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PD67-11 ENHANCED RECOVERY AFTER RADICAL CYSTECTOMY REDUCES COST AND LENGTH OF STAY: THE JOHNS HOPKINS EXPERIENCE.
THE JOURNAL OF UROLOGYâ
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lymph node dissection, and number of lymph nodes removed. Perioperative outcomes measured included length of stay (LOS), 30-day and 90-day postoperative mortality rates, as well as 30-day readmission following surgery. To minimize selection bias, observed differences in baseline characteristics between patients who received RARC vs. ORC were controlled for using a weighted propensity score analysis. Using weighted data, all endpoints were assessed using propensity-adjusted logistic regression analyses. RESULTS: Of 9,561 patients who underwent RC, 2,048 (21.4%) and 7,513 (78.6%) underwent RARC and ORC, respectively. The use of RARC has increased over time, from 16.7% in 2010 to 25.3% in 2013. With regard to oncologic outcomes, RARC was associated with similar positive surgical margins (9.4% vs. 10.7% OR:0.86, 95%CI 0.72-1.04, p¼0.12), higher rates of lymphadenectomy (96.4% vs. 92.0%, OR: 2.31, 95%CI 1.68-3.19, p<0.001), higher median lymph node count (17 vs. 12, p<0.001) and higher rates of lymph node count above the median (56.8% vs. 40.4%, OR: 1.95, 95%CI 1.56-2.43, p<0.001). With regard to postoperative outcomes, receipt of RARC was associated with a shorter median LOS (7 vs. 8, p<0.001), lower rates of pLOS (45.1% vs. 54.8%, OR: 0.68, 95%CI 0.58-0.79, p<0.001), lower 30-day (1.5% vs. 2.8%, OR: 0.49, 95%CI 0.29-0.82, p¼0.007) and 90day postoperative mortality (5.0% vs. 6.8%, OR: 0.72, 95%CI 0.54-0.95, p¼0.023). CONCLUSIONS: Our large contemporary study shows the increased adoption of RARC between 2010 and 2013, with currently more than 1 out of 4 patients undergoing RARC. RARC was associated with higher LN counts, shorter LOS and lower postoperative mortality. Source of Funding: none
PD67-10 INCIDENCE AND RISK FACTORS FOR PERITONEAL CARCINOMATOSIS FOLLOWING OPEN RADICAL CYSTECTOMY David Y Yang MD*, Igor Frank MD, Ross A Avant MD, Prabin Thapa, Stephen A Boorjian MD, Matthew K Tollefson MD, Rochester, MN INTRODUCTION AND OBJECTIVES: Recently, there has been increased interest in the incidence of peritoneal carcinomatosis (PC) following radical cystectomy (RC). Particularly, pneumoperitoneum and robotic RC have been implicated as potential risk factors for peritoneal seeding. However, little has been reported on the rates of PC in open RC patients. Herein, we characterized the frequency and risk factors of PC in open RC patients in our institutional cystectomy registry. METHODS: We identified patients with urothelial carcinoma of the bladder treated for curative intent from 1980 to 2015. Patients were categorized based on recurrence pattern through our institutional cystectomy registry. We defined PC as tumor recurrence involving the omentum, small bowel and mesentery. Clinicopathologic variables were compared using 2 sample t-test and F test. Overall and cancer-specific survival was evaluated using Kaplan-Meier methodology and log rank test. RESULTS: Between 1980 and 2015, 3,285 patients underwent open RC. One hundred and twenty nine (3.9%) patients experienced PC, 1148 (34.9%) patients had other forms of recurrence, and 2008 (61.1%) had no recurrence. Median time to PC and other recurrence were 1.3 (IQR 1.3, 2.3) and 0.9 (IQR 0.5, 2.1) years respectively (p¼0.042). Patients with PC had higher pathologic tumor and nodal stage than those with other recurrences and no recurrences (p<0.0001). Pathologic factors associated with PC include lymphovascular invasion (29.5% vs 16.7%, p¼0.0002) and positive tumor margin (5.4% vs 2.9%, p¼0.0093). Patients with PC experience worse overall and cancer specific survival than other types of recurrence (Figure).
Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017
CONCLUSIONS: PC occurred in almost 4% of our patients undergoing open RC. Worsening pathologic stage was associated with PC. Cancer death in patients with PC was almost universal at 5 years. Further analysis will be needed to determine risk factors for developing PC following RC.
Source of Funding: none
PD67-11 ENHANCED RECOVERY AFTER RADICAL CYSTECTOMY REDUCES COST AND LENGTH OF STAY: THE JOHNS HOPKINS EXPERIENCE. Alice Semerjian*, Niv Milbar, Max Kates, Michael Gorin, Heather Chalfin, Cary Stimson, William Yang, Steven Frank, Deb Hobson, Lindsay Robertson, Ken Lee, Michael Johnson, Phillip Pierorazio, Trinity Bivalacqua, Baltimore, MD INTRODUCTION AND OBJECTIVES: Many centers have adapted Enhanced Recovery after Surgery (ERAS) pathways to decrease hospital length of stay (LOS) and peri-operative complications. We report the Johns Hopkins ERAS experience, specifically evaluating complication rate, LOS, 30- and 90-day readmissions, and for the first time in an ERAS cohort, cost. METHODS: ERAS protocol (Table 1) was implemented for radical cystectomy (RC) patients in November 2015. Outcomes. readmissions and cost were compared to a matched group of 54 RC patients from an 8-month period prior to the use of ERAS. Patients were excluded if indication was not for bladder cancer or if they underwent adjunct procedures. RESULTS: 58 consecutive ERAS patients were compared to 54 pre-ERAS patients (Table 2). Cost of index hospitalization was $30,450 in the ERAS group and $35,411 in the pre-ERAS group; readmission LOS and costs were comparable between groups. Median LOS was 5 days for the ERAS group and 8.5 days for the pre-ERAS group (p¼<0.001). The pre-ERAS group had a significantly increased use of nasogastric tube (30% vs. 13.8%) and parenteral nutrition (20.4% vs. 6.9%). A trend towards increased complications occurring during index hospitalization in the pre-ERAS group was observed, although not reaching statistical significance. The ERAS group experienced a slightly higher rate of 30-day readmission, though two were for ostomy appliance issues. The most common reason for readmission was infection in both groups; there was a higher rate of GI related readmissions in the ERAS group (Figure 1). CONCLUSIONS: Implementation of the ERAS protocol at our center resulted in significantly reduced length of hospital stay and decreased cost, with comparable rates of complication and readmission.
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017
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challenging procedure with a high complication rate. We wanted to assess the feasibility and complication rates in similar cases utilizing robotic surgery. METHODS: We identified 13 patients undergoing robotic surgery after radiation therapy in our robotic surgery database. Ten underwent a cystectomy and 3 radical salvage prostatectomy. We collected demographic, surgery and post-surgery data during their hospital stay. RESULTS: In the cystectomy group there were 6 females and 4 males, mean age 68 years. Three of the patients were 81, 84 and 85 years old. Two female patients had prior brachytherapy due to cervical cancer and developed a small contracted bladder with vesico-vaginal fistula. Two males with external beam radiation and one male with brachytherapy for prostate cancer developed TCC. One male with squamous cell carcinoma and 4 others with TCC that received chemo-radiation in the past, were sent to salvage cystectomy due to local recurrence. Five patients received neoadjuvant chemotherapy prior to surgery. Mean operating time was 6:53 hours. Mean operative blood loss 461 ml. Three patients received 2 units of packed cells apiece during surgery due to blood loss of 800 ml each. The mean blood loss for the others was 291 ml. One female patient with prior multiple open abdominal surgeries had adhesions that required conversion to open surgery which ended with bowel injury and cystectomy was aborted. Post-operative complications consisted of transient ileus in 3 patients. Mean hospital stay was 6 days (range 4-8 days). Six patients were discharged with a drain due to increased serous drainage, which was later removed in our clinic. In the radical prostatectomy group mean operative time was 2:46 hours, mean blood loss was 133 ml, there were no intra-operative or post-operative complications. Mean hospital stay was 5 days (range 3-8 days). CONCLUSIONS: Robotic cystectomy and/or prostatectomy after radiation therapy to the pelvis is an effective and safe procedure. Nonetheless, it has the risk of increased blood loss during surgery, increased hospital stay and more serous secretions through the drains compared to robotic surgery in patients without prior radiation therapy. Source of Funding: none
Urolithiasis Video 11 Tuesday, May 16, 2017
7:00 AM-9:00 AM
V11-01 COMPLICATIONS OF PERCUTANEOUS ACCESS DURING PERCUTANEOUS NEPHROLITHOTOMY Vinaya Vasudevan*, Zeph Okeke, Arthur Smith, New Hyde Park, NY
Source of Funding: None
PD67-12 SAFETY & FEASIBILITY OF BLADDER AND PROSTATE ROBOTIC SURGERY AFTER RADIATION THERAPY Tareq Aro*, David Kakiashvili, Kamil Malshy, Valentin Shabataev, Gilad Amiel, haifa, Israel INTRODUCTION AND OBJECTIVES: Open surgery for removing the bladder and/or prostate after radiation therapy is a
INTRODUCTION AND OBJECTIVES: The rate of accessrelated complications for percutaneous nephrolithotomy (PCNL) has been estimated to be approximately 12.5% . Often, complications are the result of inadequate pre-operative preparation for PCNL or incorrect operative methods. In this video, we discuss several important risk factors as well as several tips to address access-related complications of PCNL. METHODS: Intraoperative risk factors for access-related complications are discussed at length. These include pre-operative considerations and anatomic considerations that would necessitate alternative forms of access, including CT-guided or laparoscopicallyguided access. Next, techniques to avoid problems at the time of establishing access are demonstrated and discussed in detail.
e1280
lymph node dissection, and number of lymph nodes removed. Perioperative outcomes measured included length of stay (LOS), 30-day and 90-day postoperative mortality rates, as well as 30-day readmission following surgery. To minimize selection bias, observed differences in baseline characteristics between patients who received RARC vs. ORC were controlled for using a weighted propensity score analysis. Using weighted data, all endpoints were assessed using propensity-adjusted logistic regression analyses. RESULTS: Of 9,561 patients who underwent RC, 2,048 (21.4%) and 7,513 (78.6%) underwent RARC and ORC, respectively. The use of RARC has increased over time, from 16.7% in 2010 to 25.3% in 2013. With regard to oncologic outcomes, RARC was associated with similar positive surgical margins (9.4% vs. 10.7% OR:0.86, 95%CI 0.72-1.04, p¼0.12), higher rates of lymphadenectomy (96.4% vs. 92.0%, OR: 2.31, 95%CI 1.68-3.19, p<0.001), higher median lymph node count (17 vs. 12, p<0.001) and higher rates of lymph node count above the median (56.8% vs. 40.4%, OR: 1.95, 95%CI 1.56-2.43, p<0.001). With regard to postoperative outcomes, receipt of RARC was associated with a shorter median LOS (7 vs. 8, p<0.001), lower rates of pLOS (45.1% vs. 54.8%, OR: 0.68, 95%CI 0.58-0.79, p<0.001), lower 30-day (1.5% vs. 2.8%, OR: 0.49, 95%CI 0.29-0.82, p¼0.007) and 90day postoperative mortality (5.0% vs. 6.8%, OR: 0.72, 95%CI 0.54-0.95, p¼0.023). CONCLUSIONS: Our large contemporary study shows the increased adoption of RARC between 2010 and 2013, with currently more than 1 out of 4 patients undergoing RARC. RARC was associated with higher LN counts, shorter LOS and lower postoperative mortality. Source of Funding: none
PD67-10 INCIDENCE AND RISK FACTORS FOR PERITONEAL CARCINOMATOSIS FOLLOWING OPEN RADICAL CYSTECTOMY David Y Yang MD*, Igor Frank MD, Ross A Avant MD, Prabin Thapa, Stephen A Boorjian MD, Matthew K Tollefson MD, Rochester, MN INTRODUCTION AND OBJECTIVES: Recently, there has been increased interest in the incidence of peritoneal carcinomatosis (PC) following radical cystectomy (RC). Particularly, pneumoperitoneum and robotic RC have been implicated as potential risk factors for peritoneal seeding. However, little has been reported on the rates of PC in open RC patients. Herein, we characterized the frequency and risk factors of PC in open RC patients in our institutional cystectomy registry. METHODS: We identified patients with urothelial carcinoma of the bladder treated for curative intent from 1980 to 2015. Patients were categorized based on recurrence pattern through our institutional cystectomy registry. We defined PC as tumor recurrence involving the omentum, small bowel and mesentery. Clinicopathologic variables were compared using 2 sample t-test and F test. Overall and cancer-specific survival was evaluated using Kaplan-Meier methodology and log rank test. RESULTS: Between 1980 and 2015, 3,285 patients underwent open RC. One hundred and twenty nine (3.9%) patients experienced PC, 1148 (34.9%) patients had other forms of recurrence, and 2008 (61.1%) had no recurrence. Median time to PC and other recurrence were 1.3 (IQR 1.3, 2.3) and 0.9 (IQR 0.5, 2.1) years respectively (p¼0.042). Patients with PC had higher pathologic tumor and nodal stage than those with other recurrences and no recurrences (p<0.0001). Pathologic factors associated with PC include lymphovascular invasion (29.5% vs 16.7%, p¼0.0002) and positive tumor margin (5.4% vs 2.9%, p¼0.0093). Patients with PC experience worse overall and cancer specific survival than other types of recurrence (Figure).
Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017
CONCLUSIONS: PC occurred in almost 4% of our patients undergoing open RC. Worsening pathologic stage was associated with PC. Cancer death in patients with PC was almost universal at 5 years. Further analysis will be needed to determine risk factors for developing PC following RC.
Source of Funding: none
PD67-11 ENHANCED RECOVERY AFTER RADICAL CYSTECTOMY REDUCES COST AND LENGTH OF STAY: THE JOHNS HOPKINS EXPERIENCE. Alice Semerjian*, Niv Milbar, Max Kates, Michael Gorin, Heather Chalfin, Cary Stimson, William Yang, Steven Frank, Deb Hobson, Lindsay Robertson, Ken Lee, Michael Johnson, Phillip Pierorazio, Trinity Bivalacqua, Baltimore, MD INTRODUCTION AND OBJECTIVES: Many centers have adapted Enhanced Recovery after Surgery (ERAS) pathways to decrease hospital length of stay (LOS) and peri-operative complications. We report the Johns Hopkins ERAS experience, specifically evaluating complication rate, LOS, 30- and 90-day readmissions, and for the first time in an ERAS cohort, cost. METHODS: ERAS protocol (Table 1) was implemented for radical cystectomy (RC) patients in November 2015. Outcomes. readmissions and cost were compared to a matched group of 54 RC patients from an 8-month period prior to the use of ERAS. Patients were excluded if indication was not for bladder cancer or if they underwent adjunct procedures. RESULTS: 58 consecutive ERAS patients were compared to 54 pre-ERAS patients (Table 2). Cost of index hospitalization was $30,450 in the ERAS group and $35,411 in the pre-ERAS group; readmission LOS and costs were comparable between groups. Median LOS was 5 days for the ERAS group and 8.5 days for the pre-ERAS group (p¼<0.001). The pre-ERAS group had a significantly increased use of nasogastric tube (30% vs. 13.8%) and parenteral nutrition (20.4% vs. 6.9%). A trend towards increased complications occurring during index hospitalization in the pre-ERAS group was observed, although not reaching statistical significance. The ERAS group experienced a slightly higher rate of 30-day readmission, though two were for ostomy appliance issues. The most common reason for readmission was infection in both groups; there was a higher rate of GI related readmissions in the ERAS group (Figure 1). CONCLUSIONS: Implementation of the ERAS protocol at our center resulted in significantly reduced length of hospital stay and decreased cost, with comparable rates of complication and readmission.
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017
e1281
challenging procedure with a high complication rate. We wanted to assess the feasibility and complication rates in similar cases utilizing robotic surgery. METHODS: We identified 13 patients undergoing robotic surgery after radiation therapy in our robotic surgery database. Ten underwent a cystectomy and 3 radical salvage prostatectomy. We collected demographic, surgery and post-surgery data during their hospital stay. RESULTS: In the cystectomy group there were 6 females and 4 males, mean age 68 years. Three of the patients were 81, 84 and 85 years old. Two female patients had prior brachytherapy due to cervical cancer and developed a small contracted bladder with vesico-vaginal fistula. Two males with external beam radiation and one male with brachytherapy for prostate cancer developed TCC. One male with squamous cell carcinoma and 4 others with TCC that received chemo-radiation in the past, were sent to salvage cystectomy due to local recurrence. Five patients received neoadjuvant chemotherapy prior to surgery. Mean operating time was 6:53 hours. Mean operative blood loss 461 ml. Three patients received 2 units of packed cells apiece during surgery due to blood loss of 800 ml each. The mean blood loss for the others was 291 ml. One female patient with prior multiple open abdominal surgeries had adhesions that required conversion to open surgery which ended with bowel injury and cystectomy was aborted. Post-operative complications consisted of transient ileus in 3 patients. Mean hospital stay was 6 days (range 4-8 days). Six patients were discharged with a drain due to increased serous drainage, which was later removed in our clinic. In the radical prostatectomy group mean operative time was 2:46 hours, mean blood loss was 133 ml, there were no intra-operative or post-operative complications. Mean hospital stay was 5 days (range 3-8 days). CONCLUSIONS: Robotic cystectomy and/or prostatectomy after radiation therapy to the pelvis is an effective and safe procedure. Nonetheless, it has the risk of increased blood loss during surgery, increased hospital stay and more serous secretions through the drains compared to robotic surgery in patients without prior radiation therapy. Source of Funding: none
Urolithiasis Video 11 Tuesday, May 16, 2017
7:00 AM-9:00 AM
V11-01 COMPLICATIONS OF PERCUTANEOUS ACCESS DURING PERCUTANEOUS NEPHROLITHOTOMY Vinaya Vasudevan*, Zeph Okeke, Arthur Smith, New Hyde Park, NY
Source of Funding: None
PD67-12 SAFETY & FEASIBILITY OF BLADDER AND PROSTATE ROBOTIC SURGERY AFTER RADIATION THERAPY Tareq Aro*, David Kakiashvili, Kamil Malshy, Valentin Shabataev, Gilad Amiel, haifa, Israel INTRODUCTION AND OBJECTIVES: Open surgery for removing the bladder and/or prostate after radiation therapy is a
INTRODUCTION AND OBJECTIVES: The rate of accessrelated complications for percutaneous nephrolithotomy (PCNL) has been estimated to be approximately 12.5% . Often, complications are the result of inadequate pre-operative preparation for PCNL or incorrect operative methods. In this video, we discuss several important risk factors as well as several tips to address access-related complications of PCNL. METHODS: Intraoperative risk factors for access-related complications are discussed at length. These include pre-operative considerations and anatomic considerations that would necessitate alternative forms of access, including CT-guided or laparoscopicallyguided access. Next, techniques to avoid problems at the time of establishing access are demonstrated and discussed in detail.