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THE SIGNIFICANCE OF SIMULTANEOUS TRANSURETHRAL RESECTION OF BLADDER TUMOR AND PROSTATE IN SUPERFICIAL BLADDER TUMOR PATIENTS WITH BLADDER OUTLET OBSTRUCTION
294
THE JOURNAL OF UROLOGY®
CONCLUSIONS: Transurethral layer-section of bladder WXPRU 78/6% LVDUHOLDEOHWHFKQLTXHWRFRQ¿UPWKHGHSWKRIPXVFOH invasion, and it can be used to successfully select a T2 muscle-invasive bladder cancer. Source of Funding: None
847 RISK FACTOR ANALYSIS IN A CONTEMPORARY CYSTECTOMY COHORT USING COMMON TERMINOLOGY CRITERIA FOR ADVERSE EVENTS Mark B Fisher*, Colin P Dinney, H Barton Grossman, Ashish M Kamat, Surena F Matin. Houston, TX. INTRODUCTION AND OBJECTIVE: Variable adverse event (AE) rates after cystectomy for bladder cancer have been reported. The FODVVL¿FDWLRQ DQG UHSRUWLQJ RI$(V LQ WKH OLWHUDWXUH LV SRRUO\ GH¿QHG QRQVWDQGDUGL]HG DQG SRWHQWLDOO\ XQGHUUHSRUWHG :H UHSRUW$( GDWD DQGDVVRFLDWHGULVNIDFWRUVXWLOL]LQJWKH&RPPRQ7HUPLQRORJ\&ULWHULD IRU$GYHUVH(YHQWV &7&$(Y WRPLQLPL]HLQWHUSUHWDWLRQELDVDQG allow future comparisons. METHODS: A retrospective review of all cystectomy cases for bladder cancer was performed from 1/2004 to 9/2006. All patients were WUHDWHGRQDVWDQGDUGL]HGSRVWRSHUDWLYHSDWKZD\$(VZHUHUHFRUGHGIRU 90 days post-operatively. Over 40 variables were included in the analysis, including age, BMI, Charleson co-morbidity score, use of neoadjuvant chemotherapy, prior therapies (such as surgery, radiation, cardiac, etc), clinical stage, laboratory values, ASA score, estimated blood loss, operative time, surgeon, and type of urinary diversion. Statistical analysis ZDVSHUIRUPHGXWLOL]LQJ)LVKHU¶VH[DFW:LOFR[RQRU.UXVNDO:DOOLVWHVWV and logistic regression analysis. RESULTS: The median age of 283 patients was 70 (35-90). Median BMI was 26.8 (17.5-46.5). Ileal conduit urinary diversion was performed in 185 patients (65.4%), Studer continent diversion in 91 (32.1%), and other in 7 (2.5%). 153 patients (54%) had at least one AE. Of the AE, 24.8% were grades 1-2, 55.6% were grade 3, and 19% were grade 4. There were no deaths within the follow-up period. Increasing DJHZDVDVVRFLDWHGZLWKORQJHUKRVSLWDOL]DWLRQ S LOHXVUHTXLULQJ TPN (p=0.043), and progressively higher rates of arrhythmia (p=0.019). Obesity was associated with higher rates of blood loss (p=0.047), ileus requiring TPN (p=0.011), acute renal failure (p=0.033), and increasing rates of AEs (p=0.0007), despite equivalent disease characteristics to non-obese. Logistic regression analysis demonstrated that increased BMI and the Charleson co-morbidity index predicted for grade 3-4 AEs. BMI and a prior cardiac history predicted for having any postoperative AE. &21&/86,216 6SHFL¿F ULVN IDFWRUV DUH DVVRFLDWHG ZLWK VSHFL¿F$(VLQSDWLHQWVXQGHUJRLQJF\VWHFWRP\ZLWK%0,FDUGLDFKLVWRU\ and co-morbidities independently predicting severity and occurrence of AEs. External validation of these data using similar CTCAE scoring ZLOODOORZEHWWHULQGLYLGXDOL]HGULVNDVVHVVPHQWDQGSDWLHQWFRXQVHOLQJ as well as uniform assessment of quality care and global opportunities for improvement. Source of Funding: None
848 THE IMPACT OF POSTOPERATIVE COMPLICATIONS ON THE TIMING OF ADJUVANT CHEMOTHERAPY IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR INVASIVE OR NODE POSITIVE BLADDER CANCER (BCa) S Machele Donat, Ahmad Shabsigh*, Caroline J Savage, Angel M Cronin, Bochner H Bernard, Guido Dalbagni, Harry W Herr, Matthew I Milowsky. New York, NY. INTRODUCTION AND OBJECTIVE: Neoadjuvant cisplatin FRPELQDWLRQ FKHPRWKHUDS\ LV DVVRFLDWHG ZLWK D VXUYLYDO EHQH¿W LQ patients with invasive BCa. In spite of these data, a recent report from the National Cancer Data Base reveals that only 11.6% of patients with Stage 3 BCa receive perioperative chemotherapy with the majority receiving treatment in the adjuvant setting (neoadjuvant 1.2% vs. adjuvant 10.4%). We explore the impact of postoperative complications on the timing and ability to deliver adjuvant therapy.
Vol. 179, No. 4, Supplement, Monday, May 19, 2008
METHODS: An IRB approved review of 1142 consecutive radical cystectomies entered into a prospective complication database ZDV XWLOL]HG DQG UHWURVSHFWLYHO\ UHYLHZHG IRU DFFXUDF\ All complications within 90 daysRIVXUJHU\ZHUHDQDO\]HGDQGJUDGHG according to the MSKCC complication grading system (Grade 1- oral PHGLFDWLRQEHGVLGH FDUH *UDGH LQWUDYHQRXV WKHUDS\ WUDQVIXVLRQ *UDGHLQWXEDWLRQLQWHUYHQWLRQDOUDGLRORJ\RUUHRSHUDWLYHLQWHUYHQWLRQ *UDGH RUJDQ UHVHFWLRQ RU FKURQLF GLVDELOLW\ DQG *UDGH GHDWK &RPSOLFDWLRQVZHUHGH¿QHGDQGVWUDWL¿HGLQWRFDWHJRULHV3DWLHQWV (pts) with grade 2-5 complications would typically be excluded from receiving adjuvant chemotherapy. The optimal time period for initiation of adjuvant chemotherapy was 6-12 weeks following surgery. RESULTS: Overall, 64% (734/1142) of pts experienced one or more complications, 83% (611/734) of which were grade 2-5. Furthermore, 57% (346/611) of grade 2-5 complications occurred between discharge and 90 days. Of these 38% (232/611) occurred within 6 weeks of discharge, although some may have recovered in time for chemotherapy. However, 19% (114/611) experienced a grade 2-5 complication between 6-12 weeks after surgery, the optimal time for adjuvant chemotherapy. Overall, readmission was required in 26% (298/1142), and 34% (382/1142) required emergency room visits. Postoperative mortality was only 1.6% CONCLUSIONS: This series demonstrates that 30% (346/1142) of pts undergoing radical cystectomy may not have been able to receive adjuvant chemotherapy due to postoperative complications. This information should be taken into consideration when planning multimodality therapy for patients with invasive bladder cancer and further supports the use of perioperative chemotherapy in the neoadjuvant setting. Source of Funding: None
849 THE SIGNIFICANCE OF SIMULTANEOUS TRANSURETHRAL RESECTION OF BLADDER TUMOR AND PROSTATE IN SUPERFICIAL BLADDER TUMOR PATIENTS WITH BLADDER OUTLET OBSTRUCTION Young Deuk Choi*, Won Sik Ham, Kyochul Koo, Young Hoon Lee, Hyun Jin Chung, Seung Ruyl Lee. Seoul, Republic of Korea. INTRODUCTION AND OBJECTIVE: We evaluated the clinical VLJQL¿FDQFHRIVLPXOWDQHRXVWUDQVXUHWKUDOUHVHFWLRQRIEODGGHUWXPRU 785% DQGSURVWDWH 7853 LQVXSHU¿FLDOEODGGHUWXPRUSDWLHQWVZLWK bladder outlet obstruction. METHODS: Between April 1997 to April 2006, 233 patients ZLWK VXSHU¿FLDO EODGGHU WXPRU ZHUH LQFOXGHG 3DWLHQWV ZHUH WUHDWHG with TURB only (n=117, Group I) or TURB with TURP (n=116, Group II). Bladder tumor recurrence was observed by cystoscopy and urine F\WRORJ\8URÀRZPHWU\ZDVSHUIRUPHGWKUHHPRQWKVDIWHUVXUJHU\ 5(68/76 7KHUHZHUHQRVLJQL¿FDQWGLIIHUHQFHVLQDJH>*URXS , PHGLDQ \HDUV,, \HDUV@WXPRUVL]HRUQXPEHU of tumors between groups I and II. The mean follow-up for Group I was 54.3 (14-125) months, and 50.1 (14-123) months for Group II. There was no evidence of cancer implantation where TURP was applied. The UHFXUUHQFHUDWHRIJURXS,,ZDVVLJQL¿FDQWO\ORZHUWKDQJURXS, *URXS I: 38.3%, II: 25.5%, p=0.044), and the time to recurrence was longer in group II than group I [Group I: mean 13.7 (3-53) months, II: 22.8 (3-52) PRQWKVS @7KHUHZDVQRVLJQL¿FDQWGLIIHUHQFHLQSURJUHVVLRQ rate between the two groups (Group I: 6.5%, II: 5.7%, p=0.788). Three months after surgery, mean residual urine volume was lower in group II (7.9±7.6cc) than in group I (21.7±19.0cc) (p<0.001). CONCLUSIONS: Following simultaneous TURB and TURP RQ VXSHU¿FLDO EODGGHU WXPRU SDWLHQWV ZLWK EODGGHU RXWOHW REVWUXFWLRQ we did not observe cancer implantation where TURP was applied. 7KHUHFXUUHQFHRIEODGGHUWXPRUZDVVLJQL¿FDQWO\ORZHUDQGWKHWLPH to recurrence longer in patients treated with simultaneous TURB and TURP compared to TURB alone. Source of Funding: None
THE JOURNAL OF UROLOGY®
CONCLUSIONS: Transurethral layer-section of bladder WXPRU 78/6% LVDUHOLDEOHWHFKQLTXHWRFRQ¿UPWKHGHSWKRIPXVFOH invasion, and it can be used to successfully select a T2 muscle-invasive bladder cancer. Source of Funding: None
847 RISK FACTOR ANALYSIS IN A CONTEMPORARY CYSTECTOMY COHORT USING COMMON TERMINOLOGY CRITERIA FOR ADVERSE EVENTS Mark B Fisher*, Colin P Dinney, H Barton Grossman, Ashish M Kamat, Surena F Matin. Houston, TX. INTRODUCTION AND OBJECTIVE: Variable adverse event (AE) rates after cystectomy for bladder cancer have been reported. The FODVVL¿FDWLRQ DQG UHSRUWLQJ RI$(V LQ WKH OLWHUDWXUH LV SRRUO\ GH¿QHG QRQVWDQGDUGL]HG DQG SRWHQWLDOO\ XQGHUUHSRUWHG :H UHSRUW$( GDWD DQGDVVRFLDWHGULVNIDFWRUVXWLOL]LQJWKH&RPPRQ7HUPLQRORJ\&ULWHULD IRU$GYHUVH(YHQWV &7&$(Y WRPLQLPL]HLQWHUSUHWDWLRQELDVDQG allow future comparisons. METHODS: A retrospective review of all cystectomy cases for bladder cancer was performed from 1/2004 to 9/2006. All patients were WUHDWHGRQDVWDQGDUGL]HGSRVWRSHUDWLYHSDWKZD\$(VZHUHUHFRUGHGIRU 90 days post-operatively. Over 40 variables were included in the analysis, including age, BMI, Charleson co-morbidity score, use of neoadjuvant chemotherapy, prior therapies (such as surgery, radiation, cardiac, etc), clinical stage, laboratory values, ASA score, estimated blood loss, operative time, surgeon, and type of urinary diversion. Statistical analysis ZDVSHUIRUPHGXWLOL]LQJ)LVKHU¶VH[DFW:LOFR[RQRU.UXVNDO:DOOLVWHVWV and logistic regression analysis. RESULTS: The median age of 283 patients was 70 (35-90). Median BMI was 26.8 (17.5-46.5). Ileal conduit urinary diversion was performed in 185 patients (65.4%), Studer continent diversion in 91 (32.1%), and other in 7 (2.5%). 153 patients (54%) had at least one AE. Of the AE, 24.8% were grades 1-2, 55.6% were grade 3, and 19% were grade 4. There were no deaths within the follow-up period. Increasing DJHZDVDVVRFLDWHGZLWKORQJHUKRVSLWDOL]DWLRQ S LOHXVUHTXLULQJ TPN (p=0.043), and progressively higher rates of arrhythmia (p=0.019). Obesity was associated with higher rates of blood loss (p=0.047), ileus requiring TPN (p=0.011), acute renal failure (p=0.033), and increasing rates of AEs (p=0.0007), despite equivalent disease characteristics to non-obese. Logistic regression analysis demonstrated that increased BMI and the Charleson co-morbidity index predicted for grade 3-4 AEs. BMI and a prior cardiac history predicted for having any postoperative AE. &21&/86,216 6SHFL¿F ULVN IDFWRUV DUH DVVRFLDWHG ZLWK VSHFL¿F$(VLQSDWLHQWVXQGHUJRLQJF\VWHFWRP\ZLWK%0,FDUGLDFKLVWRU\ and co-morbidities independently predicting severity and occurrence of AEs. External validation of these data using similar CTCAE scoring ZLOODOORZEHWWHULQGLYLGXDOL]HGULVNDVVHVVPHQWDQGSDWLHQWFRXQVHOLQJ as well as uniform assessment of quality care and global opportunities for improvement. Source of Funding: None
848 THE IMPACT OF POSTOPERATIVE COMPLICATIONS ON THE TIMING OF ADJUVANT CHEMOTHERAPY IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR INVASIVE OR NODE POSITIVE BLADDER CANCER (BCa) S Machele Donat, Ahmad Shabsigh*, Caroline J Savage, Angel M Cronin, Bochner H Bernard, Guido Dalbagni, Harry W Herr, Matthew I Milowsky. New York, NY. INTRODUCTION AND OBJECTIVE: Neoadjuvant cisplatin FRPELQDWLRQ FKHPRWKHUDS\ LV DVVRFLDWHG ZLWK D VXUYLYDO EHQH¿W LQ patients with invasive BCa. In spite of these data, a recent report from the National Cancer Data Base reveals that only 11.6% of patients with Stage 3 BCa receive perioperative chemotherapy with the majority receiving treatment in the adjuvant setting (neoadjuvant 1.2% vs. adjuvant 10.4%). We explore the impact of postoperative complications on the timing and ability to deliver adjuvant therapy.
Vol. 179, No. 4, Supplement, Monday, May 19, 2008
METHODS: An IRB approved review of 1142 consecutive radical cystectomies entered into a prospective complication database ZDV XWLOL]HG DQG UHWURVSHFWLYHO\ UHYLHZHG IRU DFFXUDF\ All complications within 90 daysRIVXUJHU\ZHUHDQDO\]HGDQGJUDGHG according to the MSKCC complication grading system (Grade 1- oral PHGLFDWLRQEHGVLGH FDUH *UDGH LQWUDYHQRXV WKHUDS\ WUDQVIXVLRQ *UDGHLQWXEDWLRQLQWHUYHQWLRQDOUDGLRORJ\RUUHRSHUDWLYHLQWHUYHQWLRQ *UDGH RUJDQ UHVHFWLRQ RU FKURQLF GLVDELOLW\ DQG *UDGH GHDWK &RPSOLFDWLRQVZHUHGH¿QHGDQGVWUDWL¿HGLQWRFDWHJRULHV3DWLHQWV (pts) with grade 2-5 complications would typically be excluded from receiving adjuvant chemotherapy. The optimal time period for initiation of adjuvant chemotherapy was 6-12 weeks following surgery. RESULTS: Overall, 64% (734/1142) of pts experienced one or more complications, 83% (611/734) of which were grade 2-5. Furthermore, 57% (346/611) of grade 2-5 complications occurred between discharge and 90 days. Of these 38% (232/611) occurred within 6 weeks of discharge, although some may have recovered in time for chemotherapy. However, 19% (114/611) experienced a grade 2-5 complication between 6-12 weeks after surgery, the optimal time for adjuvant chemotherapy. Overall, readmission was required in 26% (298/1142), and 34% (382/1142) required emergency room visits. Postoperative mortality was only 1.6% CONCLUSIONS: This series demonstrates that 30% (346/1142) of pts undergoing radical cystectomy may not have been able to receive adjuvant chemotherapy due to postoperative complications. This information should be taken into consideration when planning multimodality therapy for patients with invasive bladder cancer and further supports the use of perioperative chemotherapy in the neoadjuvant setting. Source of Funding: None
849 THE SIGNIFICANCE OF SIMULTANEOUS TRANSURETHRAL RESECTION OF BLADDER TUMOR AND PROSTATE IN SUPERFICIAL BLADDER TUMOR PATIENTS WITH BLADDER OUTLET OBSTRUCTION Young Deuk Choi*, Won Sik Ham, Kyochul Koo, Young Hoon Lee, Hyun Jin Chung, Seung Ruyl Lee. Seoul, Republic of Korea. INTRODUCTION AND OBJECTIVE: We evaluated the clinical VLJQL¿FDQFHRIVLPXOWDQHRXVWUDQVXUHWKUDOUHVHFWLRQRIEODGGHUWXPRU 785% DQGSURVWDWH 7853 LQVXSHU¿FLDOEODGGHUWXPRUSDWLHQWVZLWK bladder outlet obstruction. METHODS: Between April 1997 to April 2006, 233 patients ZLWK VXSHU¿FLDO EODGGHU WXPRU ZHUH LQFOXGHG 3DWLHQWV ZHUH WUHDWHG with TURB only (n=117, Group I) or TURB with TURP (n=116, Group II). Bladder tumor recurrence was observed by cystoscopy and urine F\WRORJ\8URÀRZPHWU\ZDVSHUIRUPHGWKUHHPRQWKVDIWHUVXUJHU\ 5(68/76 7KHUHZHUHQRVLJQL¿FDQWGLIIHUHQFHVLQDJH>*URXS , PHGLDQ \HDUV,, \HDUV@WXPRUVL]HRUQXPEHU of tumors between groups I and II. The mean follow-up for Group I was 54.3 (14-125) months, and 50.1 (14-123) months for Group II. There was no evidence of cancer implantation where TURP was applied. The UHFXUUHQFHUDWHRIJURXS,,ZDVVLJQL¿FDQWO\ORZHUWKDQJURXS, *URXS I: 38.3%, II: 25.5%, p=0.044), and the time to recurrence was longer in group II than group I [Group I: mean 13.7 (3-53) months, II: 22.8 (3-52) PRQWKVS @7KHUHZDVQRVLJQL¿FDQWGLIIHUHQFHLQSURJUHVVLRQ rate between the two groups (Group I: 6.5%, II: 5.7%, p=0.788). Three months after surgery, mean residual urine volume was lower in group II (7.9±7.6cc) than in group I (21.7±19.0cc) (p<0.001). CONCLUSIONS: Following simultaneous TURB and TURP RQ VXSHU¿FLDO EODGGHU WXPRU SDWLHQWV ZLWK EODGGHU RXWOHW REVWUXFWLRQ we did not observe cancer implantation where TURP was applied. 7KHUHFXUUHQFHRIEODGGHUWXPRUZDVVLJQL¿FDQWO\ORZHUDQGWKHWLPH to recurrence longer in patients treated with simultaneous TURB and TURP compared to TURB alone. Source of Funding: None