7:30 a.m.-10:30 a.m.
Spouse/Guest Hospitality Suite Hours
Location: Schreyvogel Room
7:30 a.m.-5:00 p.m.
Registration/Information Desk Hours
Location: Broadmoor Hall Registration Desk B
8:00 a.m.-11:00 a.m.
Board of Directors Meeting
Location: Broadmoor Hall F
11:00 a.m.-5:00 p.m.
Speaker Ready Room Hours
Location: Broadmoor Hall Show Office A
6:00 p.m.-8:00 p.m.
Welcome Reception in Exhibit Hall
Location: Broadmoor Hall B
11:00 a.m. - 12:00 p.m.
Industry Sponsored Lunch Symposium
Location: Broadmoor Hall E
12:00 p.m. - 12:05 p.m.
Location: Broadmoor Hall A
Tomas L. Griebling, MD, MPH
Kansas City, KS
12:05 p.m. - 12:10 p.m.
Program Chair Welcome
Location: Broadmoor Hall A
James M. Cummings, MD, FACS
12:10 p.m. - 12:20 p.m.
Fellows Essay Competition
Location: Broadmoor Hall A
Ty T. Higuchi, MD, PhD
|12:10 p.m. #1|
ROBOTIC BUCCAL MUCOSA GRAFT URETEROPLASTY FOR BENIGN URETERAL STRICTURE DISEASE: A SINGLE INSTITUTION EXPERIENCE
Humberto Villarreal, MD, David Koslov, MD
, Paul Maroni, MD, Ty Higuchi, M.D., PhD, Brian Flynn, MDDepartment of Surgery, Division of Urology, University of Colorado School of Medicine
Introduction and objective: Robotic buccal mucosa graft (BMG) ureteroplasty was first described in 2015 and has gained popularity in the past 4 years. Our institution has utilized BMG ureteroplasty since 2017 and herein we report this experience.
Methods: A retrospective analysis was performed in patients undergoing robotic BMG ureteroplasty from 2017-2019 at a single institution. The following data was noted: length, location, etiology, operative technique, length of follow-up, success rate, complications, and need for secondary procedures. Success rate was defined as absence ureteral obstruction both radiographically and need for subsequent intervention.
Results: A total of 92 patients underwent open or robotic ureteral reconstruction during the evaluation period of which 12 patients had robotic BMG ureteroplasty and are the focus of this study. Patients with primary repair of UPJ obstruction or ureteral stricture from external trauma were excluded. Stricture etiology included recurrent stricture after prior ureteral reconstruction (50%), stone disease (33%), and iatrogenic injury from pelvic surgery (17%). No patient had prior radiation therapy. The ureteral stricture was proximal in 10 (83%) and distal in 2 (17%). Average stricture length was 4 cm. 10 of 12 patients (83%) were managed preoperatively with a stent/nephrostomy while 10 (83%) had undergone at least one prior endoscopic intervention; mean 3 (range 1-6). Robotic BMG ureteroplasty was accomplished using an augmented anastamotic repair in 1 and onlay in 11. Mean operative time was 366 minutes and length of stay was 4 days. At the time of this analysis, 9 patients had completed follow-up at a mean of 5 months, 8 of 9 (89%) had stricture resolution while 1 (11%) failed at 4 months post-operatively requiring subsequent nephrectomy. Cryptogenic ischemic stroke was the only major post-operative complication (Clavien-Dindo grade 3 or higher).
Conclusion: Robotic BMG ureteroplasty is an important addition to ureteral reconstruction algorithm for non-radiated strictures (2-6 cm), nicely positioned between ureteroureterostomy and ileal ureteral interposition. We have found this technique useful in patients with recurrent ureteral stricture < 6 cm after failed reconstruction.
12:20 p.m. - 1:00 p.m.
Resident Essay Finalist Podium Session
Location: Broadmoor Hall A
Ty T. Higuchi, MD, PhD
|12:20 p.m. #2|
OVERCOMING PATIENT FACTORS IN THE CARE OF UNDERSERVED TESTICULAR CANCER PATIENTSNathan Chertack, MD
, Rashed Ghandour, MD, Nirmish Singla, MD, Yuval Freifeld, MD, Vitaly Margulis, MD, Solomon Woldu, MD, Aditya Bagrodia, MDDepartment of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
Introduction/Background: Socioeconomic factors are associated with worse clinical outcomes in patients with testicular cancer (TC). We sought to determine whether patient factors at a safety net hospital are overcome through the standardized treatment of TC at an academic tertiary care referral center.
Methods/Materials: The electronic medical records of patients who underwent first treatment for TC (orchiectomy) at our university hospital and safety net hospital, which are both staffed by UT Southwestern physicians, from 2006 to 2018 were reviewed. Demographic and clinicopathological variables were compared based on treatment at safety-net vs university hospital setting. The Mann-Whitney test was performed for continuous variables, reported as medians. The Fisher Exact test was performed for categorical variables, reported as percentages. Binomial logistic regression was performed to assess confounding variables.
Results: 95 patients (47%) at the university hospital and 106 patients (53%) at the safety net hospital were included in this analysis. Safety net patients had delayed presentation after symptom onset (median 65 vs 31 days, p=0.001), were more likely to initially present to the emergency department (76% vs 8%, p<0.001), were less likely to be insured (20% vs 88%, p<0.001), and had shorter median time from diagnosis to orchiectomy (1 vs 4 days, p<0.001). These patients had larger median tumor size (50 vs 30mm, p<0.001), were more likely to have higher T-stage (p=0.018), were less likely to be Stage I (58% vs 73%, p=0.028) and more likely to be Stage III (23% vs 9%, p=0.013). County hospital patients were more likely to receive chemotherapy as first treatment (47% vs 23%, p<0.001), with this association remaining significant (OR=3.5, p=0.010) after controlling for AJCC staging (OR=7, p<0.001) and number of oncology clinic visits (OR=1.2, p<0.001). There was no difference in median numbers of surveillance imaging (3 vs 3 CT scans, p=0.77), urology clinic visits (4 vs 4 visits, p=0.73), rate of cancer recurrence (13% vs 9%, p=0.51), or mortality (4% vs 0%, p=0.12) between county hospital and academic center patients.
Conclusions: While differences in timing of presentation, tumor size, and stage at presentation between patient groups do exist, oncological outcomes do not appear to be compromised. The integrated care of safety net patients at our academic center overcomes socioeconomic barriers that exist in the care of testicular cancer patients.
|12:27 p.m. #3|
NO INCREASED ADMINISTRATIVE BURDEN FROM OUTPATIENT INFLATABLE PENILE PROSTHESIS PROCEDURES: A HOSPITAL SYSTEM-WIDE ANALYSIS
Nabeel Shakir, MD, Michael Davenport, MD, Yooni Yi, MD, Christopher Keith, MD
, Rachel Bergeson, Allen Morey, MDUniversity of Texas Southwestern Medical Center, Dept. of Urology, Dallas, TX
INTRODUCTION AND OBJECTIVE: Outpatient placement of inflatable penile prosthesis (IPP) has become common worldwide. This shift raises theoretical concern of additional, unplanned post-operative encounters, leading to increased administrative burden. We sought to compare rates of these encounters in men undergoing IPP placement in the outpatient versus inpatient settings.
METHODS: A hospital system-wide database was queried for all patients undergoing first-time IPP placement with at least 6 months follow-up. Demographics and clinical encounter data including emergency room (ER) visits, readmissions, office telephone and electronic encounters within 3 and 6 months postoperatively were obtained. Outpatient procedures were performed at a dedicated outpatient surgery center (OSC) and inpatient procedures required admission for at least overnight observation.
RESULTS: From December 2014 to April 2018, 267 patients underwent first-time IPP placement, of whom 145 took place at an OSC and 64 had planned postoperative admission with median length of stay 1 day (IQR 1-2). Another 58 men had IPP placement and were initially scheduled for admission, but were discharged home from the post-anesthesia recovery unit, and were excluded from this analysis. Patients treated at an OSC were younger than those who were admitted (median 63 vs 68 years, p<0.0001). At 6 months, there were significantly fewer postoperative telephone calls and readmissions for outpatient patients (p=0.03 and 0.0002 respectively, Table 1). There was no difference in proportions of postoperative electronic messages (p=0.13) or ER visits (p=0.06).
CONCLUSIONS: At a high-volume center, outpatient IPP placement has no increased rate of postoperative unplanned encounters. The high proportions of telephone or electronic encounters overall highlight the importance of a robust administrative support system in coordinating the postoperative care of IPP patients.
|12:34 p.m. #4|
DISPARITIES IN NEOADJUVANT CHEMOTHERAPY BEFORE RADICAL CYSTECTOMY BETWEEN RURAL AND URBAN POPULATIONS: AN OPPORTUNITY TO IMPROVE HEALTHCARE DELIVERY IN AN UNDERSERVED POPULATION.Daniel Igel, MD1
, Derek Jensen, MD1
, Katie Glavin1
, Xiaqing Huang2
, Jeffrey Thompson, PhD2
, Sally Maliski, PhD, RN, FAAN3
, Elizabeth Wulff-Burchfield, MD4
, John Taylor, MD11University of Kansas Medical Center, Department of Urology, 2University of Kansas Medical Center, Department of Biostatistics, 3University of Kansas Medical Center, 4University of Kansas Medical Center, Division of Medical Oncology
Introduction/Background: While neoadjuvant chemotherapy has been shown to improve overall survival for patients with muscle-invasive bladder cancer (MIBC), rates of administration of guideline-concordant chemotherapy are staggeringly low, with a recent study demonstrating a rate of only 32%. Higher-volume centers for radical cystectomy have significantly lower rates of complications than lower-volume centers, and while patients from remote areas often travel to seek this care, it is often unfeasible for patients to also travel for chemotherapy due to the frequency of treatments. Here we sought to characterize whether there is a significant difference in preoperative neoadjuvant chemotherapy administration between rural and urban populations.
Methods/Materials: Through a retrospective review, all patients who underwent radical cystectomy for MIBC between 2008 and 2016 at a single institution were identified. Patients were then categorized as rural or urban, with rural defined as having a primary residence greater than 50 miles from our large, urban, academic medical center which is surrounded on all sides by rural areas. The threshold of 50 miles was chosen to exclude patients from the surrounding suburban areas and capture a patient population for whom travel would be prohibitively long for regular chemotherapy sessions. Whether or not patients received neoadjuvant chemotherapy was assessed, in addition to other variables including pathologic stage, race, and sex. Statistical analysis was performed using a logistic regression model.
Results: 495 patients were identified who underwent radical cystectomy for muscle invasive bladder cancer. Of these patients, 240 were from an urban area, while 255 lived in a rural area. Patients identified as being from a rural area were significantly less likely to have received neoadjuvant chemotherapy when compared to patients from urban areas (OR 0.581, p = 0.005). There also appeared to be a direct relationship between increasing distance from our academic medical center and a decreased likelihood of receiving neoadjuvant therapy, with a 13% decrease with each doubling of distance approaching statistical significance (OR 0.867, p = 0.076).
Conclusions: There is a significant disparity in the likelihood of receiving neoadjuvant chemotherapy before radical cystectomy for MIBC, with rural patients being significantly less likely to receive neoadjuvant chemotherapy compared to patients living in urban settings. Further investigation is needed to develop strategies to help rectify this disparity and improve healthcare delivery and access for rural patients with bladder cancer.
|12:41 p.m. #5|
DISCHARGE DESTINATION AND READMISSION DIAGNOSES AFTER RADICAL CYSTECTOMYJuliAnne Rathbun, MD
, Bin Ge, Gregory Petroski, PhD, David Mehr, MD, Robin Kruse, Katie Murray, DOUniversity of Missouri
Introduction and Objective—Radical cystectomy (RC) with urinary diversion for muscle invasive urothelial cell carcinoma of the bladder is an aggressive intervention with high morbidity secondary to high readmission rates and complications. This study aims to determine readmission rates and reasons after RC differ based on discharge destination.
Methods—The HealthFacts Database was utilized to identify patients with inpatient admission undergoing RC with urinary diversion and a diagnosis of bladder cancer between 2010 and 2015. Location of discharge upon leaving hospital after RC was determined. In those patients readmitted within 30 days after surgery, single most common final and discharge diagnoses of readmission were identified. These diagnoses were compared between groups using 2x2 chi-square analyses, p<0.05 was considered significant, and SAS was used for all statistical analyses.
Results—Over the 5-year time period, 850 patients were identified meeting inclusion criteria for the study. A majority were male (82%) with mean age of 69 years (SD 10.1). Mean length of stay after RC was 9.6 days (SD 4.6). Discharge destination after RC was home for 86%, skilled nursing facility (SNF) for 10% or rehabilitation facility for 4%. Location of discharge destination approached significance with SNF discharges having the lowest readmission rate (p=0.07). Of the population, 137/850 (16%) patients were readmitted within 30 days of surgery. Of the 137 readmissions, discharge location was 82% home, 16% SNF and 2% from rehab. 70% were admitted within the first two weeks after discharge, with readmission LOS being 5 days in 50% and less than 2 weeks in 90% of patients. Patients less than 80 years of age were more likely to be readmitted (p=0.02) than older patients. Diagnoses of readmission including neurological such altered mental status (56% vs 20%, p=0.002), pulmonary issues (61% vs 34%, p=0.03), and cardiac disease (33% vs 9%, p=0.008) were significantly more common in patients discharged to rehabilitation or skilled facility compared to those discharged to home. The most common readmission diagnoses in all groups were infectious and metabolic in up to 75% of patients.
Conclusions—Identifying common reasons for readmissions after RC can help guide post-operative care including discharge location. For a majority of readmissions after RC, there is no difference based on discharge location, but there are many potential life-threatening readmissions that occur in patients who were discharged to a facility rather than home. This may guide discharge destination in patients who may be at increased risk of these complications after surgery.
|12:48 p.m. #6|
IS THERE AN OPTIMAL PSA THRESHOLD FOR OBTAINING MRI-FUSION BIOPSY IN BIOPSY NAIVE PATIENTS?Luke Wang, MD
, Shawna Boyle, MD, Chad LaGrange, MDUniversity of Nebraska Medical Center, Division of Urology, Omaha, NE
Introduction: In biopsy-naïve patients who present with suspicious PSA, we must decide whether to do MRI-fusion biopsy in addition to standard 12-core biopsy. Shakir et al.(1) suggested that MRI may be unnecessary when PSA<5.2, but many patients in that cohort had prior biopsy(s). This study is conducted to evaluate whether there is an optimal PSA threshold for obtaining MRI-fusion in addition to 12-core biopsy in biopsy-naïve men.
Methods: We retrospectively evaluated 207 consecutive biopsy-naïve men with suspicious PSA/digital rectal exam (DRE) who underwent 12-core and targeted MRI-fusion biopsy with Uronav System during the same session. Clinically significant prostate cancer (cPCA) was defined as Gleason 3+4 or higher.
Results: Number of men with PSA 0 to <2.5, 2.5 to <5.2, 5.2 to <10, and 10 or above were: 6/207(2.9%), 58/207(28.0%), 105/207(50.7%), 38/207(18.4%) respectively. Number of cPCA detected on targeted biopsy (cPCAt), on 12-core (cPCA12), and combination of cPCAt and cPCA12 were 114/207(55.1%), 95/207(45.9%), 130/207(62.8%) respectively. Hence 6 men with suspicious PSA/DRE would need MRI-fusion added to 12-core in order to detect one additional cPCA.
The lowest PSA with cPCA was 0.85 in a patient with suspicious DRE. MRI-fusion biopsy was performed because of abnormal DRE in 5/6 patients with PSA<2.5, but detected no additional cPCA relative to 12-core. PSA 4.15 was the lowest value above which targeted biopsy had higher cumulative percentage of cPCA compared to 12-core (Figure1). If cutoff for adding MRI-fusion is >5.2, 11/130(8.5%) cPCA would be missed, compared to 2/130(1.5%) if cutoff was >4.15. PSA >2.5, >3.5, >4.5, >5.2 had respective sensitivities (specificities) of 98.2%(4.3%); 96.5%(6.5%); 86.8%(21.5%); 73.7%(37.6%) for detecting cPCAt, with area under the curve 0.58 (95% CI 0.5-0.66). On multivariable logistic regression adjusting for age, increasing PSA was the only predictor of cPCAt (p<0.05). MRI-fusion biopsy was more likely to detect cPCA compared to 12-core biopsy across all PSA ranges.
Conclusions: In biopsy-naïve men, a PSA threshold of >5.2 for adding MRI-fusion biopsy to standard 12-core would result in 65(31.4%) fewer MRIs and miss 8.5%(11/130) clinically significant cancers. A threshold of >4.15 would result in 17(8.2%) fewer MRIs and miss 1.5%(2/130) clinically significant cancers. Overall, adding MRI-fusion biopsy has higher likelihood of detecting clinically significant prostate cancer across all PSA ranges in biopsy-naïve men.
(1)Shakir et al. J Urol. 2014 Dec;192(6).
|12:55 p.m. #7|
POLYMORPHISMS IN THE SLC13A2(NADC1) AND SLC13A3(NADC3) GENES IN PATIENTS WITH KIDNEY STONES Mario Basulto-Martínez, MD, MSc1
, Bárbara Peña-Espinoza, PhD2
, Rafael Valdez-Ortiz, MD, PhD3
, Juan Pablo Flores-Tapia, MD1
, Marta Menjívar, PhD21Hospital Regional de Alta Especialidad de la Península de Yucatán, 2Universidad Nacional Autónoma de México, 3Hospital General de México
Introduction & objectives
The Maya region of Mexico holds the highest prevalence of Mexico, probably due to a facilitating environment as well as a genetic inheritance. The genomic background from its populations has been shown to be quite different from other surrounding ethnic groups. The single nucleotide polymorphism (SNP) I550Vof the SLC13A2gene has been associated with hypocitraturia. This gene encodes the Na+/Dicarboxylate cotransporter 1 (NaDC1) in the apical membrane of the proximal tubule, affecting urinary citrate excretion. Another candidate gene that could be associated with KS, is the SLC13A3, that encode for the NaDC3 cotransporter, which reabsorbs citrate at the basolateral membrane and might indirectly regulate NaDC1. We aimed to assess the association of SLC13A2and SLC13A3with urinary citrate excretion and KS.
Materials & methods
Stone-former patients (SF) and control subjects (CS) without KS from the Maya region of Mexico were included. Protocol was approved by the institutional board review and all participants signed consent. A 24-hours-urine metabolic panel was carried out. DNA was extracted from peripheral blood by salting-out technique and integrity was assessed by 1.5% agarose gel electrophoresis. Real time-PCR was carried out for genotyping. ANCOVA was used for comparing metabolites concentrations among inheritance models using age, sex, and BMI as covariates. A multinomial logistic regression with fixed effects was conducted for hypocitraturia among inheritance models. Kruskal-Wallis’ test was used for urinary citrate among genotypes in SF and CS.
A total of 119 subjects were included, mean age was 44.8 ± 13.8. Median urinary citrate was 114.5 mg/dL and was significantly lower in SF (P<0.001). Hypocitraturia was found in 91.4% of SF and 65.7% of CS (P=0.002). Allele frequencies for NaDC1 (A: 48%, G: 52%) and NaDC3 (A: 71%, C: 29%), were different from European populations (P=0.032, P=0.016). No deviation from Hardy–Weinberg equilibrium was observed for either SNP. The GG genotype of NaDC1 was associated with hypocitraturia, OR: 0.27 (CI 95%, 0.09-0.84, P=0.024), and the median citrate was higher in the carriers of this genotype P=0.017). Moreover, the AA genotype of NaDC3 showed higher citrate concentrations in CS (P=0.043).
The SNP of NaDC1 is associated with hypocitraturia and citrate levels. Interestingly, the variant NaDC3, seems to have a protective effect in the citrate levels in subjects who don’t express the KS phenotype, strongly suggesting more factors involved.
1:00 p.m. - 2:00 p.m.
Panel Discussion: Issues in Ureteroscopy
Location: Broadmoor Hall A
Julie M. Riley, MD, FACS
Marawan M. El Tayeb, MD
Lindsay Lombardo, DO
Saint Louis, MO
Wilson R. Molina, Jr., MD
Kansas City, KS
2:00 p.m. - 2:30 p.m.
State-of-the-Art Lecture: Management of the Adult Buried Penis
Location: Broadmoor Hall A
Maxx Gallegos, MD
2:30 p.m. - 2:45 p.m.
Location: Broadmoor Hall Foyer
2:45 p.m. - 3:15 p.m.
Critical Discussion: Complications of Sling Procedures for Female Stress Incontinence
Location: Broadmoor Hall A
Erin Travis Bird, MD, MBA
Priya Padmanabhan, MD, FACS
Royal Oak, MI
3:15 p.m. - 4:15 p.m.
Panel Discussion: Prostate Cancer: Diagnosis, Prognosis and Treatment
Location: Broadmoor Hall A
Katie S. Murray, DO, MS
Brian F. Chapin, MD
Zachary A. Hamilton, MD
St Louis, MO
|Concurrent Sessions Begin|| || |
|Concurrent Session 1 of 3|| || |
4:00 p.m. - 5:00 p.m.
Bladder Cancer Poster Session
Location: Broadmoor Hall C
Shandra S. Wilson, MD, MBA
Solomon L. Woldu, MD
Reporting Radical Cystectomy Outcomes Following Implementation of Enhanced Recovery after Surgery Protocols: A Systematic ReviewPreston kerr, MD1
, Mohamed Ray-Zack, MD1
, yannick Cerantola, MD2
, Louie Rodriguez, B.S.1
, justin collins, MD3
, James Douglas, MBBS BSc, MSc, FRCSurol4
, Hooman Djaladat, MD5
, Lucy Fairchild, RN6
, Kelly Mayson, MD, FRCPC7
, Julian Smith, MBBS, MSc, FRCS4
, Anna Johansen, M.A.8
, Peter Black, MD, FACS, FRCSC9
, Ashish Kamat, MD10
, Olle Llungqvist, MD, PHD11
, James Catto, MB ChB, PhD FRCS12
, Siamak Daneshmand, MD5
, Stephen Williams, MD, FACS11Division of Urology, The University of Texas Medical Branch, Galveston, TX, United States, 2Service d'urologie, CHU vaudois, 1011 Lausanne, Suisse, 3Orsi Academy, Melle, Belgium, 4Department of Urology, Southampton, Southampton, UK, 5USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, 6University Hospital Southampton, Southampton, UK, 7Department of Anesthesia, University of British Columbia, Vancouver, BC, Canada, 8Société Internationale d'Urologie, Montreal, Canada, 9Department of Urologic Science, University of British Columbia, Vancouver, BC, Canada, 10Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, 11Department of Surgery, Örebro University, Örebro, Sweden, 12Academic Urology Unit, University of Sheffield, Sheffield, UK.
Enhanced Recovery After Surgery (ERAS) is an evidence-based approach to perioperative care of the surgical patient. The impact of implementing ERAS protocols on post-radical cystectomy (RC) complication rate remains largely under-studied. We sought to systematically review the literature regarding RC outcomes reporting and the impact of ERAS protocol implementation with respect to RC complications, patient mortality and hospital length of stay.
A systematic review was performed using Ovid and Medline to find research articles published from 1970 through 2018 reporting RC Complications according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Randomized, prospective and retrospective studies were screened.
Overall, 4,197 articles were retrieved from electronic databases. Twenty-two (0.5%) studies reported RC outcomes in the context of ERAS and were included in the present systemic review. There were 4 randomized control trials (RCTs) which assessed specific components of ERAS protocols and outcomes following RC. Of the 18 retrospective studies which met inclusion criteria, length of stay followed by 30 and 90-d complications were most studied primary endpoints following implementation of ERAS protocols. Only one RC study to date has assessed the impact of all 26 ERAS items (including an audit) on RC outcomes. ERAS resulted in no increased risk of mortality with reduced morbidity, quicker bowel recovery, and shorter length of stay than patients who did not undergo ERAS.
Implementation of ERAS protocols was associated with reduced length of hospital stay and post-operative complication rate with no increased risk of mortality. RC outcomes need to be interpreted in the context of ERAS. However, limited studies control for ERAS in RC outcomes data reporting and only one study to date has assessed the impact of all 26 ERAS items (including an audit) on RC outcomes.
Gender-specific disparities in peri-operative outcomes following radical cystectomy: a population based analysis.
Johar Syed, M.D.1
, Zachary Hamilton, M.D.1
, Joshua Fernelius2
, Facundo Davaro, M.D.1
, Allison May, M.D.1
, Sameer Siddiqui, M.D.1
, Desmond Stallworth2
, Coleman McFerrin21Saint Louis University, School of Medicine, Department of Surgery, Division of Urology, 2Saint Louis University School of Medicine
INTRODUCTION AND OBJECTIVES: Radical cystectomy is a major morbid procedure, however the gender specific differences are not well reported in larger cohorts of patients. This study aims to evaluate the perioperative outcomes of radical cystectomy patients by gender utilizing the National Cancer Database (NCDB).
METHODS: Data for this analysis was derived from NCDB Participant User File for bladder cancer from 2004 to 2015. Patients undergoing radical cystectomy for non-metastatic bladder cancer were divided into male and female cohorts and compared in terms of basic, clinical, and pathologic parameters. Time to cystectomy was the primary outcome, while the secondary outcomes included neoadjuvant chemotherapy (NAC), pathologic node positive disease, positive margins, length of stay, 30-day readmission and overall survival (OS). Linear, logistic, and cox regression analyses were performed to identify effect of gender on aforementioned parameters.
RESULTS: Out of 21100, 5434 (25.8%) were female patients. Female patients were significantly older, more likely to have cT3 and cN+ disease, and less likely to receive NAC. The mean time from diagnosis to cystectomy was 82.7 days, which was significantly shorter than males (90, p<0.001). Pathologic T3 stage, pN+ and positive margins were significantly higher for females. On linear and logistic regression analysis, female gender was associated with decreased time to cystectomy, decreased use of NAC (OR: 0.92, p=0.02) and increased risk of pN+ and positive margins (OR: 1.07 and 1.15, p=0.04 and 0.004, respectively). On K-M analysis 2 year OS was significantly shorter for females.
CONCLUSIONS: Review of NCDB reveals a higher pathologic stage, node and margin positive status, and poorer overall survival for females, despite a shorter time from diagnosis to cystectomy.
Association of Physician and Hospital Characteristics with the Use of Radical Cystectomy among Patients with Muscle-Invasive Bladder CancerPreston Kerr, MD1
, Vishnukamal Golla, MD, MPH2
, Hemalkumar Mehta, PHD1
, Karim Chamie, MD2
, Mohamed Ray-Zack, MD1
, Jacques Baillargeon, PHD3
, Yong-Fang Kuo, PHD4
, Yong Shan, PHD1
, Stephen Williams, MD, FACS11Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, 2Department of Urology, University of California Los Angeles, Los Angeles, CA, USA, 3Division of Epidemiology, Sealy Center on Aging, The University of Texas Medical Branch at Galveston, Galveston, TX, 4Department of Medicine, Division of Biostatistics, Sealy Center on Aging, The University of Texas Medical Branch at Galveston, Galveston, TX
Background: Only one out of five muscle-invasive bladder cancer patients receive radical cystectomy, a guideline-recommended treatment. Prior studies evaluated patient characteristics associated with radical cystectomy use. We aimed to determine bladder cancer diagnosing physician and hospital characteristics associated with the use of radical cystectomy.
Methods: This cohort study used linked SEER-Medicare Data from 2002 to 2011. We included older adults (age>65 years) diagnosed with muscle-invasive bladder cancer. For each patient, a urologist who performed transurethral resection of bladder tumor was assigned as a diagnosing physician. The diagnosing physician was assigned to one hospital based on where he/she performed more than half of all urologic surgeries. Two-level hierarchical model (patients nested within hospitals) were constructed to determine the association of patient, physician and hospital characteristics with radical cystectomy use.
Results: A total of 7,097 patients were diagnosed by 4,601 physicians who were affiliated with 822 hospitals. Overall, the radical cystectomy utilization rate was 26.5%. Only 4.8% of the variation in radical cystectomy was attributed to the hospital level. In the two-level hierarchical model, patients diagnosed by female physicians were more likely to undergo radical cystectomy (32.8% vs. 25.8%; OR=1.62, 95% CI=1.31-2.01). Higher radical cystectomy volume by diagnosing physicians and hospitals increased radical cystectomy use (Table 1). Diagnosing physician characteristics (age, years in practice, employment status), and hospital characteristics (teaching status, location, type of hospital) were not associated with radical cystectomy use. Additionally, the utilization of radical cystectomy by a treating urologist increased with surgeon volume but was not impacted by hospital volume (Table 1). Patient characteristics such as age, male, higher comorbidity burden were associated with lower likelihood of radical cystectomy use.
Conclusions: Physician and hospital factors do not largely contribute to the receipt of radical cystectomy. Radical cystectomy volume by treating urologist had up to 6-fold increase in use of surgery with affiliated hospital volume having no significant impact, however, diagnosing urologist and affiliated hospital volumes impact radical cystectomy utilization. These findings have important health policy implications regarding centralization of care which support high volume surgeons with appropriate hospital infrastructure to increase use.
IMPACT OF BLADDER CANCER DIAGNOSIS ON DAILY LIFETaha Anwar, MD1
, Mojgan Golzy, PhD2
, Katie S Murray, DO, MS11Department of Surgery-Urology Division, University of Missouri, Columbia, MO, 2Department of Health Management and Informatics, Biostatistics and Research Design Unit, University of Missouri, Columbia, MO
Bladder cancer is the fifth most common cancer in the United States, with an estimated 80,470 new cases in 2019 and over 500,000 living with the disease. It is primarily a disease of older individuals, with greater than 70% of cases diagnosed in patients aged 65 and older. Activities of daily living (ADLs) can measure functional status and are associated with quality of life, hospital admission rates, overall health and mortality in older adults. Prior studies have shown decline in ADLs after cancer diagnosis, with variable decline based on primary cancer site. However, this has not been well studied in bladder cancer patients. We sought to examine the overall effect of bladder cancer diagnosis on ADLs.
Data from the Surveillance, Epidemiology and End Results registries were linked with Medicare Health Outcomes Survey (MHOS) data. Patients with bladder cancer were identified and those who had a pre and post diagnosis survey were included in the analysis. Survey results regarding ADLs (i.e. bathing, dressing, eating, getting in and out of chairs, walking, using toilet) were analyzed with reported inability to complete tasks or completing them with difficulty vs performing tasks without difficulty. Results before and after bladder cancer diagnosis were compared using Chi-square testing. Statistical significance was maintained at p<0.05 and SAS was used for analyses.
498 patients with bladder cancer were identified who had a pre and post diagnosis survey. 410 (82%) were white and 363 (73%) were male. The median age was 76.7 years (IQR: 72.3 – 81.7). The median time from initial to follow up survey was 755 days (IQR: 728 – 771). There was a decline in the percentage of patients reporting no difficulty in each individual task from before to after diagnosis; this decline was statistically significant in bathing (89% to 84%, p=0.024) and using the toilet (93% to 89%, p=0.03). Furthermore, there was a significant decline in self-reported general health after diagnosis compared to before (p<0.001). Table 1 shows patient responses rating of general health.
Bladder cancer diagnosis is associated with a significant decline in functional status and overall health. Better recognition and support of functional decline is needed in this patient population. Further study is needed for factors that may be most predictive of decline in functional independence.