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MP64-12 RISK FACTORS FOR 30-DAY HOSPITAL READMISSION OF ROBOTIC PARTIAL NEPHRECTOMY PATIENTS
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Monday, May 19, 2014
MP64-12 RISK FACTORS FOR 30-DAY HOSPITAL READMISSION OF ROBOTIC PARTIAL NEPHRECTOMY PATIENTS Luis Felipe Brandao*, Homayoun Zargar, Humberto Laydner, Oktay Akca, Riccardo Autorino, Oliver Ko, Dinesh Samarasekera, Jianbo Li, Jayram Krishnan, John Rabets, Georges-Pascal Haber, Jihad Kaouk, Robert Stein, Cleveland, OH INTRODUCTION AND OBJECTIVES: Since 2009, Centers for Medicare and Medicaid Services (CMS) began publishing 30-day readmission data for selected medical diseases. The Readmission Reduction Program went into effect on October 1st, 2012 and hospitals are now financially penalized for excess readmissions. The purpose of this study is to identify factors associated with 30-day readmission after robotic partial nephrectomy (RPN). METHODS: We retrospectively reviewed our Institutional Review Board approved database of RPN. Demographics and perioperative parameters were analyzed. Comparisons between both groups were evaluated using Wilcoxon rank-sum test for continuous variables, while chi-square test, or Fisher’s exact test (if events number were small) were used for categorical variables. Simple or multivariable logistic regression analysis was applied to identify factors associated with readmission. Results were considered significant when p value was <0.05. RESULTS: We identified 627 patients who underwent RPN from March 2006 to march 2013. Twenty nine patients (4.6%) were readmitted within 30 days. Postoperative bleeding was responsible for 6 (20%) readmissions, followed by pulmonary embolism with 3 cases and retroperitoneal abscess in 2 patients. Moreover, two patients had urine fistula requiring surgical intervention. Other causes of readmission included chest pain (2), pneumonia (2), vomiting (2), deep venous thrombosis (2), ileus (2), pyelonephritis (1), bladder perforation (1), abdominal pain (1), trocar hernia (1), dehydration (1) and wound infection (1). In total, 11 (37.9%) patients presented with major complications ( Clavien grade 3). When both groups were compared, there was no significant difference in age, body mass index, tumor size, R.E.N.A.L. score, operative time, blood loss, hospital stay and warm ischemia time. On univariable and multivariable analysis, only Charlson score was found to be significantly associated (p¼0.021) with readmission. The chance of readmission increases 57% for Charlson score higher than 4. CONCLUSIONS: Patient‘s health status before the surgery as assessed by the Charlson comorbidity index was the only factor associated with early readmission. Perioperative factors did not have an impact on the 30-day readimission rate. Source of Funding: none
MP64-13 NON-METASTATIC RENAL CANCERS OF MODERATE TO HIGH COMPLEXITY ARE AMENABLE TO PARTIAL NEPHRECTOMY AFTER NEOADJUVANT SUNITINIB Cesar Ercole*, Cleveland, OH; Brian Lane, Grand Rapids, MI; Hyung Kim, Los Angeles, CA; Ithaar Derweesh, San Diego, CA; Rebecca O’Malley, Buffalo, NY; Joseph Klink, Newburgh, IN; Kerrin Palazzi, San Diego, CA; Brian Rini, Steven Campbell, Cleveland, OH INTRODUCTION AND OBJECTIVES: Systemic therapy with sunitinib has been shown to facilitate surgery with unresectable renal cell carcinoma (RCC). We sought to evaluate the effect of sunitinib on moderate- to high-complexity RCC in efforts to determine tumor characteristics that favor the conversion of a mass not initially readily amenable to partial nephrectomy (PN) to one that may be managed successfully with systemic therapy and a subsequent PN. METHODS: Patient information at 4 institutions was reviewed to assess outcomes of radical nephrectomy (RN) or PN after sunitinib therapy for localized RCC. Data were collected for pre- and posttreatment characteristics of the primary renal mass (e.g. size, RENAL score, venous involvement), renal function, and surgical outcomes.
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Patient who completed presurgical sunitinib therapy with the intent for subsequent surgical intervention were included in this analysis. RESULTS: Of 83 patients treated with presurgical sunitinib, 43 patients presented with moderate- to high-complexity renal masses (median clinical size: 7.2cm, interquartile range(IQR): 5.2-8.2; median RENAL score: 10, IQR: 9-11), in the absence of clinical evidence of lymph node or distant metastases. Absolute indications for PN included 9 patients with solitary kidney, 8 with bilateral RCC, and 27 patients with preoperative GFR<60. Following a median of 2 cycles of sunitinib (range: 2-5), median tumor size was 5.1cm (IQR: 4.1-7) and RENAL was 9 (IQR: 8-10). A total of 49 kidneys met criteria for this analysis and surgery was performed in 48 (98%) as one patient was deemed unfit for surgery. PN was completed successfully for 36 tumors (75%), including 10 using a minimally-invasive approach. A reduction in tumor area was observed in 94% (median decrease: 32.5%,IQR 19.5e 46.5%) and reduction in RENAL score was determined in 74% (26 by 1 point, 10 by 2 points). Main sunitinib side effects were fatigue related. Surgical complications of Grade 3 occurred in 5% of PN, where one patient required attention for a wound hernia and another patient required embolization for an AV fistula presenting with gross hematuria. CONCLUSIONS: PN can be safely performed after sunitinib, including for some tumors not considered amenable to PN at initial presentation. We feel that presurgical sunitinib therapy for biopsyproven clear cell RCC for which PN is not deemed feasible is a reasonable approach in select patients. Source of Funding: None
MP64-14 “TRIFECTA” AFTER PARTIAL NEPHRECTOMY IN SOLITARY KIDNEY. Andre Luis Abreu*, Andrew Hung, Andre Berger, Raed Azhar, Sameer Chopra, Jie Cai, Osamu Ukimura, Monish Aron, Inderbir Gill, Mihir Desai, Los Angeles, CA INTRODUCTION AND OBJECTIVES: To compare renal function and Trifecta outcomes between complete hilar clamping vs no clamping during partial nephrectomy (PN) in solitary kidney. METHODS: We analyzed the data of 79 patients that underwent robotic/laparoscopic PN in solitary kidney from a historical (1999 to 2012) cohort. The patients underwent hilar control according to the technique used along the evolution of PN, as follows: conventional clamping (CC) PN (tumor excision and kidney reconstruction under main artery clamp), early unclamping (EU) PN (tumor excision and only the hemostasis under main artery clamp) and anatomical zero-ischemia (AZI) PN (either no clamping or only super-selective tumor-specific arterial branch clamping was employed for tumor excision). The patient was considered achieving the “Trifecta” after PN if the eGFR (estimated glomerular filtration rate) decreased less than 10% from baseline AND negative cancer margins AND no urological complications. The demographics, perioperative and renal function and Trifecta outcomes were analyzed. Fisher’s or KruskalWallis tests and linear regression modeling were applied for statistical analysis and for correlation between warm ischemia (WI) and postoperative eGFR (significant if p<0.05). RESULTS: The results are summarized in the Table. There were 31, 33 and 15 patients in the CC-PN, EU-PN and AZI-PN, respectively. The size and complexity of the tumors, and baseline renal function were not significant different between the groups. The WI time decreased from 33min to 15min to zero (p<0.001) for CC-PN, EU-PN and AZI-PN, respectively. Negative surgical margins were consistent high for all the groups. The eGFR decreased 38% vs 29% vs 3% (p¼0.003) and the number of patients in which eGFR decrease > 10% comparing to baseline was 27 (87%), 23 (70%) and 4 (27%), p¼0,002, for CC-PN, EU-PN and AZI-PN, respectively. The Trifecta was achieved in 4 (13%), 9 (27%) and 9 (60%), p¼0.003, of CC-PN, EU-PN and AZI-PN patients, respectively. On univariate analysis, every minute increased in WI during robotic/laparoscopic PN decreased the postoperative average eGFR by 1 ml/min/1.73m2 (r ¼ -0.52, p<0.001)
Vol. 191, No. 4S, Supplement, Monday, May 19, 2014
MP64-12 RISK FACTORS FOR 30-DAY HOSPITAL READMISSION OF ROBOTIC PARTIAL NEPHRECTOMY PATIENTS Luis Felipe Brandao*, Homayoun Zargar, Humberto Laydner, Oktay Akca, Riccardo Autorino, Oliver Ko, Dinesh Samarasekera, Jianbo Li, Jayram Krishnan, John Rabets, Georges-Pascal Haber, Jihad Kaouk, Robert Stein, Cleveland, OH INTRODUCTION AND OBJECTIVES: Since 2009, Centers for Medicare and Medicaid Services (CMS) began publishing 30-day readmission data for selected medical diseases. The Readmission Reduction Program went into effect on October 1st, 2012 and hospitals are now financially penalized for excess readmissions. The purpose of this study is to identify factors associated with 30-day readmission after robotic partial nephrectomy (RPN). METHODS: We retrospectively reviewed our Institutional Review Board approved database of RPN. Demographics and perioperative parameters were analyzed. Comparisons between both groups were evaluated using Wilcoxon rank-sum test for continuous variables, while chi-square test, or Fisher’s exact test (if events number were small) were used for categorical variables. Simple or multivariable logistic regression analysis was applied to identify factors associated with readmission. Results were considered significant when p value was <0.05. RESULTS: We identified 627 patients who underwent RPN from March 2006 to march 2013. Twenty nine patients (4.6%) were readmitted within 30 days. Postoperative bleeding was responsible for 6 (20%) readmissions, followed by pulmonary embolism with 3 cases and retroperitoneal abscess in 2 patients. Moreover, two patients had urine fistula requiring surgical intervention. Other causes of readmission included chest pain (2), pneumonia (2), vomiting (2), deep venous thrombosis (2), ileus (2), pyelonephritis (1), bladder perforation (1), abdominal pain (1), trocar hernia (1), dehydration (1) and wound infection (1). In total, 11 (37.9%) patients presented with major complications ( Clavien grade 3). When both groups were compared, there was no significant difference in age, body mass index, tumor size, R.E.N.A.L. score, operative time, blood loss, hospital stay and warm ischemia time. On univariable and multivariable analysis, only Charlson score was found to be significantly associated (p¼0.021) with readmission. The chance of readmission increases 57% for Charlson score higher than 4. CONCLUSIONS: Patient‘s health status before the surgery as assessed by the Charlson comorbidity index was the only factor associated with early readmission. Perioperative factors did not have an impact on the 30-day readimission rate. Source of Funding: none
MP64-13 NON-METASTATIC RENAL CANCERS OF MODERATE TO HIGH COMPLEXITY ARE AMENABLE TO PARTIAL NEPHRECTOMY AFTER NEOADJUVANT SUNITINIB Cesar Ercole*, Cleveland, OH; Brian Lane, Grand Rapids, MI; Hyung Kim, Los Angeles, CA; Ithaar Derweesh, San Diego, CA; Rebecca O’Malley, Buffalo, NY; Joseph Klink, Newburgh, IN; Kerrin Palazzi, San Diego, CA; Brian Rini, Steven Campbell, Cleveland, OH INTRODUCTION AND OBJECTIVES: Systemic therapy with sunitinib has been shown to facilitate surgery with unresectable renal cell carcinoma (RCC). We sought to evaluate the effect of sunitinib on moderate- to high-complexity RCC in efforts to determine tumor characteristics that favor the conversion of a mass not initially readily amenable to partial nephrectomy (PN) to one that may be managed successfully with systemic therapy and a subsequent PN. METHODS: Patient information at 4 institutions was reviewed to assess outcomes of radical nephrectomy (RN) or PN after sunitinib therapy for localized RCC. Data were collected for pre- and posttreatment characteristics of the primary renal mass (e.g. size, RENAL score, venous involvement), renal function, and surgical outcomes.
e705
Patient who completed presurgical sunitinib therapy with the intent for subsequent surgical intervention were included in this analysis. RESULTS: Of 83 patients treated with presurgical sunitinib, 43 patients presented with moderate- to high-complexity renal masses (median clinical size: 7.2cm, interquartile range(IQR): 5.2-8.2; median RENAL score: 10, IQR: 9-11), in the absence of clinical evidence of lymph node or distant metastases. Absolute indications for PN included 9 patients with solitary kidney, 8 with bilateral RCC, and 27 patients with preoperative GFR<60. Following a median of 2 cycles of sunitinib (range: 2-5), median tumor size was 5.1cm (IQR: 4.1-7) and RENAL was 9 (IQR: 8-10). A total of 49 kidneys met criteria for this analysis and surgery was performed in 48 (98%) as one patient was deemed unfit for surgery. PN was completed successfully for 36 tumors (75%), including 10 using a minimally-invasive approach. A reduction in tumor area was observed in 94% (median decrease: 32.5%,IQR 19.5e 46.5%) and reduction in RENAL score was determined in 74% (26 by 1 point, 10 by 2 points). Main sunitinib side effects were fatigue related. Surgical complications of Grade 3 occurred in 5% of PN, where one patient required attention for a wound hernia and another patient required embolization for an AV fistula presenting with gross hematuria. CONCLUSIONS: PN can be safely performed after sunitinib, including for some tumors not considered amenable to PN at initial presentation. We feel that presurgical sunitinib therapy for biopsyproven clear cell RCC for which PN is not deemed feasible is a reasonable approach in select patients. Source of Funding: None
MP64-14 “TRIFECTA” AFTER PARTIAL NEPHRECTOMY IN SOLITARY KIDNEY. Andre Luis Abreu*, Andrew Hung, Andre Berger, Raed Azhar, Sameer Chopra, Jie Cai, Osamu Ukimura, Monish Aron, Inderbir Gill, Mihir Desai, Los Angeles, CA INTRODUCTION AND OBJECTIVES: To compare renal function and Trifecta outcomes between complete hilar clamping vs no clamping during partial nephrectomy (PN) in solitary kidney. METHODS: We analyzed the data of 79 patients that underwent robotic/laparoscopic PN in solitary kidney from a historical (1999 to 2012) cohort. The patients underwent hilar control according to the technique used along the evolution of PN, as follows: conventional clamping (CC) PN (tumor excision and kidney reconstruction under main artery clamp), early unclamping (EU) PN (tumor excision and only the hemostasis under main artery clamp) and anatomical zero-ischemia (AZI) PN (either no clamping or only super-selective tumor-specific arterial branch clamping was employed for tumor excision). The patient was considered achieving the “Trifecta” after PN if the eGFR (estimated glomerular filtration rate) decreased less than 10% from baseline AND negative cancer margins AND no urological complications. The demographics, perioperative and renal function and Trifecta outcomes were analyzed. Fisher’s or KruskalWallis tests and linear regression modeling were applied for statistical analysis and for correlation between warm ischemia (WI) and postoperative eGFR (significant if p<0.05). RESULTS: The results are summarized in the Table. There were 31, 33 and 15 patients in the CC-PN, EU-PN and AZI-PN, respectively. The size and complexity of the tumors, and baseline renal function were not significant different between the groups. The WI time decreased from 33min to 15min to zero (p<0.001) for CC-PN, EU-PN and AZI-PN, respectively. Negative surgical margins were consistent high for all the groups. The eGFR decreased 38% vs 29% vs 3% (p¼0.003) and the number of patients in which eGFR decrease > 10% comparing to baseline was 27 (87%), 23 (70%) and 4 (27%), p¼0,002, for CC-PN, EU-PN and AZI-PN, respectively. The Trifecta was achieved in 4 (13%), 9 (27%) and 9 (60%), p¼0.003, of CC-PN, EU-PN and AZI-PN patients, respectively. On univariate analysis, every minute increased in WI during robotic/laparoscopic PN decreased the postoperative average eGFR by 1 ml/min/1.73m2 (r ¼ -0.52, p<0.001)