- Email: [email protected]
MP96-18 IMPACT OF PROSTATE CANCER THERAPY ON URINARY INCONTINENCE AND QUALITY OF LIFE
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017
METHODS: IRB approved, retrospective review was performed on 383 consecutive non-metastatic patients who underwent definitive RC at a single National Cancer Institute (NCI) designated comprehensive care center between 2001-2014. Zip code derived proxies of socioeconomic status were collected in reference to patient primary residence using US Census data, in addition to characteristics of referring facilities including size, teaching status, and cancer center designation. Travel distance was estimated via straight line distance calculated from latitude and longitude. Multivariable logistic regression analysis was performed to identify factors associated with delay to cystectomy, defined as > 12 weeks from diagnosis of muscle invasive disease to RC. Patients residing outside the US were excluded from analysis. RESULTS: Twenty-two patients residing outside the US were excluded, leaving 363 patients for final analysis. Median travel distance was 15.1 miles, and median time from diagnosis to RC was 8 weeks. On multivariable analysis, referral from a non-NCI designated comprehensive care center (OR 3.1 95% CI [1.04 - 9.15] p¼0.042), diagnosis outside of our hospital network (OR 5.5 95% CI [1.66 - 18.01] p¼0.005), and receipt of neoadjuvant chemotherapy (OR 28 95% CI [14.1 - 56.2] p<0.001) were associated delay to RC. Patient age (p¼.842), size of referring hospital (p¼0.53), median household income (p¼0.16) and estimated patient travel distance (p¼0.41) were not associated with delay. CONCLUSIONS: In an urban environment, distance to treatment facility was not associated with delay to RC. Delay was associated with characteristics referring institutions, including cancer center designation. Further investigation is warranted to determine if consolidation of care to designated centers for complex disease processes such as bladder cancer may improve patient outcomes. Source of Funding: None
MP96-17 LOWER SERUM ALBUMIN LEVELS ARE ASSOCIATED WITH LONGER LENGTHS OF STAY (LOS) FOLLOWING CYSTECTOMY: THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM Rohan Bhalla*, Li Wang, Sam Chang, Mark Tyson, Nashville, TN INTRODUCTION AND OBJECTIVES: Serum albumin levels have been reported to be a valid measure of nutritional status for epidemiologic studies. However, contemporary population-based epidemiologic data evaluating the effect of preoperative albumin levels on LOS after cystectomy and urinary diversion is limited. In this study, we measure the relationship between preoperative serum albumin level and hospital LOS and hypothesized that decreasing preoperative albumin levels would be associated with increasing LOS. Such an association would strengthen the importance of preoperative nutritional optimization prior to cystectomy. METHODS: Data was acquired from the 2014-2015 National Surgical Quality Improvement Program database. We identified 2,469 adult patients who underwent a cystectomy between January 1st 2014 and December 31st 2015. The primary outcome was hospital LOS and the primary exposure was preoperative albumin. We fit proportional odds logistic model with patient-level variables that were either known to be associated with increased LOS or that we had hypothesized would be prior to model fitting. We allowed all continuous variables to have a nonlinear relationship with the primary outcome using restricted cubic spline with 5 knots. RESULTS: Multivariable proportional odds logistic regression determined that preoperative serum albumin was independently associated with LOS (OR: 0.81; 95% CI: 0.64-1.02; p<0.001). Figure 1 demonstrates that LOS increases significantly for patients with a serum albumin level of less than 4 g/dl. Other significant predictors include older age (OR 1.56; 95% CI 1.21-2.01; p<0.001), elevated BMI (OR 1.48; 95% CI 1.17-1.86; p<0.001), and non-Caucasian patients (OR 1.7; 95% CI 1.34-2.18; p<0.001).
e1301
CONCLUSIONS: This study provides evidence that lower preoperative serum albumin levels are associated with increasing LOS. Efforts to optimize a patient’s nutritional status prior to cystectomy undoubtedly have many benefits, including a shorter LOS.
Source of Funding: The project described was supported by the National Center for Research Resources, Grant UL1 RR024975-01, and is now at the National Center for Advancing Translational Sciences, Grant 2 UL1 TR00044506. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
MP96-18 IMPACT OF PROSTATE CANCER THERAPY ON URINARY INCONTINENCE AND QUALITY OF LIFE Andrew Wang, Paul McClain*, Robert Given, Norfolk, VA INTRODUCTION AND OBJECTIVES: Prostate cancer therapy is known to affect urinary symptoms in men, and its effect on quality of life can depend upon which type of treatment is received. This study is a retrospective review of a large database of men who underwent surgical prostate cancer treatment to assess the impact of therapy on quality of life in prostate cancer patients. METHODS: A total of 501 patients who underwent treatment for prostate cancer at a single institution from 2004-2014 were reviewed. The patients in this database were stratified into three groups with respect to the type of therapy received–robot-assisted laparoscopic radical prostatectomy (RLP), brachytherapy, and cryotherapy. Urinary incontinence related quality of life (HRQoL) was assessed at baseline and again at 1-60 months after therapy using the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. Preoperative and postoperative urinary incontinence scores were compared using a Student’s t-test. RESULTS: Baseline patient characteristics were similar between each treatment group. Diabetes was the only comorbidity correlated with urinary symptoms. Baseline urinary incontinence scores were 93.3, 94.5, and 88.2 in the RLP, brachytherapy, and cryotherapy groups, respectively with a significant difference between the RLP and cryotherapy groups (p ¼ 0.046). Urinary incontinence worsened in all three groups at the first follow-up (2.2 months) after treatment (p < 0.0001). The corresponding scores at long term follow-up were 72.0 (p < 0.0001), 78.1 (p < 0.0001), and 83.1 (p ¼ 0.165). The RLP group
THE JOURNAL OF UROLOGYâ
e1302
urinary incontinence improved over time, while the brachytherapy group incontinence did not change significantly after short term follow-up. Only the cryotherapy group achieved a return to baseline at mean follow-up of 17.3 months. No significant difference was found between mean urinary incontinence for RLP and brachytherapy at long-term follow-up (p ¼ 0.128). CONCLUSIONS: Due to the high survival of patients who receive treatment for prostate cancer, quality of life is a major concern when choosing therapy. All three types of prostate cancer treatment studied above cause a short-term worsening of urinary incontinence. Long term, RLP and brachytherapy are associated with worsening of urinary incontinence, whereas cryotherapy is associated with the least impact. Comparatively, RLP and brachytherapy yield similar post-therapy urinary incontinence outcomes. Source of Funding: none
MP96-19 RETURN TO EMERGENCY DEPARTMENT AFTER PEDIATRIC UROLOGY PROCEDURES Naimet K Naoum Alsaigh, Michael Chua*, Jessica Ming, Joana Dos Santos, Megan Saunders, Roberto I Lopes, Martin Koyle, Walid Farhat, Toronto, Canada INTRODUCTION AND OBJECTIVES: Unplanned postoperative return to emergency department (ED) and readmission represent a quality bench outcome and pose a considerable cost burden for health care systems. Here we evaluate a free-standing tertiary care children0 s hospital to identify potential causes and explore areas for improvement. METHODS: A Quality Improvement Board approved retrospective study was performed in our institution identifying all surgical cases done under the service of Urology from October 2012 to September 2015. Baseline demographics, surgeon, operation type and duration, ASA class, and type of admission were evaluated. Patients who returned to ED within 30 days from surgery date were identified. The ED records were reviewed for time of ED return, reason for visit, and treatment received. Univariate and multivariate statistical analysis were done to identify variables that are associated with ED return. Odds ratio (OR) and 95% confidence Intervals (95%CI) were generated to determine the magnitude of relationships. RESULTS: A total of 4125 surgical cases were performed. Overall mean age was 59.9 months (SEM 0.94); with 85.1% of the patients were males. Three hundred forty-nine (8.5%) had unplanned return to the ED within 30 days from the surgery. 15.2% (53) of these returned patients required readmission and 4.3% (15) of them needed further surgical interventions, which were mainly urinary drainage procedures. Penile surgeries accounted for 34.9% of the returns. The most common reason for the ED visit was urinary tract infection in 17.2%, followed by issues related to urethral catheters and wounds (14.3% each). Univariate analysis and multivariate analysis revealed that, the directly associated variables to ED returns were patients younger than 3 yr old (OR 1.48 95%CI 1.18 to 1.87), those lived in the same city with our institution (OR 2.16 95%CI 1.69 -2.76) , procedure time > 150mins (OR 1.5 95%CI 1.12 to 2.00) and in-patient procedures (OR 1.4 95%CI 1.06 to 1.84). The Inguino-scrotal surgery types have significantly lesser ED returns (OR 0.30 95%CI 0.22 to 0.43). CONCLUSIONS: This study shows that the majority of ED returns can be managed conservatively, and probably are preventable. This offers an opportunity for quality improvement by highlighting the importance of optimizing peri-operative family / patient education, reinforcing post-operative instructions and assures an understanding of family expectations.
Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017
MP96-20 CHALLENGING THE PARADIGM OF MANDATORY OVERNIGHT OBSERVATION AFTER ELECTIVE PERCUTANEOUS NEPHROSTOMY TUBE PLACEMENT Jennifer Robles*, Nicole Miller, Nashville, TN INTRODUCTION AND OBJECTIVES: The typical paradigm for patients who undergo elective percutaneous nephrostomy tube placement (PCN) is 23-hr observation to monitor for post-procedure complications such as sepsis or bleeding. However, many similar Interventional Radiology (IR) procedures such as biopsies or abscess drainage are done on an outpatient basis. This maximizes patient and provider satisfaction while reducing medical costs and resource utilization. Our objective is to evaluate the safety of elective PCN placement and to identify which groups should be considered for outpatient PCN placement. METHODS: We performed a retrospective chart review of 374 patients at our institution who underwent PCN or nephroureteral tube placement by IR from 1/2014 - 1/2016. We excluded inpatients, patients with suspected urosepsis, pregnancy, age <18 yrs or pelvic kidneys. All patients were admitted for observation. We collected data on demographics, clinical characteristics, procedural details and post-PCN clinical course. T-test and Chi-squared analysis were used to assess risk factors for statistical significance. RESULTS: We identified 94 patients who underwent electively scheduled PCN placement (see Table 1). There were no major (Clavien Gr III-IV) complications, episodes of sepsis or hemorrhage. There were 8 patients (9%) with systemic inflammatory response syndrome (SIRS): tachycardia (6), fevers (5) and chills (2). Excluding a patient with pancytopenia due to chemotherapy, 100% of patients with SIRS had stones, 6/7 had staghorn stones (p¼0.001) and 5/7 had been treated for positive cultures pre-PCN. They were also statistically more likely to have had difficult procedures & positive PCN cultures. Neither chronically colonized or purulent-appearing urine were associated with complications. CONCLUSIONS: Our data suggests that most patients do not require admission for observation after elective PCN placement. Risk factors for post-PCN complications include large stone burden, longer fluoroscopy time, and difficult PCN access. One-third of patients with staghorn stones developed SIRS and they accounted for the majority of complications despite pre-PCN antibiotic treatment, highlighting the importance of renal pelvic urine cultures and close post-procedural observation for this high-risk group.
Source of Funding: none
Source of Funding: none
Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017
METHODS: IRB approved, retrospective review was performed on 383 consecutive non-metastatic patients who underwent definitive RC at a single National Cancer Institute (NCI) designated comprehensive care center between 2001-2014. Zip code derived proxies of socioeconomic status were collected in reference to patient primary residence using US Census data, in addition to characteristics of referring facilities including size, teaching status, and cancer center designation. Travel distance was estimated via straight line distance calculated from latitude and longitude. Multivariable logistic regression analysis was performed to identify factors associated with delay to cystectomy, defined as > 12 weeks from diagnosis of muscle invasive disease to RC. Patients residing outside the US were excluded from analysis. RESULTS: Twenty-two patients residing outside the US were excluded, leaving 363 patients for final analysis. Median travel distance was 15.1 miles, and median time from diagnosis to RC was 8 weeks. On multivariable analysis, referral from a non-NCI designated comprehensive care center (OR 3.1 95% CI [1.04 - 9.15] p¼0.042), diagnosis outside of our hospital network (OR 5.5 95% CI [1.66 - 18.01] p¼0.005), and receipt of neoadjuvant chemotherapy (OR 28 95% CI [14.1 - 56.2] p<0.001) were associated delay to RC. Patient age (p¼.842), size of referring hospital (p¼0.53), median household income (p¼0.16) and estimated patient travel distance (p¼0.41) were not associated with delay. CONCLUSIONS: In an urban environment, distance to treatment facility was not associated with delay to RC. Delay was associated with characteristics referring institutions, including cancer center designation. Further investigation is warranted to determine if consolidation of care to designated centers for complex disease processes such as bladder cancer may improve patient outcomes. Source of Funding: None
MP96-17 LOWER SERUM ALBUMIN LEVELS ARE ASSOCIATED WITH LONGER LENGTHS OF STAY (LOS) FOLLOWING CYSTECTOMY: THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM Rohan Bhalla*, Li Wang, Sam Chang, Mark Tyson, Nashville, TN INTRODUCTION AND OBJECTIVES: Serum albumin levels have been reported to be a valid measure of nutritional status for epidemiologic studies. However, contemporary population-based epidemiologic data evaluating the effect of preoperative albumin levels on LOS after cystectomy and urinary diversion is limited. In this study, we measure the relationship between preoperative serum albumin level and hospital LOS and hypothesized that decreasing preoperative albumin levels would be associated with increasing LOS. Such an association would strengthen the importance of preoperative nutritional optimization prior to cystectomy. METHODS: Data was acquired from the 2014-2015 National Surgical Quality Improvement Program database. We identified 2,469 adult patients who underwent a cystectomy between January 1st 2014 and December 31st 2015. The primary outcome was hospital LOS and the primary exposure was preoperative albumin. We fit proportional odds logistic model with patient-level variables that were either known to be associated with increased LOS or that we had hypothesized would be prior to model fitting. We allowed all continuous variables to have a nonlinear relationship with the primary outcome using restricted cubic spline with 5 knots. RESULTS: Multivariable proportional odds logistic regression determined that preoperative serum albumin was independently associated with LOS (OR: 0.81; 95% CI: 0.64-1.02; p<0.001). Figure 1 demonstrates that LOS increases significantly for patients with a serum albumin level of less than 4 g/dl. Other significant predictors include older age (OR 1.56; 95% CI 1.21-2.01; p<0.001), elevated BMI (OR 1.48; 95% CI 1.17-1.86; p<0.001), and non-Caucasian patients (OR 1.7; 95% CI 1.34-2.18; p<0.001).
e1301
CONCLUSIONS: This study provides evidence that lower preoperative serum albumin levels are associated with increasing LOS. Efforts to optimize a patient’s nutritional status prior to cystectomy undoubtedly have many benefits, including a shorter LOS.
Source of Funding: The project described was supported by the National Center for Research Resources, Grant UL1 RR024975-01, and is now at the National Center for Advancing Translational Sciences, Grant 2 UL1 TR00044506. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
MP96-18 IMPACT OF PROSTATE CANCER THERAPY ON URINARY INCONTINENCE AND QUALITY OF LIFE Andrew Wang, Paul McClain*, Robert Given, Norfolk, VA INTRODUCTION AND OBJECTIVES: Prostate cancer therapy is known to affect urinary symptoms in men, and its effect on quality of life can depend upon which type of treatment is received. This study is a retrospective review of a large database of men who underwent surgical prostate cancer treatment to assess the impact of therapy on quality of life in prostate cancer patients. METHODS: A total of 501 patients who underwent treatment for prostate cancer at a single institution from 2004-2014 were reviewed. The patients in this database were stratified into three groups with respect to the type of therapy received–robot-assisted laparoscopic radical prostatectomy (RLP), brachytherapy, and cryotherapy. Urinary incontinence related quality of life (HRQoL) was assessed at baseline and again at 1-60 months after therapy using the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. Preoperative and postoperative urinary incontinence scores were compared using a Student’s t-test. RESULTS: Baseline patient characteristics were similar between each treatment group. Diabetes was the only comorbidity correlated with urinary symptoms. Baseline urinary incontinence scores were 93.3, 94.5, and 88.2 in the RLP, brachytherapy, and cryotherapy groups, respectively with a significant difference between the RLP and cryotherapy groups (p ¼ 0.046). Urinary incontinence worsened in all three groups at the first follow-up (2.2 months) after treatment (p < 0.0001). The corresponding scores at long term follow-up were 72.0 (p < 0.0001), 78.1 (p < 0.0001), and 83.1 (p ¼ 0.165). The RLP group
THE JOURNAL OF UROLOGYâ
e1302
urinary incontinence improved over time, while the brachytherapy group incontinence did not change significantly after short term follow-up. Only the cryotherapy group achieved a return to baseline at mean follow-up of 17.3 months. No significant difference was found between mean urinary incontinence for RLP and brachytherapy at long-term follow-up (p ¼ 0.128). CONCLUSIONS: Due to the high survival of patients who receive treatment for prostate cancer, quality of life is a major concern when choosing therapy. All three types of prostate cancer treatment studied above cause a short-term worsening of urinary incontinence. Long term, RLP and brachytherapy are associated with worsening of urinary incontinence, whereas cryotherapy is associated with the least impact. Comparatively, RLP and brachytherapy yield similar post-therapy urinary incontinence outcomes. Source of Funding: none
MP96-19 RETURN TO EMERGENCY DEPARTMENT AFTER PEDIATRIC UROLOGY PROCEDURES Naimet K Naoum Alsaigh, Michael Chua*, Jessica Ming, Joana Dos Santos, Megan Saunders, Roberto I Lopes, Martin Koyle, Walid Farhat, Toronto, Canada INTRODUCTION AND OBJECTIVES: Unplanned postoperative return to emergency department (ED) and readmission represent a quality bench outcome and pose a considerable cost burden for health care systems. Here we evaluate a free-standing tertiary care children0 s hospital to identify potential causes and explore areas for improvement. METHODS: A Quality Improvement Board approved retrospective study was performed in our institution identifying all surgical cases done under the service of Urology from October 2012 to September 2015. Baseline demographics, surgeon, operation type and duration, ASA class, and type of admission were evaluated. Patients who returned to ED within 30 days from surgery date were identified. The ED records were reviewed for time of ED return, reason for visit, and treatment received. Univariate and multivariate statistical analysis were done to identify variables that are associated with ED return. Odds ratio (OR) and 95% confidence Intervals (95%CI) were generated to determine the magnitude of relationships. RESULTS: A total of 4125 surgical cases were performed. Overall mean age was 59.9 months (SEM 0.94); with 85.1% of the patients were males. Three hundred forty-nine (8.5%) had unplanned return to the ED within 30 days from the surgery. 15.2% (53) of these returned patients required readmission and 4.3% (15) of them needed further surgical interventions, which were mainly urinary drainage procedures. Penile surgeries accounted for 34.9% of the returns. The most common reason for the ED visit was urinary tract infection in 17.2%, followed by issues related to urethral catheters and wounds (14.3% each). Univariate analysis and multivariate analysis revealed that, the directly associated variables to ED returns were patients younger than 3 yr old (OR 1.48 95%CI 1.18 to 1.87), those lived in the same city with our institution (OR 2.16 95%CI 1.69 -2.76) , procedure time > 150mins (OR 1.5 95%CI 1.12 to 2.00) and in-patient procedures (OR 1.4 95%CI 1.06 to 1.84). The Inguino-scrotal surgery types have significantly lesser ED returns (OR 0.30 95%CI 0.22 to 0.43). CONCLUSIONS: This study shows that the majority of ED returns can be managed conservatively, and probably are preventable. This offers an opportunity for quality improvement by highlighting the importance of optimizing peri-operative family / patient education, reinforcing post-operative instructions and assures an understanding of family expectations.
Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017
MP96-20 CHALLENGING THE PARADIGM OF MANDATORY OVERNIGHT OBSERVATION AFTER ELECTIVE PERCUTANEOUS NEPHROSTOMY TUBE PLACEMENT Jennifer Robles*, Nicole Miller, Nashville, TN INTRODUCTION AND OBJECTIVES: The typical paradigm for patients who undergo elective percutaneous nephrostomy tube placement (PCN) is 23-hr observation to monitor for post-procedure complications such as sepsis or bleeding. However, many similar Interventional Radiology (IR) procedures such as biopsies or abscess drainage are done on an outpatient basis. This maximizes patient and provider satisfaction while reducing medical costs and resource utilization. Our objective is to evaluate the safety of elective PCN placement and to identify which groups should be considered for outpatient PCN placement. METHODS: We performed a retrospective chart review of 374 patients at our institution who underwent PCN or nephroureteral tube placement by IR from 1/2014 - 1/2016. We excluded inpatients, patients with suspected urosepsis, pregnancy, age <18 yrs or pelvic kidneys. All patients were admitted for observation. We collected data on demographics, clinical characteristics, procedural details and post-PCN clinical course. T-test and Chi-squared analysis were used to assess risk factors for statistical significance. RESULTS: We identified 94 patients who underwent electively scheduled PCN placement (see Table 1). There were no major (Clavien Gr III-IV) complications, episodes of sepsis or hemorrhage. There were 8 patients (9%) with systemic inflammatory response syndrome (SIRS): tachycardia (6), fevers (5) and chills (2). Excluding a patient with pancytopenia due to chemotherapy, 100% of patients with SIRS had stones, 6/7 had staghorn stones (p¼0.001) and 5/7 had been treated for positive cultures pre-PCN. They were also statistically more likely to have had difficult procedures & positive PCN cultures. Neither chronically colonized or purulent-appearing urine were associated with complications. CONCLUSIONS: Our data suggests that most patients do not require admission for observation after elective PCN placement. Risk factors for post-PCN complications include large stone burden, longer fluoroscopy time, and difficult PCN access. One-third of patients with staghorn stones developed SIRS and they accounted for the majority of complications despite pre-PCN antibiotic treatment, highlighting the importance of renal pelvic urine cultures and close post-procedural observation for this high-risk group.
Source of Funding: none
Source of Funding: none