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MP5-06 90-DAY COMPLICATIONS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY ON ENHANCED RECOVERY PROTOCOL
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Friday, May 15, 2015
e47
90-day time point. Though wound complications were lower in ERAS, the borderline p-value is inconclusive in demonstrating a reduction of complications in that category. 90-day Complications by Category Category
ERAS
Controls
p-value
Dehydration
14.2%
9.3%
0.22
Wound
11.8%
20.4%
0.05
Thromboembolism
7.7 %
9.3%
0.21
Infection
32.0%
41.7%
0.10
Cardiovascular
11.8%
13.9%
0.62
Pulmonary
4.1%
4.6%
0.85
Gastrointestinal
21.3%
33.3%
0.03
Renal/Metabolic
17.2%
23.1%
0.22
Neurologic
1.2%
1.9%
0.65
Hematological
25.4%
17.6%
0.13
Other
13.0%
7.4%
0.14
Death
4.1%
4.6%
0.85
Source of Funding: None Source of Funding: NIH KL2 TR001109
MP5-07 MP5-06 90-DAY COMPLICATIONS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY ON ENHANCED RECOVERY PROTOCOL Behrod Katebian*, Soroush Bazargani, Los Angeles, CA; Hamed Ahmadi, Portland, OR; Gus Miranda, Jie Cai, Anne Schuckman, Siamak Daneshmand, Hooman Djaladat, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Enhanced recovery after surgery (ERAS) protocol is designed to improve perioperative care and decrease hospital stay without increasing complications. We have previously shown ERAS facilitates bowel function recovery and shortens hospital stay after radical cystectomy (RC) without increasing hospital readmission rates within the first 30-days. We now evaluate our ERAS protocol for complications in the first 90 days following RC. METHODS: All patients who underwent open RC with the ERAS perioperative protocol from 5/12 to 08/14 were included in the study. The protocol focuses on avoiding bowel preparation and nasogastric tube, early feeding, nonnarcotic pain management and the use of cholinergic and u-opioid antagonists. Non-consenting and patients lost to follow-up were excluded. 90-day complications (Clavien-Dindo grading system), readmissions and emergency room (ER) visits were prospectively recorded and compared to a group of matched controls (non-ERAS) who underwent RC from 10/08 to 5/12 by the same surgeons. Controls were matched by: age, sex, smoking status, BMI, Charlson comorbidity index and pathology stage. RESULTS: A total of 169 consecutive patients (ERAS) and 108 controls (non-ERAS) were included in the study. The median ages of groups were 71.0 (ERAS) and 69.9 (controls). The 90-day major complication rate was 24.3%, and 22.2%; while the minor complication rate was 53.9% vs 57.4% for ERAS and controls respectively (p¼0.34). Furthermore, the median number of complications per patient was 1.0 and 2.0 for ERAS and controls (p¼0.29). The rate of Gastrointestinal (GI) complications (21.3 vs. 33.3%; p¼0.03) and wound complications (11.8% vs. 20.4%; p¼0.05) were both lower in ERAS. Finally, the 90-day readmission rate (29.6% vs 26.9%; p¼0.24) and ER visit rate (37.9% vs 35.2%; p¼0.20) were not different between ERAS and controls respectively. CONCLUSIONS: Our ERAS protocol does not increase overall complication rates, hospital readmissions or ER visits compared to matched non-ERAS patients 90-days following RC. Furthermore, ERAS significantly reduces the frequency of GI complications during the
AN EMPIRICAL EVALUATION OF VARIATION IN INTENSITY OF SURVIVORSHIP CARE AND ITS EFFECT ON KIDNEY CANCER-SPECIFIC SURVIVAL William Sohn*, Amy Graves, Sam Chang, Daniel Barocas, David Penson, Matthew Resnick, Nashville, TN INTRODUCTION AND OBJECTIVES: There remains little consensus surrounding the optimal frequency of surveillance after the surgical treatment of renal cell carcinoma (RCC) to maximize value in the survivorship phase of kidney cancer care. Additionally, there is no definitive evidence that earlier identification of recurrence translates into improvements in survival. The purpose of this study was to characterize the variation in intensity of follow-up imaging and evaluate the association between intensity of surveillance and disease specific survival (DSS). METHODS: We identified incident cases of localized RCC treated with surgery in SEER-Medicare data from 2004e2009. Surveillance intervals were categorized as short and intermediate (0e15 and 15e36 months post-surgery, respectively) after which patients were followed until death or censoring. We identified counts of chest and abdominal imaging attributed to RCC within these periods, truncated 6 months before death or last follow-up to minimize the impact of increased end-of-life intensity of care. We used multivariable negative binomial models to assess associations between imaging counts and patient, disease, and treatment characteristics. Finally, using competing risks analysis, we evaluated the relationship between the intensity of follow-up with DSS. RESULTS: Mean (SD) number of chest and abdominal images were 0.8 (1.0) and 1.0 (1.0) during the short interval and 0.8 (1.2) and 1.0 (1.2) during the intermediate interval. For each outcome and during each surveillance interval, black race and increasing age were associated with decreased imaging intensity (p<0.05). Adverse pathologic features (stage and grade) and operation type were associated with increased imaging intensity (p<0.05). Increased chest and abdomen imaging in either the short- and intermediate-term interval were not associated with any improvement in DSS and, in fact, were associated with increased hazard of kidney cancer-specific mortality (all p<0.001). This finding remained true in pathologic stage subgroups (Figure). CONCLUSIONS: We identified wide variation in the intensity of follow-up during the early- and intermediate- survivorship experience for RCC. However, increased intensity of follow-up does not appear to be protective, rather DSS appears worse in patients undergoing more frequent imaging. While this may be explained in part due to reverse
Vol. 193, No. 4S, Supplement, Friday, May 15, 2015
e47
90-day time point. Though wound complications were lower in ERAS, the borderline p-value is inconclusive in demonstrating a reduction of complications in that category. 90-day Complications by Category Category
ERAS
Controls
p-value
Dehydration
14.2%
9.3%
0.22
Wound
11.8%
20.4%
0.05
Thromboembolism
7.7 %
9.3%
0.21
Infection
32.0%
41.7%
0.10
Cardiovascular
11.8%
13.9%
0.62
Pulmonary
4.1%
4.6%
0.85
Gastrointestinal
21.3%
33.3%
0.03
Renal/Metabolic
17.2%
23.1%
0.22
Neurologic
1.2%
1.9%
0.65
Hematological
25.4%
17.6%
0.13
Other
13.0%
7.4%
0.14
Death
4.1%
4.6%
0.85
Source of Funding: None Source of Funding: NIH KL2 TR001109
MP5-07 MP5-06 90-DAY COMPLICATIONS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY ON ENHANCED RECOVERY PROTOCOL Behrod Katebian*, Soroush Bazargani, Los Angeles, CA; Hamed Ahmadi, Portland, OR; Gus Miranda, Jie Cai, Anne Schuckman, Siamak Daneshmand, Hooman Djaladat, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Enhanced recovery after surgery (ERAS) protocol is designed to improve perioperative care and decrease hospital stay without increasing complications. We have previously shown ERAS facilitates bowel function recovery and shortens hospital stay after radical cystectomy (RC) without increasing hospital readmission rates within the first 30-days. We now evaluate our ERAS protocol for complications in the first 90 days following RC. METHODS: All patients who underwent open RC with the ERAS perioperative protocol from 5/12 to 08/14 were included in the study. The protocol focuses on avoiding bowel preparation and nasogastric tube, early feeding, nonnarcotic pain management and the use of cholinergic and u-opioid antagonists. Non-consenting and patients lost to follow-up were excluded. 90-day complications (Clavien-Dindo grading system), readmissions and emergency room (ER) visits were prospectively recorded and compared to a group of matched controls (non-ERAS) who underwent RC from 10/08 to 5/12 by the same surgeons. Controls were matched by: age, sex, smoking status, BMI, Charlson comorbidity index and pathology stage. RESULTS: A total of 169 consecutive patients (ERAS) and 108 controls (non-ERAS) were included in the study. The median ages of groups were 71.0 (ERAS) and 69.9 (controls). The 90-day major complication rate was 24.3%, and 22.2%; while the minor complication rate was 53.9% vs 57.4% for ERAS and controls respectively (p¼0.34). Furthermore, the median number of complications per patient was 1.0 and 2.0 for ERAS and controls (p¼0.29). The rate of Gastrointestinal (GI) complications (21.3 vs. 33.3%; p¼0.03) and wound complications (11.8% vs. 20.4%; p¼0.05) were both lower in ERAS. Finally, the 90-day readmission rate (29.6% vs 26.9%; p¼0.24) and ER visit rate (37.9% vs 35.2%; p¼0.20) were not different between ERAS and controls respectively. CONCLUSIONS: Our ERAS protocol does not increase overall complication rates, hospital readmissions or ER visits compared to matched non-ERAS patients 90-days following RC. Furthermore, ERAS significantly reduces the frequency of GI complications during the
AN EMPIRICAL EVALUATION OF VARIATION IN INTENSITY OF SURVIVORSHIP CARE AND ITS EFFECT ON KIDNEY CANCER-SPECIFIC SURVIVAL William Sohn*, Amy Graves, Sam Chang, Daniel Barocas, David Penson, Matthew Resnick, Nashville, TN INTRODUCTION AND OBJECTIVES: There remains little consensus surrounding the optimal frequency of surveillance after the surgical treatment of renal cell carcinoma (RCC) to maximize value in the survivorship phase of kidney cancer care. Additionally, there is no definitive evidence that earlier identification of recurrence translates into improvements in survival. The purpose of this study was to characterize the variation in intensity of follow-up imaging and evaluate the association between intensity of surveillance and disease specific survival (DSS). METHODS: We identified incident cases of localized RCC treated with surgery in SEER-Medicare data from 2004e2009. Surveillance intervals were categorized as short and intermediate (0e15 and 15e36 months post-surgery, respectively) after which patients were followed until death or censoring. We identified counts of chest and abdominal imaging attributed to RCC within these periods, truncated 6 months before death or last follow-up to minimize the impact of increased end-of-life intensity of care. We used multivariable negative binomial models to assess associations between imaging counts and patient, disease, and treatment characteristics. Finally, using competing risks analysis, we evaluated the relationship between the intensity of follow-up with DSS. RESULTS: Mean (SD) number of chest and abdominal images were 0.8 (1.0) and 1.0 (1.0) during the short interval and 0.8 (1.2) and 1.0 (1.2) during the intermediate interval. For each outcome and during each surveillance interval, black race and increasing age were associated with decreased imaging intensity (p<0.05). Adverse pathologic features (stage and grade) and operation type were associated with increased imaging intensity (p<0.05). Increased chest and abdomen imaging in either the short- and intermediate-term interval were not associated with any improvement in DSS and, in fact, were associated with increased hazard of kidney cancer-specific mortality (all p<0.001). This finding remained true in pathologic stage subgroups (Figure). CONCLUSIONS: We identified wide variation in the intensity of follow-up during the early- and intermediate- survivorship experience for RCC. However, increased intensity of follow-up does not appear to be protective, rather DSS appears worse in patients undergoing more frequent imaging. While this may be explained in part due to reverse