PD9-08 RISK ASSESSMENT OF LATE COMPLICATIONS AFTER ROBOTIC RADICAL CYSTECTOMY WITH TOTAL INTRACORPOREAL URINARY DIVERSION

THE JOURNAL OF UROLOGYâ

Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015

e197

PD9-06

PD9-07

LONG-TERM FUNCTIONAL OUTCOME AND COMPLICATIONS AFTER RADICAL CYSTECTOMY AND ORTHOTOPIC NEOBLADDER DIVERSION

EARLY AND LATE COMPLICATIONS OF ROBOTIC RADICAL CYSTECTOMY AND INTRA-CORPOREAL URINARY DIVERSION

Michael Maidaa, Burbank, CA; Gus Miranda, Inderbir Gill, Siamak Daneshmand, Hooman Djaladat*, Los Angeles, CA INTRODUCTION AND OBJECTIVES: To evaluate long-term clinical outcome and complications of patients with Urothelial Bladder Cancer (UBC) who underwent radical cystectomy (RC) and orthotopic neobladder (ONB) diversion with minimum of 15 years follow-up. METHODS: Using our IRB approved institutional bladder cancer database, we identified 1,964 patients who underwent RC for UBC at our institution between 1971 and 2008. 121 patients who underwent RC and ONB (Kock pouch to the urethra) with more than 15 years follow-up were subjects of this study. We reviewed the clinicopathological variables, long-term complications and outcome of this cohort. Detailed follow-up were found in 96/121 patients (79.3%). eGFR analysis was done on 32 patients with information available on BMI, pre-op Cr, and at least 2 Cr reading of 3,6,10, 15 years with 1 of the readings being at least 10 years. RESULTS: Of the 121 patients, 118 were male (97.5%). Mean age at cystectomy was 59.3 years with a median follow-up of 18.3 years (range 15.1 - 23). Pathologic stage at cystectomy was <¼pT1 (70, 57.9%), pT2 (32, 26.4%), pT3 (14, 11.6%) and pT4 (5, 4.1%) and pNþ (11, 9.1%) with N1 (4, 3.3%) and N2 (7, 5.8%). Neoadjuvant chemo, radiation and adjuvant chemo were used in 9 (7.4%), 2 (1.7%) and 33 (27%) cases, respectively. There were 6 patients with recurrences (3 urethral, 1 pelvis, 1 distant, and 1 upper tract) at median of 9.23 years (range 1.2 e 17.2) after cystectomy. Only 1 of the patients died of the disease (at 16.3 years); 27 died of non-cancer cause (mean 18.2; 15.223.0), 5 died of secondary cancer (17.1; 15.4-20.0), 3 died of unknown cause (15.3; 15.1-15.4), and 85 are alive without evidence of disease (18.5; 15.1-23.0). CONCLUSIONS: The most common complications in ONB patients with more than 15 yrs follow-up were pouch-related, with afferent limb stenosis and pouch stones contributing the most. A gradual decrease in GFR over time was seen throughout the patient population, thus making renal insufficiency a prevalent complication in long-term survivors with ONB.

Raed A. Azhar, Andre Luis de Castro Abreu*, Evren Suer, Jie Cai, Gus Miranda, Raj Satkunasivam, Charles Metcalfe, Kelvin Wong, Andre Berger, Monish Aron, Inderbir S. Gill, Mihir Desai, Los Angeles, CA INTRODUCTION AND OBJECTIVES: To present 90-day perioperative complications stratified by urinary diversion type in patients undergoing robotic radical cystectomy and completely intra-corporeal urinary diversion. METHODS: Data were analyzed from 128 patients undergoing robotic intracorporeal diversion between July 2010 to June 2014 from our bladder cancer database. Perioperative complications were categorized as early (<30 day) or late (30e90 day) and complication severity was classified using the Clavien-Dindo syatem. RESULTS: A total of 107 men and 21 women with a median age of 71 years and a median body mass index of 27.1 Kg/m2 underwent RRC and ICD. Orthotropic neobladder was performed in 48 patients (37.5%). The median postoperative length of stay was 6 days (range 3e31). Over a median follow-up of 8.15 months (range 0.49 e 38.5), early (<30 days) and late complications (30e90 days) occurred in 87 (68%) and 102 (79.7%) of patients, respectively. A total of 25 patients (19.5%) required blood transfusion perioperativly. Of those; 22 (17%) had ileal conduit and 3 (2.3%) had neobladder. The perioperative mortality was 1.6%. Complications are detailed in Table 1. Specifically there were 1.75% early and 3.2% late surgical complications. Moreover, 0.32% patients developed a uretero-enteric stricture. CONCLUSIONS: RRC with complete ICD is safe and technically feasible with acceptable peri-operative morbidity. Prospective randomized trails comparing ICD versus open diversion are necessary to compare peri-operative morbidity. Early Total n (%) Complications

Ileal conduit n (%)

Late

p

Total n (%)

Ileal conduit n (%)

0.9

102 (79.7)

65 (50.8)

37 (29)

16 (12.5)

26 (20.3)

15 (11.7)

11 (8.6)

46 (36)

Neobladder n (%)

87 (68%)

55 (43)

32 (25)

41 (32)

25 (19.5)

Clavien Classification None

Neobladder n (%)

0.7

0.3

Low <¼ 2

61 (47.7)

37 (29)

24 (18.8)

67 (52.3)

High >¼3

26 (20.3)

18 (14)

8 (6.25

35 (27.3)

24 (10.6)

7 (3.1)

33 (10.6)

24 (7.7)

9 (2.9)

Types

19(14.8)

21 (16.4) 16 (12.5)

0.8

Bleeding

31(13.7)

0.7

Infections

43 (19)

29 (12.8)

14 (6.2)

72 (23.1)

42 (13.5)

30 (9.6)

Metabolic (dehydration & electrolytes imbalance)

51 (22.5)

38 (16.7)

13 (5.7)

70 (22.4)

46 (14.7)

24 (7.7)

Surgical

4 (1.8)

3 (1.3)

1 (0.4)

10 (3.2)

22 (9.7)

14 (6.2)

8 (3.5)

35 (11.2)

Gastrointestinal

26 (11.5)

18 (8)

8 (3.5)

Thromboembolic

10 (4.4)

8 (3.5)

2 (0.9)

Other

40 (17.6)

26 (11.5)

15 (6.6)

44 (14)

28 (9)

Genitourinary

p 0.7

4 (1.28)

6 (1.9)

19 (6.1)

16 (5.1)

34 (11)

22 (7.1)

12 (3.9)

13 (4.2)

10 (3.2)

3 (0.96) 16 (5.1)

Source of Funding: None

PD9-08 RISK ASSESSMENT OF LATE COMPLICATIONS AFTER ROBOTIC RADICAL CYSTECTOMY WITH TOTAL INTRACORPOREAL URINARY DIVERSION Mariaconsiglia Ferriero*, Rome, Italy; Giuseppe Simone, Turin, Italy; Rocco Papalia, Salvatore Guaglianone, Michele Gallucci, Rome, Italy

Source of Funding: None

INTRODUCTION AND OBJECTIVES: Robotic radical cystectomy (RRC) with intracorporeal urinary diversion (UD) is a challenging procedure with a high rate of perioperative complications. In this study we assessed the risk of late complications after RRC with intracorporeal UD. METHODS: From October 2012 to October 2014, 100 consecutive unselected patients with cT2-4a/cN1-3/cM0 bladder cancer

THE JOURNAL OF UROLOGYâ

e198

underwent RRC, extended lymphadenectomy and totally intracorporeal UD. Baseline demographics, perioperative and follow up data were prospectively collected. Univariable and multivariable regression analysis were performed to identify independent predictors of surgery related (SR) and any kind of late complications at six-mo evaluation. RESULTS: Out of 100 RRC, we selected 87 consecutive patients with a minimum 6-mo follow up. Sixty-nine patients received a Padua Ileal bladder (54 male and 15 female), while 18 patients received an ileal conduit. At a six-mo follow up 60 (68.9%) patients experienced any kind of late complication, 49 (56.4%) were SR. Ortotopic UD, preoperative eGFR and learning curve were significant predictors of SR complication at univariable analysis (p¼ 0.032, p¼0.042 and p¼0.05, respectively). At multivariable analysis, the only independent predictor of surgical related late complications was orthotopic UD (p ¼ 0.010; HR: 5.01 [95% CI, 1.47e17.04]). Learning curve and preoperative eGFR were significant predictors of any complications at univariable analysis (p¼ 0.008, and p¼0.044, respectively). At multivariable analysis, the only independent predictor of any kind of late complications was the learning curve (p ¼ 0.025; HR: 0.97 [95% CI, 0.95e0.99]). CONCLUSIONS: RRC with intracorporeal neobladder is feasible but associated to higher risks of SR complications at six-mo evaluation. Learning curve plays a key role for a stepwise reduction of perioperative complications.

Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015

longer operative times and higher rates of post-operative infectious complications.

Source of Funding: None

PD9-09 ANALYSIS OF PERIOPERATIVE OUTCOMES FOR PROCEDURES INVOLVING URINARY DIVERSION USING THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) DATABASE Robert C. Kovell*, David C. Brooks, Devin A. Haddad, Ahmed A. Aboumohamed, Ryan P. Terlecki, Winston Salem, NC INTRODUCTION AND OBJECTIVES: Surgeries requiring urinary diversion have been associated with high rates of perioperative morbidity and mortality. Understanding factors that contribute to the risks of these surgeries is important for improving surgical outcomes and properly counseling patients. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) database, we identified patients undergoing urinary diversion using a bowel segment, with or without cystectomy, performed between 2010 and 2012. We compared preoperative characteristics, surgical parameters and 30-day postoperative outcomes. We stratified patients based on the continence status of the diversion, incontinent (ID) v continent (CD). Statistical significance was assessed using chi square, t-test and ANOVA. RESULTS: We identified 1959 urinary diversions in the NSQIP database: 1568 IDs (80.0%) and 391 CDs (20.0%). Concomitant cystectomy was performed with 1468 (93.6%) IDs and 374 (95.7%) CDs. Among various preoperative characteristics analyzed, higher rates of COPD (4.4% v 9.1%), previous cardiac surgery (1.8% v 4.3%), HTN (47% v 63%), and metastatic cancer (2.1% v 4.7%) were associated with patients undergoing ID. Pre-operative creatinine levels were higher in patients undergoing ID (1.08 v 1.19 mg/dL). CD patients were more likely to have undergone pre-operative chemotherapy (10.5% v 5.5%). Operative time was longer for CDs (388 min v 336 min). Post-operative UTI (13.8% v 7.9%) and sepsis rates (11.5% v 7.9%) were significantly higher in CDs, whereas transfusion rates were higher with IDs (37.1% v 45.2%). No differences were observed in the rates of thromboembolic events or postoperative renal insufficiency. Thirty day readmission rates (18.2% v 15.5%), length of stay (10.2 v 10.7 days), occurrence of any NSQIP captured complication (57.5% v 60.1%) and mortality (1.5% v 2.1%) were not statistically different between CD and ID. CONCLUSIONS: Surgeries involving urinary diversion continue to have significant morbidity. While continent diversion offers patients a number of long term advantages, these must be balanced against

Source of Funding: None

PD9-10 TIMING OF URETERAL STENT REMOVAL AND POSTOPERATIVE COMPLICATIONS FOLLOWING RADICAL CYSTECTOMY WITH URINARY DIVERSION Justin Matulay, Christopher Sayegh, Julia Finkelstein, Mark Silva*, G. Joel DeCastro, New York, NY INTRODUCTION AND OBJECTIVES: Ureteral stent placement following radical cystectomy with urinary diversion is a commonplace practice. Stenting has been shown to reduce the rate of certain surgical complications such as anastomotic stricture and urinary leak. However, there is concern that ureteral stents may increase the rate of infection. To our knowledge, there is no published data on the optimal timing for stent removal postoperatively. Therefore, we sought to evaluate if there was any association between the length of time that ureteral stents remained in place and related postoperative complications. METHODS: We retrospectively analyzed data on 58 patients from our prospectively maintained cohort of radical cystectomy patients. We noted the day of each stent removal and all complications that occurred during the hospitalization as well as after discharge. A telephone questionnaire was conducted at 1 month and 3 months post-operatively. We defined stent-related complications as pelvic collection, anastamotic leak, stricture, and UTI/ pyelonephritis and infectious complications as sepsis and UTI/ pyelonephritis. RESULTS: Baseline characteristics for the 58 patients are presented in Table 1. With a median follow-up of 3 months, there were 21 stent-related complications in 18 (31%) patients. Median time from the date of surgery until first and second ureteral stent removal was 5.5 days and 6 days, respectively. There was no significant difference between the median day of either stent