Smith MD, Eric Wallen MD, Raj S Pruthi MD, FACS, Matthew Nielsen MD The University of North Carolina, Chapel Hill, NC
J Am Coll Surg
INTRODUCTION: We sought to determine self-reported practices of the use of cytology and urine-based markers in the settings of general use, surveillance, and assessment of response after intravesical therapy for patients with non-muscle-invasive bladder cancer (NMIBC). METHODS: An electronic survey was developed by the Bladder Cancer Advocacy Network (BCAN) to elicit self-reported utilization of different management strategies for NMIBC. The survey was circulated to urologists via the AUA, SUO and LUGPA distribution lists. 512 respondents completed the survey. RESULTS: AAmong all respondents, 93% report sending cytology routinely (via barbotage 25% of the time) in general use. In contrast, 37% report using NMP22 in this setting, 54% report using FISH, and 32% (45% of SUO respondents vs. 31% of AUA respondents, p⫽0.04) responded that there is “no role for urine-based markers in this setting.” Similar proportions were reported in the specific settings of routine surveillance and post-BCG assessment. When presented with the vignette of a positive marker test and negative cytology and cystoscopy, 36% of respondents chose to proceed to the OR for biopsy, 37% chose to repeat cystoscopy and cytology in 3 months, 21% chose “no role for markers in this setting” and 13% chose “other.” CONCLUSIONS: In the absence of more specific guidance, the results of this electronic survey suggest considerable variation in the use and interpretation of urine-based markers in NMIBC. These preliminary data underscore the need for prospective studies to validate the optimal role of urine-based markers in the setting of NMIBC.
An evaluation of adjuvant chemotherapy eligibility rates among patients undergoing radical cystectomy Patrick Selph MD, Joshua Langston MD, Jed Ferguson MD, PhD, Ankur Manvar MD, Matthew Nielsen MD, Eric Wallen MD, Raj S Pruthi MD, FACS The University of North Carolina, Chapel Hill, NC INTRODUCTION: Adjuvant chemotherapy has been shown to be beneficial for patients with extravesical bladder cancer (pT⬎2, N⬎0), but the use of nephrotoxic platinum-based regimens is limited by post-operative renal function. We sought to evaluate the eligibility of post-cystectomy patients at our institution for adjuvant chemotherapy. METHODS: A retrospective review of patients (2000-2009) who underwent radical cystectomy was performed. Only patients who underwent cystectomy for urothelial carcinoma and who had 6-month post-operative eGFR values (calculated by MDRD calculation) were included (n⫽218). Lack of evidence extravesical disease (n⫽147) or lack of an eGFR of ⬍60 at 6 months post-op (n⫽5) excluded patients from the study, leaving 91 patient for evaluation of adjuvant eligibility. RESULTS: The mean age of all cystectomy patients was 67.0 years, with 29% female, and 12% African American. Mean post-operative eGFR was 62.4. Out of 91 patients with extravesicular disease, 42 (46%) had an eGFR⬎60 and were thus eligible for platinum-based
Vol. 213, No. 3S, September 2011
Surgical Forum Abstracts S147
adjuvant chemotherapy–leaving 54% ineligible due to renal insufficiency. Ineligible patients had an average eGFR of 43.2 compared to 78.5 for eligible patients. Caucasians (vs. African Americans) were more likely to be ineligible (62% vs. 14%;p⫽0.002). Older patients (ⱖ70y) were nearly twice as likely to be ineligible as younger patients (⬍70y) (70% v 40%;p⫽0.01).No differences were observed when analyzed by gender (p⫽0.37). CONCLUSIONS: Our single-institution retrospective study shows that 54% of patients with extravesical disease at cystectomy are ineligible for cisplatin-based adjuvant chemotherapy based on their postoperative renal function and that older patients and Caucasian patients are more likely to be ineligible.
Significance of re-resecting T1 bladder tumors: singleinstitution analysis in a modern cohort of patients Joshua Langston MD, Patrick Selph MD, Ankur Manvar MD, Jed Ferguson MD, Matthew Nielsen MD, Eric Wallen MD, Raj S Pruthi MD, FACS The University of North Carolina, Chapel Hill, NC INTRODUCTION: Recent AUA guidelines have recommended the use of re-resection of T1 bladder tumors. Re-resections more accurately stage patients and provide prognostic information that may aide in selecting of initial therapies. We examined the findings and outcomes of re-resection of T1 bladder tumors in a single institution analysis of a modern cohort of patients. METHODS: A retrospective analysis was performed on a case series of 556 TURBT procedures at a single institution from 2007–2010. From this series, 56 patients were noted to undergo re-resection for T1 bladder cancer, and these patients were utilized for this analysis. RESULTS: Of the 56 patients, 15 had no muscle in the initial specimen and 41 had muscle. Those without muscle (vs.with muscle) in the initial specimen were more likely to be T2 on re-resection (27% vs. 2%) and less likely to have no residual disease (20% vs. 34%). Findings of re-resection were no residual disease (n⫽17),⬍T1 (n⫽12), T1(n⫽22), and T2(n⫽5;includes one with T1 micropapillary). Initial treatment approach is shown in the table – overall and based on findings of re-resection.For those receiving initial intravesical therapy, recurrence rates were lowest for with no residual disease on re-resection versus ⬍t1 vs. T1 (24% vs. 50% vs. 42%). In this cohort, 17 patients underwent RCx – 12 as initial therapy (10 ⱕT2; 1 T3; 1 N⫹) and 5 as salvage therapy (4 ⱕT2; 1 N⫹) OVERALL negative ⬍ T1 T1 T2
n (%)
Intravesical tx, %
RCx, %
Other, %
56 17 (30) 12 (21) 22 (39) 5 (9)
70 100 83 55 0
21 0 8 36 60
9 0 8 9 40
CONCLUSIONS: Re-resection of T1 tumors provides important staging and prognostic information and may help determine most appropriate initial therapy for this group of patients.
Complications following concomitant bladder/urethral injury and pelvic fracture utilizing a national dataset Alex J Vanni MD, Jim Hotaling MD, B Tyler Garland MD, Christian Hamlat MD, Jin Wang PhD, Hunter Wessells MD, FACS, Bryan Voelzke MD University of Washington, Seattle, WA INTRODUCTION: Complications following traumatic bladder and urethral injuries managed with a suprapubic tube is limited to small, single institution series. We utilized the National Trauma Data Bank to investigate complications occurring in patients with lower urinary tract trauma and pelvic fractures. METHODS: Patients with pelvic fractures between 2002–6 and 2008 were identified in the NTDB by Abbreviated Injury Scale. Patients with pelvic fractures requiring surgery who had concomitant bladder or urethral injuries were linked by ICD-9 codes and evaluated. Demographic and clinical characteristics were compared with chi-square and t-tests. A Poisson regression analysis was performed to determine the relative risk of predictors for complications related to bladder or urethral trauma. RESULTS: There were 5,339 bladder/urethral injuries available for analysis, of whom 1,461 had pelvic fracture surgery. In patients with a bladder/urethral injury who had orthopedic pelvic surgery, 35% of patients with a SPT developed complications compared to 28% of patients without a SPT (p⫽0.06). Surgical site infection occurred in 1.6% of patients without a SPT versus 3.6% of patients with a SPT (p⫽0.06). Multivariate analysis revealed an increased risk of complication in patients treated with a SPT (RR 1.33; 95% CI 1.19–1.50), ISS⬎25 (RR 2.53; 95% CI 2.25–2.84), pelvic fracture surgery (RR 1.23; 95% CI 1.12–1.36), diabetes (RR 1.64; 95% CI 1.02–1.75), and hypertension (RR 1.64; 95% CI 1.41–1.90). CONCLUSIONS: In a large national trauma database, SPT placement, pelvic fracture repair, ISS⬎25, diabetes and hypertension were all associated with an increased risk of complication in patients with a traumatic bladder or urethral injury.
Race and insurance status are risk factors for orchiectomy due to testicular trauma Marc A Bjurlin DO, Lee C Zhao MD, MS, Sandra M Goble MS, Courtney M Hollowell MD Cook County Hospital, Chicago, IL INTRODUCTION: Race and insurance status has been shown to independently predict for disparities in outcomes after trauma. It is unknown whether these factors play a role in testicular salvage rates after testicular trauma. We searched the National Trauma Data Bank (NTDB) to investigate if socioeconomic status, race, and rural location predict for testicular salvage. METHODS: Patients who sustained testicular trauma were identified in the NTDB v9.1. Procedure codes for orchiectomy and orchidorrhaphy were used to determine risk of testicular salvage. Univariate analysis for the influence of age, injury severity score (ISS), race, insurance status, and rural location was performed.
Surgical Forum Abstracts
IR-GM rats, a chronic kidney injury model. However, hPKC (F⫹) have more pronounced effects on renal inflammation and oxidative stress. These data support the possibility of using EPO-producing human kidney cells as components of cell-based therapies for degenerative kidney diseases.
Trends in regionalization of adrenalectomy to higher volume surgical centers Jay Simhan MD, Marc C Smaldone MD, Daniel J Canter MD, Fang Zhu PhD, Russell B Starkey MBA, Karyn B Stitzenberg MD, MPH, Robert G Uzzo MD, FACS, Alexander Kutikov MD Fox Chase Cancer Center, Philadelphia, PA and University of North Carolina, Chapel Hill INTRODUCTION: Although centralization of surgical procedures to high volume centers has been described previously, patterns of care for adrenal surgery are unknown. We investigated trends in regionalization of care for patients undergoing adrenalectomy using hospital discharge data from 3 Northeastern states. METHODS: Using 1996-2009 hospital discharge data from NY, NJ and PA, all patients ⱖ 18 years undergoing adrenalectomy were identified. Hospital volume status was assigned by quintiles based on number of procedures performed on a per hospital basis in 1996 and divided as very low volume hospital (VLVH), low (LVH), moderate (MVH), high (HVH) and very high (VHVH). Outcome variables were examined by hospital volume status over time using logistic regression models. RESULTS: From 1996 to 2009, 8,338 patients underwent adrenalectomy with a significant shift towards regionalization to VHVHs (17 to 42%, p⬍0.001). For each successive year, odds of having surgery performed at a VLVH decreased by 14% (OR 0.86 [CI 0.84–0.89]). There were significant differences in patient age, race, geographic location, and payer group (p⬍0.0001) comparing VLVHs to VHVHs. Patients at VHVHs were less likely to be ⱖ55 years (OR 0.91 [CI 0.86–0.96]), insured through Medicaid (OR 0.58 [CI 0.41-0.83]), or be uninsured (OR 0.29 [CI 0.20–0.44]). Controlling for year treated, patients were less likely to die in the hospital if treated at a VHVH (OR 0.38 [CI 0.19–0.75]). CONCLUSIONS: These data demonstrates centralization of adrenalectomy to VHVHs since 1996 with improved clinical outcomes. Inequities in access to care to higher volume centers appear to exist and require further investigation.
Patterns of utilization of urine-based markers in nonmuscle-invasive bladder cancer: Results from the BCAN/ SUO/AUA/LUGPA electronic survey Patrick Selph MD, Joshua Langston MD, Gilad Amiel MD, Tom Guzzo MD, Yair Lotan MD, Neal Shore MD, Angela Smith MD, Eric Wallen MD, Raj S Pruthi MD, FACS, Matthew Nielsen MD The University of North Carolina, Chapel Hill, NC
J Am Coll Surg
INTRODUCTION: We sought to determine self-reported practices of the use of cytology and urine-based markers in the settings of general use, surveillance, and assessment of response after intravesical therapy for patients with non-muscle-invasive bladder cancer (NMIBC). METHODS: An electronic survey was developed by the Bladder Cancer Advocacy Network (BCAN) to elicit self-reported utilization of different management strategies for NMIBC. The survey was circulated to urologists via the AUA, SUO and LUGPA distribution lists. 512 respondents completed the survey. RESULTS: AAmong all respondents, 93% report sending cytology routinely (via barbotage 25% of the time) in general use. In contrast, 37% report using NMP22 in this setting, 54% report using FISH, and 32% (45% of SUO respondents vs. 31% of AUA respondents, p⫽0.04) responded that there is “no role for urine-based markers in this setting.” Similar proportions were reported in the specific settings of routine surveillance and post-BCG assessment. When presented with the vignette of a positive marker test and negative cytology and cystoscopy, 36% of respondents chose to proceed to the OR for biopsy, 37% chose to repeat cystoscopy and cytology in 3 months, 21% chose “no role for markers in this setting” and 13% chose “other.” CONCLUSIONS: In the absence of more specific guidance, the results of this electronic survey suggest considerable variation in the use and interpretation of urine-based markers in NMIBC. These preliminary data underscore the need for prospective studies to validate the optimal role of urine-based markers in the setting of NMIBC.
An evaluation of adjuvant chemotherapy eligibility rates among patients undergoing radical cystectomy Patrick Selph MD, Joshua Langston MD, Jed Ferguson MD, PhD, Ankur Manvar MD, Matthew Nielsen MD, Eric Wallen MD, Raj S Pruthi MD, FACS The University of North Carolina, Chapel Hill, NC INTRODUCTION: Adjuvant chemotherapy has been shown to be beneficial for patients with extravesical bladder cancer (pT⬎2, N⬎0), but the use of nephrotoxic platinum-based regimens is limited by post-operative renal function. We sought to evaluate the eligibility of post-cystectomy patients at our institution for adjuvant chemotherapy. METHODS: A retrospective review of patients (2000-2009) who underwent radical cystectomy was performed. Only patients who underwent cystectomy for urothelial carcinoma and who had 6-month post-operative eGFR values (calculated by MDRD calculation) were included (n⫽218). Lack of evidence extravesical disease (n⫽147) or lack of an eGFR of ⬍60 at 6 months post-op (n⫽5) excluded patients from the study, leaving 91 patient for evaluation of adjuvant eligibility. RESULTS: The mean age of all cystectomy patients was 67.0 years, with 29% female, and 12% African American. Mean post-operative eGFR was 62.4. Out of 91 patients with extravesicular disease, 42 (46%) had an eGFR⬎60 and were thus eligible for platinum-based
Vol. 213, No. 3S, September 2011
Surgical Forum Abstracts S147
adjuvant chemotherapy–leaving 54% ineligible due to renal insufficiency. Ineligible patients had an average eGFR of 43.2 compared to 78.5 for eligible patients. Caucasians (vs. African Americans) were more likely to be ineligible (62% vs. 14%;p⫽0.002). Older patients (ⱖ70y) were nearly twice as likely to be ineligible as younger patients (⬍70y) (70% v 40%;p⫽0.01).No differences were observed when analyzed by gender (p⫽0.37). CONCLUSIONS: Our single-institution retrospective study shows that 54% of patients with extravesical disease at cystectomy are ineligible for cisplatin-based adjuvant chemotherapy based on their postoperative renal function and that older patients and Caucasian patients are more likely to be ineligible.
Significance of re-resecting T1 bladder tumors: singleinstitution analysis in a modern cohort of patients Joshua Langston MD, Patrick Selph MD, Ankur Manvar MD, Jed Ferguson MD, Matthew Nielsen MD, Eric Wallen MD, Raj S Pruthi MD, FACS The University of North Carolina, Chapel Hill, NC INTRODUCTION: Recent AUA guidelines have recommended the use of re-resection of T1 bladder tumors. Re-resections more accurately stage patients and provide prognostic information that may aide in selecting of initial therapies. We examined the findings and outcomes of re-resection of T1 bladder tumors in a single institution analysis of a modern cohort of patients. METHODS: A retrospective analysis was performed on a case series of 556 TURBT procedures at a single institution from 2007–2010. From this series, 56 patients were noted to undergo re-resection for T1 bladder cancer, and these patients were utilized for this analysis. RESULTS: Of the 56 patients, 15 had no muscle in the initial specimen and 41 had muscle. Those without muscle (vs.with muscle) in the initial specimen were more likely to be T2 on re-resection (27% vs. 2%) and less likely to have no residual disease (20% vs. 34%). Findings of re-resection were no residual disease (n⫽17),⬍T1 (n⫽12), T1(n⫽22), and T2(n⫽5;includes one with T1 micropapillary). Initial treatment approach is shown in the table – overall and based on findings of re-resection.For those receiving initial intravesical therapy, recurrence rates were lowest for with no residual disease on re-resection versus ⬍t1 vs. T1 (24% vs. 50% vs. 42%). In this cohort, 17 patients underwent RCx – 12 as initial therapy (10 ⱕT2; 1 T3; 1 N⫹) and 5 as salvage therapy (4 ⱕT2; 1 N⫹) OVERALL negative ⬍ T1 T1 T2
n (%)
Intravesical tx, %
RCx, %
Other, %
56 17 (30) 12 (21) 22 (39) 5 (9)
70 100 83 55 0
21 0 8 36 60
9 0 8 9 40
CONCLUSIONS: Re-resection of T1 tumors provides important staging and prognostic information and may help determine most appropriate initial therapy for this group of patients.
Complications following concomitant bladder/urethral injury and pelvic fracture utilizing a national dataset Alex J Vanni MD, Jim Hotaling MD, B Tyler Garland MD, Christian Hamlat MD, Jin Wang PhD, Hunter Wessells MD, FACS, Bryan Voelzke MD University of Washington, Seattle, WA INTRODUCTION: Complications following traumatic bladder and urethral injuries managed with a suprapubic tube is limited to small, single institution series. We utilized the National Trauma Data Bank to investigate complications occurring in patients with lower urinary tract trauma and pelvic fractures. METHODS: Patients with pelvic fractures between 2002–6 and 2008 were identified in the NTDB by Abbreviated Injury Scale. Patients with pelvic fractures requiring surgery who had concomitant bladder or urethral injuries were linked by ICD-9 codes and evaluated. Demographic and clinical characteristics were compared with chi-square and t-tests. A Poisson regression analysis was performed to determine the relative risk of predictors for complications related to bladder or urethral trauma. RESULTS: There were 5,339 bladder/urethral injuries available for analysis, of whom 1,461 had pelvic fracture surgery. In patients with a bladder/urethral injury who had orthopedic pelvic surgery, 35% of patients with a SPT developed complications compared to 28% of patients without a SPT (p⫽0.06). Surgical site infection occurred in 1.6% of patients without a SPT versus 3.6% of patients with a SPT (p⫽0.06). Multivariate analysis revealed an increased risk of complication in patients treated with a SPT (RR 1.33; 95% CI 1.19–1.50), ISS⬎25 (RR 2.53; 95% CI 2.25–2.84), pelvic fracture surgery (RR 1.23; 95% CI 1.12–1.36), diabetes (RR 1.64; 95% CI 1.02–1.75), and hypertension (RR 1.64; 95% CI 1.41–1.90). CONCLUSIONS: In a large national trauma database, SPT placement, pelvic fracture repair, ISS⬎25, diabetes and hypertension were all associated with an increased risk of complication in patients with a traumatic bladder or urethral injury.
Race and insurance status are risk factors for orchiectomy due to testicular trauma Marc A Bjurlin DO, Lee C Zhao MD, MS, Sandra M Goble MS, Courtney M Hollowell MD Cook County Hospital, Chicago, IL INTRODUCTION: Race and insurance status has been shown to independently predict for disparities in outcomes after trauma. It is unknown whether these factors play a role in testicular salvage rates after testicular trauma. We searched the National Trauma Data Bank (NTDB) to investigate if socioeconomic status, race, and rural location predict for testicular salvage. METHODS: Patients who sustained testicular trauma were identified in the NTDB v9.1. Procedure codes for orchiectomy and orchidorrhaphy were used to determine risk of testicular salvage. Univariate analysis for the influence of age, injury severity score (ISS), race, insurance status, and rural location was performed.