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PD39-08 PROPENSITY-MATCHED COMPARISON OF SURVIVAL OUTCOMES IN PATIENTS UNDERGOING RADICAL CYSTECTOMY VERSUS BLADDER PRESERVING TRIMODAL THERAPY
THE JOURNAL OF UROLOGYâ
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Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
PD39-07 SURGEON VARIATION IN THE COSTS OF RADICAL CYSTECTOMY Jeffrey Leow*, Alexander Cole, Steven Chang, Christian Meyer, Adam Kibel, Boston, MA; Mani Menon, Detroit, MI; Thomas Seisen, Boston, MA; Jesse Sammon, Detroit, MI; Mark Preston, Boston, MA; Benjamin Chung, Palo Alto, CA; Maxine Sun, Quoc-Dien Trinh, Boston, MA
Source of Funding: None
PD39-06 COST DASHBOARDS FOR RADICAL CYSTECTOMY: ACCOUNTING FOR SURGEON COST VARIATION Alan Thong*, Wazim Narain, Donna Boccamazzo, Peter Sidi, Guido Dalbagni, Bernard Bochner, New York, NY INTRODUCTION AND OBJECTIVES: In addition to promoting quality, new payment models are emerging with a mandate to control healthcare costs. On a national level, there is significant variation in the cost of major index cancer operations. Accurate cost accounting, clinician-defined metrics, risk-adjustment, and feedback of data are essential steps in using cost data for quality improvement. We sought to account for institutional direct costs incurred during radical cystectomy, identify the main cost drivers in the index hospitalization, and examine surgeon variability in the main cost drivers within the context of patient characteristics. METHODS: Direct itemized institutional cost data for 321 consecutive radical cystectomies performed by 5 de-identified surgeons was obtained. Costs were adjusted using a multiplier equal to the ratio of normalized Medicare reimbursement over institutional reported cost. Interactive web-based dashboards were created to feedback patient characteristics, outcomes, cost components, and anonymized surgeon cost comparisons. Analysis of variance was used to compare patient characteristics and cost components across surgeons. Multivariable logistic regression was used to model above average costs on surgeon and patient specific factors. RESULTS: The median adjusted total cost per case was $13009.57 (interquartile range $11254.82, $15730.53). Inpatient, anesthesia, disposable device, operating room, and physician costs accounted for the majority of the total costs incurred. Inpatient costs were not significantly different across surgeons, however maximum differences between cost means for anesthesia ($93.62, p¼0.0039), disposable device (energy devices, $279.48, p<0.0001; staplers, $494.73, p<0.0001), operating room ($1168.55, p<0.0001), and physician costs ($1362.20, p<0.0001) did differ significantly across surgeons. Adjusting for patient factors including gender, American Society of Anesthesiologists status, diversion type, and total lymph node count, these significant differences in cost across surgeons persisted. CONCLUSIONS: Cost accounting using dashboards identified significant cost differences across surgeons performing radical cystectomy at our institution independent of differences in patient characteristics. Additional longitudinal cost data is needed to determine if such anonymized, interactive cost feedback through dashboards can improve the value of surgical care by reducing cost without sacrificing quality. Source of Funding: National Cancer Institute Training Grant T32 CA82088-16
INTRODUCTION AND OBJECTIVES: In a cost-conscious healthcare environment, identifying unwarranted costs and cost variability is paramount. Bladder cancer (BCa) incurs the highest lifetime treatment costs per patient of all cancers and radical cystectomy (RC), as a cornerstone of BCa treatment, is a major contributor. Under these premises, the aim of the current study was to assess individual surgeon-level variations and identify independent predictors of high- and low-cost RC. METHODS: We queried the Premier all-payer discharge database to accrue a study cohort of a weighted sample of 11,225 individuals who underwent RC by 292 unique surgeons at 144 different hospitals between 2003 and 2013. Surgeon and hospital volume as well as 90-day direct hospital costs (2014 US$) were ranked and divided into high and low volume, and high and low costs. High volume and costs were defined as values above the 90th percentile while low volume and costs corresponded to costs and volume below the 10th percentile. Multivariable logistic regression models identified independent predictors of high and low costs, while multilevel hierarchal models determined variability of various characteristics on costs. RESULTS: Mean 90-day direct hospital costs for each RC patient was $32,261 (95% CI $31220 - $33,302). There were 70 surgeons whose mean costs associated with each RC fell in the lowest decile of costs (<$16,278), with mean costs of $13,654 (95% CI: $13,191 to $14,116). There were 113 surgeons with mean costs for each RC in the top decile (>$51,285), with mean costs of $82,642 (95% CI: $76541 to $88744). Factors associated with high costs include worse comorbidity profile (vs. no comorbidity: OR 3.45, 95% CI 2.215.38, p<0.0001) and laparoscopic approach (vs. open: 2.83, 95% CI: 1.52 to 5.27, p¼0.0004). We found that patient, hospital and surgeon characteristics had a modest effect on the variability of costs (4.9%, 2.1%, 0.6% respectively). However, the presence of a 90-day major complication after RC and a prolonged postoperative length of stay contributed substantially to the overall cost variability (18.1% and 18.2% respectively). CONCLUSIONS: There was a nearly 6-fold difference in costs between the most and least costly surgeons performing RC. There appears to be a key role played by individual surgeons across a large nationally representative sample. Given the modest variability in costs contributed by hospital and surgeon characteristics, the avoidance and prompt management of major complications may be key to reduce unwarranted variability in BCa/RC costs. Source of Funding: none
PD39-08 PROPENSITY-MATCHED COMPARISON OF SURVIVAL OUTCOMES IN PATIENTS UNDERGOING RADICAL CYSTECTOMY VERSUS BLADDER PRESERVING TRIMODAL THERAPY Girish Kulkarni*, Thomas Hermanns, Kathy Li, Yanliang Wei, Bimal Bhindi, Cynthia Kuk, Srikala Sridhar, Theodorus van der Kwast, Peter Chung, Robert Bristow, Padraig Warde, Milosevic Michael, Neil Fleshner, Michael Jewett, Alexandre Zlotta, Toronto, Canada INTRODUCTION AND OBJECTIVES: We started in 2008 a Multidisciplinary Bladder Cancer Clinic (MDBCC), where complex bladder cancer patients are assessed concurrently by urologic and radiation oncologists, with support from medical oncologists. Patients have the opportunity to discuss various treatment options including radical cystectomy (RC) or bladder sparing trimodal therapy (TMT;
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
endoscopic resection, radiotherapy and chemotherapy). Although reports have shown comparable outcomes of TMT to cystectomy, no direct comparison to RC has been published and no randomized studies are available. We report our long term outcomes of multidisciplinary care, comparing TMT to surgery using propensity-matched analyses. METHODS: Patients seen in our MDBCC receiving TMT for MIBC from 2008 to 2012 were identified and matched, using propensity scores, to patients operated by RC. Matching occurred on age, ECOG status, Charlson comorbidity score, cT stage, cN stage and date of treatment. Overall survival (OS) and disease-specific survival (DSS) were assessed with Cox Proportional hazards modeling and competing risk analysis, respectively. RESULTS: Between 2008 and 2012, 248 patients were assessed in the MDBCC. Of these, 162 (65%) had MIBC. Nearly half (80) opted for radiotherapy +/- concurrent cisplatin chemotherapy and 49 underwent full bladder preservation with TMT as their primary therapy. We matched 48 TMT patients with 48 RC patients with no imbalances. Median age of the cohort was 67.5 years with 29.2% cT3/cT4. With a median follow up time of 3.62 years, there were 19 (39.6%) deaths (7 from bladder cancer) in the RC group and 15 (31.3%) deaths (6 from bladder cancer) in the TMT group. 5 year DSS was 85.2% and 84.7% with TMT and surgery, respectively (p>0.05). There was no statistically significant difference in DSS between the two groups (HR for TMT 1.31 (0.40-4.23), p¼0.66) or in OS (HR for TMT 0.77 (0.341.75), p¼0.53). CONCLUSIONS: Bladder cancer patients benefit from a multidisciplinary approach. In selected patients with MIBC, chemo-radiation yields survival outcomes similar to matched RC patients. BC patients should be offered the possibility to discuss various treatment options. Source of Funding: None.
PD39-09 CHEMORADIOTHERAPY IN OCTOGENARIANS AS PRIMARY TREATMENT FOR MUSCLE INVASIVE BLADDER CANCER Victor McPherson*, George Rodrigues, Glenn Bauman, Nicholas Power, London, Canada INTRODUCTION AND OBJECTIVES: Radical cystectomy is the gold standard therapy for muscle invasive bladder cancer (MIBC) and achieves an overall 5 year survival of 57%. However, in the octogenarian population, cystectomy results in a 6.8-11.1% perioperative mortality rate, which is significantly higher than the approximately 2.2% rate in younger patients. There is clear evidence that aggressive local therapy improves overall and cancer specific survival in this group. Trimodality therapy is a bladder sparing therapeutic regimen composed of TURBT followed by combination chemoradiotherapy, with intent for salvage cystectomy in non-responders and patients who recur, and has a 62.5-90% initial complete response rate. In this study, we evaluate the use of TURBT and chemoradiotherapy without the option of salvage cystectomy in octogenarian patients deemed to not be surgical candidates. METHODS: A retrospective cohort of patients aged 80-89 with biopsy proven invasive urothelial carcinoma received combination chemoradiotherapy between 2008-June 2014 was identified. Outcomes were evaluated by Kaplan Meier (KM) analysis and Cox regression. RESULTS: For the 40 patients, the mean age was 84.5 (range 80-89), with 28 males and 12 females. Seventeen patients received hypofractionated radiotherapy (Low Dose; 37.5-40 Gy), while 23 received conventionally fractionated radiotherapy (High Dose; 50-65 Gy); 30 patients received carboplatin as a radiosensitizing agent, 7 received 5-Fluorouracil and Mitomycin C, and 3 received cisplatin. Mean overall survival (OS) was 20.7 (IQR 12.75-23.25) months, while mean recurrence free survival was 13.75 (3.75-16.5) months. By KM analysis, patients who received chemosensitizing agents other than carboplatin had an improved OS but not improved local recurrence free
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survival (LRFS) and patients who received high dose radiotherapy showed improved OS and LRFS, while having no significant differences in grade 3-4 toxicities. Univariate cox regression identified hydronephrosis as a predictor of worse OS and high dose radiotherapy (HDR) and non-carboplatin chemotherapy regimens as predictors of improved OS, while hydronephrosis predicted local recurrence and HDR improved local recurrence rates. CONCLUSIONS: Primary chemoradiotherapy for non-operative patients with MIBC is relatively safe and was associated with a 3 year OS of 54.9% and 3 year RFS of 42.3%. Outcomes were associated with choice of radiation fractionation and chemosensitization regimen. Source of Funding: None
PD39-10 DO BLADDER CANCER PATIENTS WITH CLINICALLY METASTATIC LYMPH NODE DISEASE BENEFIT FROM RADICAL CYSTECTOMY? Bashir Al Hussein Al Awamlh*, Daniel Nguyen, Michael Shulster, Padriac O’malley, David M. Golombos, Patrick Lewicki, Benjamin Stone, Douglas Scherr, New York, NY INTRODUCTION AND OBJECTIVES: With recent advances in chemotherapeutic regimens, there is evidence that some patients with clinically metastatic lymph node disease will benefit from preoperative chemotherapy followed by local consolidation with radical surgery. However, the role of radical cystectomy (RC) in this setting remains largely unknown. We report our experience with patients who had clinically enlarged nodes and ultimately underwent RC METHODS: Patients charts were retrospectively reviewed. Patients with clinical node (cN+) disease on pre-op imaging represented our cohort of interest. For survival analyses, the comparison cohort included patients who had no evidence of node metastasis in pre-op imaging, yet had nodal disease in final pathology (pN+). Patients with visceral disease were excluded. Cancer- specific survival (CSS) and overall survival (OS) were estimated using the Kaplan-Meier method RESULTS: A total of 25 patients with cN+ disease were identified. Of those 25, 15 (60%) had loco-regional enlarged nodes and 10 (40%) had non-local disease. Twenty patients (80%) and 13 (52%) received pre-op and adjuvant chemotherapy, respectively. Of the 20 patients who received pre-op chemotherapy, 11 (55%) had a documented response in imaging prior to surgery. On final pathology, 13 (52%) patients had pT2 stage, 6 (24%) had pT3 and 6 (24%) had pT4. Nine (36%) patients had pN0 at RC, all of which had received pre-op chemotherapy. Sixteen (64%) patients had pN+ disease, of which 11 (69%) had received pre-op chemotherapy. The median follow-up for surviving patients was 15 months. At last follow-up, 14 had a recurrence, of which 12 died from bladder cancer. 10 patients were alive without recurrence. Patients with clinical locoregional disease had better OS (92% and 50% vs. 50% and 38%, p¼0.011) and CSS (92% and 50% vs. 50% and 38%, p¼ 0.041) at 1 and 3 years, than those with clinical non local nodal enlargement. Next, we compared survival probabilities of the 25 cN+ patients and those of 55 patients who had no evidence of node metastasis in pre-op imaging, yet had nodal disease in final pathology. The actuarial OS at 1 and 3 years (74% and 33% vs. 61% and 35%) and CSS at 1 and 3 years (74% and 41% vs. 71% and 43%) probabilities between the two groups were not statistically different (p>0.05) CONCLUSIONS: A subset of patients with clinically metastatic lymph node disease achieve durable survival after RC associated with perioperative chemotherapy. For selected patients with clinically metastatic disease, most likely limited, the option of combined therapy with chemotherapy and surgery should be discussed Source of Funding: none
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Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
PD39-07 SURGEON VARIATION IN THE COSTS OF RADICAL CYSTECTOMY Jeffrey Leow*, Alexander Cole, Steven Chang, Christian Meyer, Adam Kibel, Boston, MA; Mani Menon, Detroit, MI; Thomas Seisen, Boston, MA; Jesse Sammon, Detroit, MI; Mark Preston, Boston, MA; Benjamin Chung, Palo Alto, CA; Maxine Sun, Quoc-Dien Trinh, Boston, MA
Source of Funding: None
PD39-06 COST DASHBOARDS FOR RADICAL CYSTECTOMY: ACCOUNTING FOR SURGEON COST VARIATION Alan Thong*, Wazim Narain, Donna Boccamazzo, Peter Sidi, Guido Dalbagni, Bernard Bochner, New York, NY INTRODUCTION AND OBJECTIVES: In addition to promoting quality, new payment models are emerging with a mandate to control healthcare costs. On a national level, there is significant variation in the cost of major index cancer operations. Accurate cost accounting, clinician-defined metrics, risk-adjustment, and feedback of data are essential steps in using cost data for quality improvement. We sought to account for institutional direct costs incurred during radical cystectomy, identify the main cost drivers in the index hospitalization, and examine surgeon variability in the main cost drivers within the context of patient characteristics. METHODS: Direct itemized institutional cost data for 321 consecutive radical cystectomies performed by 5 de-identified surgeons was obtained. Costs were adjusted using a multiplier equal to the ratio of normalized Medicare reimbursement over institutional reported cost. Interactive web-based dashboards were created to feedback patient characteristics, outcomes, cost components, and anonymized surgeon cost comparisons. Analysis of variance was used to compare patient characteristics and cost components across surgeons. Multivariable logistic regression was used to model above average costs on surgeon and patient specific factors. RESULTS: The median adjusted total cost per case was $13009.57 (interquartile range $11254.82, $15730.53). Inpatient, anesthesia, disposable device, operating room, and physician costs accounted for the majority of the total costs incurred. Inpatient costs were not significantly different across surgeons, however maximum differences between cost means for anesthesia ($93.62, p¼0.0039), disposable device (energy devices, $279.48, p<0.0001; staplers, $494.73, p<0.0001), operating room ($1168.55, p<0.0001), and physician costs ($1362.20, p<0.0001) did differ significantly across surgeons. Adjusting for patient factors including gender, American Society of Anesthesiologists status, diversion type, and total lymph node count, these significant differences in cost across surgeons persisted. CONCLUSIONS: Cost accounting using dashboards identified significant cost differences across surgeons performing radical cystectomy at our institution independent of differences in patient characteristics. Additional longitudinal cost data is needed to determine if such anonymized, interactive cost feedback through dashboards can improve the value of surgical care by reducing cost without sacrificing quality. Source of Funding: National Cancer Institute Training Grant T32 CA82088-16
INTRODUCTION AND OBJECTIVES: In a cost-conscious healthcare environment, identifying unwarranted costs and cost variability is paramount. Bladder cancer (BCa) incurs the highest lifetime treatment costs per patient of all cancers and radical cystectomy (RC), as a cornerstone of BCa treatment, is a major contributor. Under these premises, the aim of the current study was to assess individual surgeon-level variations and identify independent predictors of high- and low-cost RC. METHODS: We queried the Premier all-payer discharge database to accrue a study cohort of a weighted sample of 11,225 individuals who underwent RC by 292 unique surgeons at 144 different hospitals between 2003 and 2013. Surgeon and hospital volume as well as 90-day direct hospital costs (2014 US$) were ranked and divided into high and low volume, and high and low costs. High volume and costs were defined as values above the 90th percentile while low volume and costs corresponded to costs and volume below the 10th percentile. Multivariable logistic regression models identified independent predictors of high and low costs, while multilevel hierarchal models determined variability of various characteristics on costs. RESULTS: Mean 90-day direct hospital costs for each RC patient was $32,261 (95% CI $31220 - $33,302). There were 70 surgeons whose mean costs associated with each RC fell in the lowest decile of costs (<$16,278), with mean costs of $13,654 (95% CI: $13,191 to $14,116). There were 113 surgeons with mean costs for each RC in the top decile (>$51,285), with mean costs of $82,642 (95% CI: $76541 to $88744). Factors associated with high costs include worse comorbidity profile (vs. no comorbidity: OR 3.45, 95% CI 2.215.38, p<0.0001) and laparoscopic approach (vs. open: 2.83, 95% CI: 1.52 to 5.27, p¼0.0004). We found that patient, hospital and surgeon characteristics had a modest effect on the variability of costs (4.9%, 2.1%, 0.6% respectively). However, the presence of a 90-day major complication after RC and a prolonged postoperative length of stay contributed substantially to the overall cost variability (18.1% and 18.2% respectively). CONCLUSIONS: There was a nearly 6-fold difference in costs between the most and least costly surgeons performing RC. There appears to be a key role played by individual surgeons across a large nationally representative sample. Given the modest variability in costs contributed by hospital and surgeon characteristics, the avoidance and prompt management of major complications may be key to reduce unwarranted variability in BCa/RC costs. Source of Funding: none
PD39-08 PROPENSITY-MATCHED COMPARISON OF SURVIVAL OUTCOMES IN PATIENTS UNDERGOING RADICAL CYSTECTOMY VERSUS BLADDER PRESERVING TRIMODAL THERAPY Girish Kulkarni*, Thomas Hermanns, Kathy Li, Yanliang Wei, Bimal Bhindi, Cynthia Kuk, Srikala Sridhar, Theodorus van der Kwast, Peter Chung, Robert Bristow, Padraig Warde, Milosevic Michael, Neil Fleshner, Michael Jewett, Alexandre Zlotta, Toronto, Canada INTRODUCTION AND OBJECTIVES: We started in 2008 a Multidisciplinary Bladder Cancer Clinic (MDBCC), where complex bladder cancer patients are assessed concurrently by urologic and radiation oncologists, with support from medical oncologists. Patients have the opportunity to discuss various treatment options including radical cystectomy (RC) or bladder sparing trimodal therapy (TMT;
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
endoscopic resection, radiotherapy and chemotherapy). Although reports have shown comparable outcomes of TMT to cystectomy, no direct comparison to RC has been published and no randomized studies are available. We report our long term outcomes of multidisciplinary care, comparing TMT to surgery using propensity-matched analyses. METHODS: Patients seen in our MDBCC receiving TMT for MIBC from 2008 to 2012 were identified and matched, using propensity scores, to patients operated by RC. Matching occurred on age, ECOG status, Charlson comorbidity score, cT stage, cN stage and date of treatment. Overall survival (OS) and disease-specific survival (DSS) were assessed with Cox Proportional hazards modeling and competing risk analysis, respectively. RESULTS: Between 2008 and 2012, 248 patients were assessed in the MDBCC. Of these, 162 (65%) had MIBC. Nearly half (80) opted for radiotherapy +/- concurrent cisplatin chemotherapy and 49 underwent full bladder preservation with TMT as their primary therapy. We matched 48 TMT patients with 48 RC patients with no imbalances. Median age of the cohort was 67.5 years with 29.2% cT3/cT4. With a median follow up time of 3.62 years, there were 19 (39.6%) deaths (7 from bladder cancer) in the RC group and 15 (31.3%) deaths (6 from bladder cancer) in the TMT group. 5 year DSS was 85.2% and 84.7% with TMT and surgery, respectively (p>0.05). There was no statistically significant difference in DSS between the two groups (HR for TMT 1.31 (0.40-4.23), p¼0.66) or in OS (HR for TMT 0.77 (0.341.75), p¼0.53). CONCLUSIONS: Bladder cancer patients benefit from a multidisciplinary approach. In selected patients with MIBC, chemo-radiation yields survival outcomes similar to matched RC patients. BC patients should be offered the possibility to discuss various treatment options. Source of Funding: None.
PD39-09 CHEMORADIOTHERAPY IN OCTOGENARIANS AS PRIMARY TREATMENT FOR MUSCLE INVASIVE BLADDER CANCER Victor McPherson*, George Rodrigues, Glenn Bauman, Nicholas Power, London, Canada INTRODUCTION AND OBJECTIVES: Radical cystectomy is the gold standard therapy for muscle invasive bladder cancer (MIBC) and achieves an overall 5 year survival of 57%. However, in the octogenarian population, cystectomy results in a 6.8-11.1% perioperative mortality rate, which is significantly higher than the approximately 2.2% rate in younger patients. There is clear evidence that aggressive local therapy improves overall and cancer specific survival in this group. Trimodality therapy is a bladder sparing therapeutic regimen composed of TURBT followed by combination chemoradiotherapy, with intent for salvage cystectomy in non-responders and patients who recur, and has a 62.5-90% initial complete response rate. In this study, we evaluate the use of TURBT and chemoradiotherapy without the option of salvage cystectomy in octogenarian patients deemed to not be surgical candidates. METHODS: A retrospective cohort of patients aged 80-89 with biopsy proven invasive urothelial carcinoma received combination chemoradiotherapy between 2008-June 2014 was identified. Outcomes were evaluated by Kaplan Meier (KM) analysis and Cox regression. RESULTS: For the 40 patients, the mean age was 84.5 (range 80-89), with 28 males and 12 females. Seventeen patients received hypofractionated radiotherapy (Low Dose; 37.5-40 Gy), while 23 received conventionally fractionated radiotherapy (High Dose; 50-65 Gy); 30 patients received carboplatin as a radiosensitizing agent, 7 received 5-Fluorouracil and Mitomycin C, and 3 received cisplatin. Mean overall survival (OS) was 20.7 (IQR 12.75-23.25) months, while mean recurrence free survival was 13.75 (3.75-16.5) months. By KM analysis, patients who received chemosensitizing agents other than carboplatin had an improved OS but not improved local recurrence free
e933
survival (LRFS) and patients who received high dose radiotherapy showed improved OS and LRFS, while having no significant differences in grade 3-4 toxicities. Univariate cox regression identified hydronephrosis as a predictor of worse OS and high dose radiotherapy (HDR) and non-carboplatin chemotherapy regimens as predictors of improved OS, while hydronephrosis predicted local recurrence and HDR improved local recurrence rates. CONCLUSIONS: Primary chemoradiotherapy for non-operative patients with MIBC is relatively safe and was associated with a 3 year OS of 54.9% and 3 year RFS of 42.3%. Outcomes were associated with choice of radiation fractionation and chemosensitization regimen. Source of Funding: None
PD39-10 DO BLADDER CANCER PATIENTS WITH CLINICALLY METASTATIC LYMPH NODE DISEASE BENEFIT FROM RADICAL CYSTECTOMY? Bashir Al Hussein Al Awamlh*, Daniel Nguyen, Michael Shulster, Padriac O’malley, David M. Golombos, Patrick Lewicki, Benjamin Stone, Douglas Scherr, New York, NY INTRODUCTION AND OBJECTIVES: With recent advances in chemotherapeutic regimens, there is evidence that some patients with clinically metastatic lymph node disease will benefit from preoperative chemotherapy followed by local consolidation with radical surgery. However, the role of radical cystectomy (RC) in this setting remains largely unknown. We report our experience with patients who had clinically enlarged nodes and ultimately underwent RC METHODS: Patients charts were retrospectively reviewed. Patients with clinical node (cN+) disease on pre-op imaging represented our cohort of interest. For survival analyses, the comparison cohort included patients who had no evidence of node metastasis in pre-op imaging, yet had nodal disease in final pathology (pN+). Patients with visceral disease were excluded. Cancer- specific survival (CSS) and overall survival (OS) were estimated using the Kaplan-Meier method RESULTS: A total of 25 patients with cN+ disease were identified. Of those 25, 15 (60%) had loco-regional enlarged nodes and 10 (40%) had non-local disease. Twenty patients (80%) and 13 (52%) received pre-op and adjuvant chemotherapy, respectively. Of the 20 patients who received pre-op chemotherapy, 11 (55%) had a documented response in imaging prior to surgery. On final pathology, 13 (52%) patients had pT2 stage, 6 (24%) had pT3 and 6 (24%) had pT4. Nine (36%) patients had pN0 at RC, all of which had received pre-op chemotherapy. Sixteen (64%) patients had pN+ disease, of which 11 (69%) had received pre-op chemotherapy. The median follow-up for surviving patients was 15 months. At last follow-up, 14 had a recurrence, of which 12 died from bladder cancer. 10 patients were alive without recurrence. Patients with clinical locoregional disease had better OS (92% and 50% vs. 50% and 38%, p¼0.011) and CSS (92% and 50% vs. 50% and 38%, p¼ 0.041) at 1 and 3 years, than those with clinical non local nodal enlargement. Next, we compared survival probabilities of the 25 cN+ patients and those of 55 patients who had no evidence of node metastasis in pre-op imaging, yet had nodal disease in final pathology. The actuarial OS at 1 and 3 years (74% and 33% vs. 61% and 35%) and CSS at 1 and 3 years (74% and 41% vs. 71% and 43%) probabilities between the two groups were not statistically different (p>0.05) CONCLUSIONS: A subset of patients with clinically metastatic lymph node disease achieve durable survival after RC associated with perioperative chemotherapy. For selected patients with clinically metastatic disease, most likely limited, the option of combined therapy with chemotherapy and surgery should be discussed Source of Funding: none