PD29-04 HISPANO-AMERICAN EXPERIENCE IN MINIMALLY INVASIVE PARTIAL NEPHRECTOMY

THE JOURNAL OF UROLOGYâ

Vol. 193, No. 4S, Supplement, Sunday, May 17, 2015

Table 2 Multivariate Regression Analysis: Variables Influencing % Change in Ipsilateral Functional Renal Parenchymal Volume (FRPV) B

95% CI

p-value

CCI

-0.075

-1.114, 0.964

0.887

Preoperative GFR

-0.070

-.182, 0.043

0.222

Ischemia Time (minutes)

-0.279

-.501, -0.057

0.014

Warm

-3.165

-10.227, 3.898

0.377

EBL (cc)

0.005

-0.005, 0.014

0.325

Lap

-2.068

-9.506, 5.369

0.583

Robotic

-0.768

-7.941, 6.406

0.833

Ischemia Type Cold

reference

e649

were DOC (OS 23 mos; DSS 14 mos); Stage IV, 39.1% were DOD and 48.5% were DOC (OS 33 mos; DSS 15 mos) (p<0.0001). CONCLUSIONS: Octogenarians and nonagenarians with Stage I RCC are likely over treated and those with Stage IV disease likely do not enjoy a survival benefit from surgical management. Appropriately selected patients with Stage II and III disease may benefit from aggressive surgical treatment. We detected no racial disparities in the delivery of surgical treatment, however female patients are more likely to receive aggressive management for localized RCC. Source of Funding: None

Approach Open

reference

Tumor Size (cm)

-2.365

-3.845, -0.885

0.002

E-Score

-6.771

-10.822, -2.719

0.001

N-Score

0.540

-2.346, 3.426

0.712

-1.922

-8.660, 4.816

A-Score Anterior (a) Neither (x) Posterior (p)

PD29-03 NEPHROMETRY SCORES AND THEIR RELATION TO PERIOPERATIVE AND POST-OPERATIVE OUTCOMES AFTER ROBOTIC PARTIAL NEPHRECTOMY Renato B. Corradi, Emily Vertosick, Daniel P. Nguyen, Antoni Vilaseca, Daniel D. Sjoberg, Maximiliano Spaliviero, Karim A. Touijier, Paul Russo, Jonathan A. Coleman, Renato Corradi*, New York, NY

reference 0.574

-5.590

-10.921, -0.259

0.040

L-Score

-1.245

-4.131, 1.640

0.395

H-Component

-6.728

-15.059, 1.604

0.113

*CI ¼ confidence interval, CCI ¼ Charlson Comorbidity Index, GFR ¼ glomerular filtration rate, unit in mL/min/1.73m2, EBL ¼ estimated blood loss

Source of Funding: none

PD29-02 SURGICAL MANAGEMENT OF RENAL CELL CARCINOMA IN OCTOGENARIANS AND NONAGENARIANS: DEFINING APPROPRIATE TREATMENT STANDARDS Zachary Klaassen*, Rita P. Jen, Augusta, GA; John M. DiBianco, Roseau, Dominica; Lael Reinstatler, Daniel Belew, Qiang Li, Rabii Madi, Martha K. Terris, Augusta, GA INTRODUCTION AND OBJECTIVES: Nearly 25% of all cases of renal cell carcinoma (RCC) are diagnosed in patients 80 years of age. Additionally, in the United States, the life expectancy at 80 years is 8.10 years for men and 9.61 years for women. Using a populationbased cohort, we sought to evaluate the surgical treatment patterns and survival outcomes in octogenarians and nonagenarians with RCC. METHODS: Patients 80 years of age with RCC treated either with radical nephrectomy (RN), partial nephrectomy or cryoablation were extracted from the SEER database from 19882010 (n¼7,453). Sociodemographic variables, surgical treatment modality, cause of death, and median overall survival (OS) and disease specific survival (DSS) were reported. Descriptive statistics and Kaplan Meier analysis were performed to compare variables between stages and between treatment modalities. RESULTS: There were 4528 patients (60.7%) with Stage I, 844 patients (11.3%) with Stage II, 1398 patients (18.8%) with Stage III, and 683 patients (9.2%) with Stage IV RCC. Females were more likely to have advanced disease compared to males (female Stage I e 46.6% vs IV e 34.7%; male Stage I e 53.4% vs IV  65.4%, p<0.0001). Furthermore, females were more likely to receive aggressive treatment for localized disease (Stage I RN e female 83.1% vs male 78.3%, p¼0.001; Stage II RN e female 98.5% vs male 94.4%, p¼0.009). Caucasians were more likely to have advanced disease compared to African Americans (AA) (Caucasian Stage I e 89.8% vs IV e 91.3%; AA Stage I e 6.0% vs IV e 4.1%, p ¼0.0007), however there were no differences in treatment modality between races for localized disease. Among patients with Stage I RCC, 10.6% were dead of disease (DOD) and 36.5% were dead of other causes (DOC) (OS 41 mos; DSS 22 mos). For patients with Stage II, 20.2% were DOD and 37.0% were DOC (OS 35 mos; DSS 21 mos); Stage III, 30.1% were DOD and 26.1%

INTRODUCTION AND OBJECTIVES: The feasibility as well as the rate of complications of partial nephrectomy (PN) are related to anatomic attributes of the tumor. Different nephrometry scores based on renal imaging have been reported in order to create a standardized and reproducible way to characterize renal tumor anatomy. However, little is known about which tumors characteristics are truly related to perioperative technical features after robotic PN. We aimed to identify whether nephrometry score subscales or Cindex were associated with estimated blood loss (EBL), ischemia time, hospital stay (LOS), or change in eGFR after robotic PN. METHODS: Between 2008 and 2014, we identified 283 patients who had imaging sufficient to assign RENAL, PADUA and C-index scores after undergoing a robotic PN. Univariate linear regression was used to assess whether C-index or any of the nephrometry score subscales were associated with EBL or ischemia time. For LOS, multivariable linear regression models were created and adjusted for age and ASA score. eGFR was assessed at 6 and 12 months post-operatively by creating a linear regression model adjusted for pre-operative eGFR. RESULTS: Tumor size, was found to be highly associated with peri-operative outcomes, with larger tumors resulting in significantly increased EBL and ischemia time (p<0.0001 for both). Renal sinus (p<0.0001 for both) and renal rim (p¼0.0002, p<0.0001) from the PADUA score, exophytic/endophytic (E/E) from PADUA and RENAL (p¼0.03, p¼0.001), location relative to polar lines scales (RENAL) (p¼0.003, p<0.0001) and the C-index (p¼0.02, p<0.0001) were all significantly associated with EBL and ischemia time, respectively. The C-index (p¼0.014), E/E (p¼0.049), renal sinus (p¼0.015) and medial renal rim (p¼0.001) locations were significantly associated with increased LOS. Tumors infiltrating or <4 mm from the collecting system or within 4mm of renal sinus fat had significantly increased EBL (p¼0.013, p¼0.008), ischemia time (p<0.0001 for both) and LOS (p¼0.001, p¼0.002, respectively). The subscales associated with a decrease in eGFR at 12 months post-operatively were longitudinal location (p¼0.014), renal rim (p¼0.019), renal sinus (p¼0.003), and the C-index (p¼0.017). CONCLUSIONS: Several nephrometry score subscales were associated with perioperative and postoperative outcomes. These associations can be used for case mix adjustment in programs of quality assurance, for example, when comparing the outcomes of different surgeons and techniques. Source of Funding: none

PD29-04 HISPANO-AMERICAN EXPERIENCE IN MINIMALLY INVASIVE PARTIAL NEPHRECTOMY Fernando Pablo Secin*, Buenos Aires, Argentina; Octavio Castillo ~ena, Cadiz, Santiago de Chile, Chile; Patricio Aitor García Marchin Alberto Jurado Navarro, Agustin Rovegno, Anamaria Autran, Buenos

THE JOURNAL OF UROLOGYâ

e650

Aires, Argentina; Oscar Rodriguez Faba, Joan Palou Redorta, Barcelona, Spain; Jose Rozanec, Marcelo Featherstone, Pablo Holst, Buenos ~ ez Bragayrac, Rene Sotelo, Caracas, Aires, Argentina; Luciano Nun Venezuela; Ricardo Faveretto, Stenio Zequi, San Pablo, Brazil;  ~eiro, Madrid, Spain; Mario Alvarez Maestro, Luis Martinez Pin Gustavo Villoldo, Alberto Villaronga, Buenos Aires, Argentina; Diego Abreu Clavijo, Montevideo, Uruguay; Ivar Vidal Mora, Santiago de Chile, Chile; Diana Finkelstein, Juan Ignacio Monzo Gardiner, Buenos Aires, Argentina; Oscar Schatloff, Santiago de Chile, Chile; lix Santaella Torres, Andres Hernandez Porras, Tijuana, Mexico; Fe Distrito Federal, Mexico; Rodolfo Sanchez Salas, Hugo Alberto Davila, Caracas, Venezuela; Humberto Villavicencio Mavrich, Barcelona, Spain INTRODUCTION AND OBJECTIVES: There is scant information on results of minimally invasive partial nephrectomy (PN) in Hispanic-America. Our aim was to describe the perioperative and oncology outcomes in a series of laparoscopic or robotic PNs for renal tumors treated in 16 centers of Hispanic-America from 1/1992-8/2014. METHODS: A data base including clinical, surgical and outcome information was submitted to the collaborating institutions. We estimated proportions, medians, 95% confidence intervals, Kaplan Meier curves, logistic and Cox regression analyses to explore variables associated with complications and recurrence. Clavien classification was used to tabulate complications. The study has been performed under the scope of the American Confederation of Urology (CAU). RESULTS: We evaluated 1034 laparoscopic or robotic PNs. Median age: 58 years, with a 2:1 male to female ratio. 97% was carried out via purely laparoscopic and 83% by a trans peritoneal approach. Median surgical time: 150 minutes, with warm ischemia time of 20 minutes and intraoperative bleeding of 150cc. 80% of the lesions were malignant, with clear cell histology being 62.4% of the total. The median maximum tumour diameter was 2.8 cm. with a positive margins rate of 7.5%. Median hospitalization: 3 days. The overall complication rate was 21%; Clavien (C) 1: 5%; C 2: 10%; C 3A: 1.43%; C 3B: 3.8%; C 4A: 0.82% and C 4B: 0.2%. There were no reported deaths. Bleeding and urinary fistula were the main causes of re operation. Transfusion rate: 13%. Bleeding was the main cause of conversion to radical nephrectomy (1.5%) and conversion to open partial nephrectomy (2.8%). In multivariate analysis, maximum tumour diameter, (p: 0.011) and the presence of two or more tumours in the same renal unit (p< 0.001) were significantly associated with greater likelihood of complications. Nineteen patients presented recurrence and or progression of the disease in a median follow-up of 22.8 months. The local or distant 5year progression free rate was 93% (95%CI:89,96). The corresponding cancer specific and overall survival was 99% (95%CI: 98,100) and 98 %(95%CI:96,99), respectively. Females (p:0.005), presence of bilateral tumours (p:0.004), need for reoperation (p 0.003) and the presence of positive margin (p 0.003) were significantly associated with a greater likelihood of disease recurrence and or progression. CONCLUSIONS: Laparoscopic PN with or without robotic assistance in these centres of Hispanic America have perioperative outcomes, complications and 5-year progression free rates similar to those published in other parts of the world. Source of Funding: None

Vol. 193, No. 4S, Supplement, Sunday, May 17, 2015

ethical challenges, especially when complex oncological procedures are indicated. Our series focuses on the safety and feasibility of performing these procedures under transfusion free restrictions. METHODS: An IRB approved retrospective analysis was performed studying Jehovah’s Witness patients who underwent transfusion free urological surgical procedures at our institution between 2003 and 2013. Comorbidity was measured using the Charlson Comorbidity Index and complications were measured using the Clavien-Dindo Score. RESULTS: A total of 58 patient charts were analyzed (68% male, average age 59). Procedures were classified based on transfusion risk quoted in the literature. Procedures with negligible transfusion risk (<5%) were classified as “minor” (22% of patients) while those with a risk of 5-15% were classified as “major” (41% of patients). TURBT and PCNL were classified as “endoscopic” (11% of patients). “High risk” classification was reserved for procedures with a transfusion rate of >15% (26% of patients). Mean preoperative and postoperative Hb was 13.7 and 11.6 respectively with the lowest post-operative Hb recorded at 7.6. EBL ranged from minimal to 1600cc. No mortalities were recorded and no patients had interventions for post-operative bleeding. The majority of complications were Clavien-Dindo Class II, with two Class III and one Class IV complication. Various perioperative interventions were used including preoperative use of Erythropoietin, hemodilution, use of cell saver, and use of hemostatic agents. CONCLUSIONS: Our study supports the feasibility and safety of performing complex urological surgical procedures without blood transfusion in a carefully selected subset of patients. There were no mortalities in our series, and the rate of significant postoperative complications was 5%.

Procedure

Number of Patients (N)

Minor

Urethral Repair

3

14.2

240

Minor

Vaginal Slings

3

12.6

48

NA

Minor

IPP and AUS

6

14.2

30

14.4

Endoscopic

TURP

2

12.7

100

11.5

Endoscopic

Percutaneous Nephrolithotomy

2

10.3

75

10.1

Risk Classification

Endoscopic

PreOperative Hemoglobin (g/dL)

Estimated Blood Loss (mL)

PostOperative Hemoglobin (g/dL) 12.6

TURBT

4

11.7

205

11.2

Major

Open Radical Prostatectomy

12

13.9

366

11.1

Major

Robotic Radical Prostatectomy

8

15.1

150

13.4

Major

Bladder Augmentation

1

11.9

300

10.7

Major

Debridement for Fournier’s Gangrene

1

10.3

200

9.7

Major

Lap and Robotic Radical Nephrectomy

4

12.1

38

10.9

Major

Robotic Partial Nephrectomy

6

13.0

125

11.2

High Risk

Open Radical Nephrectomy

5

11.6

900

10.8

High Risk

Radical Nephrectomy with Contiguous Liver Resection

1

16.4

1600

11.3

High Risk

Radical Cystectomy and Neobladder

5

14.0

237

11.6

High Risk

Radical Nephrectomy with Level III IVC Tumor Thrombectomy

2

14.0

850

11.5

High Risk

Post Chemo RPLND

1

12.7

500

11.5

Source of Funding: None

PD29-05 MAJOR UROLOGIC PROCEDURES IN JEHOVAH’S WITNESS POPULATION: A STUDY OF SAFETY AND FEASIBILITY Siamak Daneshmand*, Los Angeles, CA; Antoin Douglawi, Alhambra, CA INTRODUCTION AND OBJECTIVES: Blood transfusion is a valuable and sometimes lifesaving element of high risk surgical procedures. Although transfusion rates of urological surgery have decreased in the last decade, transfusion continues to be common practice with high risk procedures such as cystectomies or nephrectomies with caval thrombectomies. Some patients are unable to receive blood due to limited availability, transfusion reactions, hemolytic disorders, or religious convictions. This presents surgeons with medical and

PD29-06 ONCOLOGIC SURVEILLANCE FOLLOWING SURGICAL RESECTION FOR RENAL CELL CARCINOMA: A NOVEL RISK-BASED APPROACH Suzanne Stewart*, R. Houston Thompson, Stephen Boorjian, Sarah Psutka, Christine Lohse, John Cheville, Bradley Leibovich, Igor Frank, Rochester, MN INTRODUCTION AND OBJECTIVES: The appropriate duration of surveillance for renal cell carcinoma (RCC) following radical or partial nephrectomy remains unknown. Uniform adherence to current