Poster Session 2 - Moderated - Urothelial & Testis Cancers

OBJECTIVE: Our objective was to analyze the contribution of fixed OR times to TURBT efficiency, and the impact of various factors (time of day and number of procedures per day) on these time points. Fixed OR times, all procedure time points except surgeon operating time, are potentially modifiable and may therefore represent a target for quality improvement initiatives. 

METHODS: Over a consecutive 24-month period, all fixed OR times from TURBT procedures were prospectively collected. Fixed OR times were defined as: in room time to anesthesia release time (IRAT), anesthesia release time to cut time (ARCT), in room time to cut time (IRCT) (combines IRAT and ARCT), and close time to wheels out time (CTWO). Variable OR time was defined as cut to close (CTCT). We also analyzed the impact of time of day on TURBTs. Comparisons between groups were made using the Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. 

RESULTS: 777 TURBT procedures were evaluated. Median fixed OR time occupied 49.4% of the total procedure time (range 5.8%-97.5%). Median total OR time was 63.0 min (27-233). Number of TURBTs in a day did not have a statistically significant impact on IRAT (P=0.22), IRCT (P=0.18), or CTCT (P=0.44). Median ARCT was longer when there were <2 TURBTs in a day (<2: 13 min, range: 3.0-45 vs. ≥2: 12 min, 1.0-38, P=0.04). Median CTWO was longer when there were ≥2 TURBTs in a day (<2: 7.0 min, 1.0-35 vs. ≥2: 8.0 min, 1.0-33, P=0.02). Time of day did not have a statistically significant effect on ARCT (P=0.79), CTWO (P=0.34), or CTCT (P=0.13). Median IRAT was faster in the morning (10.0 min, range: 2.0-54.0) than it was in the afternoon (11.0 min, 3.0-67) (P=0.02). Median IRCT was 23 min in both the morning (range: 1.0-57) and afternoon (13.0-80) (P=0.03).

CONCLUSIONS: Fixed OR times made up roughly half of total TURBT procedure time and therefore must be considered in OR efficiency analyses. The number of TURBT performed in a day and the time of day did not have a significant impact on OR efficiency.

Objectives:  Patient, or clinical factors, are the most commonly identified variables associated with hospital readmission after radical cystectomy (RC). Hospital and physician characteristics have been suggested as contributing factors for readmission in other major surgeries. This study investigates the contribution of patient, physician and hospital factors on hospital readmission after RC.

Methods: This was a retrospective review of the Surveillance Epidemiology and End Results (SEER)-Medicare database focusing on bladder cancer patients who underwent RC between 2007-2016.  These  claims were identified by using ICD-9/ICD-10 or HCPCS codes, from which the annual hospital and physician volumes were calculated and classified as low, medium and high. Univariate and multivariable analyses were done for 90-day readmission as the outcome using a multilevel model to explore the association between readmission and characteristics of patient, hospital, and physician. The intraclass correlation coefficient (ICC) for hospital, physician and patient levels were also calculated.  

Results: In 3530 patients, 1291 (36.6%) were readmitted within 90 days of surgery.  On univariate analysis, continent urinary diversion (OR 1.533),   greater NCI comorbidity score (OR 1.460 for NCI 2-4 vs <2; OR 1.754 for NCI >4 vs <2), robotic approach (OR 1.210), AJCC stage (stage III vs stage I, OR 0.777), hospital length of stay (OR 1.037), Northeast vs Western hospital location (OR 4.19), and any postoperative complication (OR 6.790) were significantly (p<0.05) associated with 90-day hospital readmission. On multilevel multivariable analysis, factors significantly (p<0.05) associated with 90-day readmission included continent urinary diversion (OR 1.462), robotic approach (OR 1.299), and any postoperative complication (OR 6.865).  Neither hospital volume, physician volume, hospital region, teaching hospital status, nor NCI center designation were associated with hospital readmission. The main source of variation was determined to be at the patient level (92.5%), followed by the physician (5.1%), and then hospital (2.4%) levels.   

Conclusions: Ninety-day hospital readmission at the time of RC is high, with around one-third of patients requiring a readmission. Patient-specific factors are the most important in impacting the odds of readmission, while hospital and physician factors contribute minimally to this outcome. Consequently, efforts to reduce readmission rates should focus on the patient level.

Objectives: Enhanced recovery after surgery (ERAS) protocols have shown to improve the perioperative outcomes in patients undergoing radical cystectomy (RC) for bladder cancer. However, limited data is available regarding the long-term outcomes of these patients. The aim of this study is to evaluate the oncological outcomes in patients who underwent RC with ERAS protocol. 

 Materials and Methods: Using our IRB-approved bladder cancer database, we reviewed the records of patients who underwent RC for primary urothelial bladder carcinoma with curative intent from January 2003 to December 2019 (ERAS implemented March 2012 on consecutive patients). The primary and secondary outcomes were recurrent-free and overall survival. Multivariable cox regression analysis was performed to evaluate the effect of ERAS as an independent variable on oncological outcomes.  

 Results: A total of 1903 (ERAS=725 and non-ERAS=1178) patients were included in this study. The baseline and clinicopathological features of the patients are shown in Table-1. In multivariable analysis adjusting for other relevant factors, ERAS was not independently associated with recurrent-free and overall survival following RC (HR 0.87, p=0.3 and 0.84, p=0.19, respectively) (Figure-1). 

 Conclusions: Enhanced recovery after surgery protocols fails to impact the long-term oncologic outcomes in patients undergoing RC for bladder cancer. 

Introduction

Bladder cancer patients can achieve no residual disease status at the time of radical cystectomy (RC) following transurethral resection (TURBT) alone (pT0) or neoadjuvant chemotherapy (NAC) (ypT0). This population has favorable survival potential, yet limited data is available on their oncological outcomes. We examined the recurrence patterns in these patients and the implications for post-operative surveillance.

Methods

A retrospective review of our IRB-approved bladder cancer database identified patients who underwent RC between 2000 - 2019 and were found to have no residual disease (pT0N0). The primary outcome was recurrence-free survival (RFS).

Results

A total of 234 patients with a median age of 66 years were included. NAC was used in 89 (38%) patients and 145 (62%) cases were rendered pT0 following TURBT alone. In a median follow up of 44 months, there were 16 (6.8%) recurrences, 1 (63%) of which occurred in the ypT0 group. None of the patients with clinical Ta/Tis disease had a recurrence after RC. The median time to recurrence was 9 months. All but one of the recurrences in the ypT0 group were within 2 years of cystectomy, while half of the recurrences in the pT0 group occurred after 2 years. Patients with ypT0 had worse 2- and 5-year RFS compared to the pT0 group (85% and 84% vs. 99% and 95%, respectively; p=0.003). Variant histology was noted in 49 (21%) patients and the recurrence rate was higher in this subgroup compared to those with urothelial carcinoma (12.2% vs. 5.4%, p = 0.02). Lung metastasis and involvement of distant organs, while rare, was noted at similar rates in both groups (Figure 1B).

Conclusion

Patients with pT0N0 pathology at the time of cystectomy should prudently undergo long-term surveillance as recurrence and metastasis can still develop up to 4 years after surgery. Patients achieving ypT0 after NAC exhibit worse prognosis and shorter times to recurrence, closer follow-up may be considered.

Introduction and Objective

Radical cystectomy (RC) with neoadjuvant cisplatin-based chemotherapy (NAC) or Trimodality therapy (maximal TURBT along with chemoradiation) is considered standard of care (SOC) for the treatment of non-metastatic, muscle-invasive bladder cancer (MIBC). Herein, we investigated MIBC treatment patterns by race/ethnicity, SES and insurance status using the California Cancer Registry.

 Methods

We identified cases of AJCC Stage II-III bladder cancer (BC) in the California Cancer Registry from 1995-2017. Multivariate statistical analysis was performed with the determinates of race/nativity, gender, socioeconomic status, age, insurance type, marital status, stage, tumor size, time from diagnosis to treatment, presence of positive lymph nodes and/or metastasis. Patients were separated into two groups based on receipt of standard of care (SOC) treatment defined as NAC+RC or concurrent chemoradiation, vs. non-SOC as RC alone. Non-Latino White (NLW) was defined as the reference.

 Results

Of 7,952 cases of AJCC Stage II-III BC, US-born Latinos (USLs) had the lowest odds (OR 0.49, p<0.05) of receiving SOC amongst all racial groups. Younger patients (64 years and below) were more likely than older patients to receive SOC treatment, with the lowest odds of receiving SOC amongst patients aged 73 to 81 years (OR 0.68, p<0.05). There were no statistically significant differences in odds of receiving SOC by gender, insurance type, marital status or SES. 

Conclusions

Our study found significant differences in overall treatment and standard of care treatment for muscle-invasive bladder cancer by race/ethnicity, nativity and age, but not by gender, SES or insurance type. 

Objectives: Patients with chronic kidney disease (CKD) are poor candidates for standard treatments for muscle-invasive bladder cancer (MIBC) and may be more likely to experience adverse outcomes when diagnosed with MIBC. To investigate factors associated with development of advanced CKD following radical cystectomy.

Materials and Methods: Using national Veterans Health Administration utilization files, we identified 3,360 patients who underwent radical cystectomy for MIBC between 2004 and 2018. We examined factors associated with development of advanced CKD (eGFR of <30 mL/min/1.73 m²) after radical cystectomy using multivariable logistic, and proportional hazards regression, with and without consideration of competing risks. We examined survival using Kaplan-Meier product limit estimates and proportional hazards regression.

Results: Median age at surgery was 67 years and mean preoperative eGFR was 69.1 ±20.3 mL/min/1.73 m². Approximately three out of ten patients (n=962, 29%) progressed to advanced CKD within 12 months. Older age (HR per 5 year increase 1.15, 95% CI 1.10 to 1.20), pre-operative hydronephrosis (HR 1.50, 95% CI 1.29 to 1.76), adjuvant chemotherapy (HR 1.19, 95% CI 1.00 to 1.41), higher comorbidity index (HR 1.13, 95% CI 1.11 to 1.16 per point) and lower baseline kidney function (HR 0.75 CI 0.73 to 0.78) were associated with developing advanced CKD. Baseline kidney function at the time of surgery was associated with survival. 

Conclusions: Impaired kidney function at baseline is associated with progression to advanced CKD and mortality after radical cystectomy. Preoperative kidney function should be incorporated into risk stratification algorithms for patients undergoing radical cystectomy.

Figure: Sankey diagram demonstrating flow of kidney function stages for 3,360 patients from preoperative baseline to 6 months following radical cystectomy. The width of each bar is proportional to the number of patients represented.

Introduction:

Early ambulation is imperative in facilitating recovery after radical cystectomy (RC); however, objectively measuring ambulation can be challenging. Wearable fitness trackers (WFTs) are a novel and promising method of objectively tracking activity levels. Herein, we use WFTs to objectively assess associations between perioperative activity levels and postoperative outcomes and discharge disposition after RC.

Methods:

We conducted a prospective study of patients undergoing open and robotic RC at our institution. Patients were given WFTs to wear continuously up to 2 weeks preoperatively, during the postoperative inpatient stay, and up to 2 weeks after discharge. Daily activity levels were automatically recorded by WFTs as step counts and calories burned. Outcomes were analyzed with Mann-Whitney Test.

Results:

55 patients were given WTFs for median (IQR) 18 (15 – 23) days. Median age was 74 (65.0 – 79.5) years, BMI was 26.1 (23.6 – 31.1) kg/m², and length of stay (LOS) was 4 (3.5 – 6) days. Of the 55 patients, 44 (80.0%) were male, 41 (74.5%) underwent open RC, 27 (49%) had orthotopic diversion, and 11 (20.0%) were discharged to nursing facilities. Patients undergoing ileal conduit had lower step counts preoperatively (median 4,425 vs 6,064, p=.021), but inpatient activity was not impacted by diversion type. (Table 1) Discharge to a nursing facility was associated with lower activity levels both preoperatively (median step count 5,647 vs 3,764, p=0.02; calories burned 2,261 vs 1,678, p=0.016) and while inpatient (calories burned 1,966 vs 1,711, p=0.022). Decreased activity levels preoperatively and while inpatient also correlated with prolonged LOS (> 5 days) (p<0.01).

Conclusion:

WFTs are an effective method of objectively tracking perioperative patient activity levels. Lower perioperative activity levels correlate with worse outcomes after RC, including prolonged LOS and discharge to a nursing facility. Future studies will aim to delineate the role of perioperative activity trackers in guiding discharge disposition.

Introduction:

Radical cystectomy (RC) is associated with high complication rates. While the Clavien classification system is widely used for urologic surgeries, its limited interrater reliability and purposeful lack of specificity for surgical specialties presents difficulties when comparing cystectomy complications across institutions. We propose an adapted cystectomy-specific complication classification system based on a large cohort of patients undergoing RC that aims to improve standardization and consistency in complication reporting.

Methods: 

The proposed adapted cystectomy-specific system was retrospectively evaluated on all patients in our IRB-approved database undergoing RC at our institution from 2003 to 2019. All 90-day complications with their respective Clavien grades were reclassified using the proposed system and supplemental index of complications described in Table 1. Complications during the hospital course were analyzed with multivariate regression to compare postoperative outcome predictions between the proposed and Clavien systems.

Results:

Of the 1,881 patients, 1,645 (87%) experienced a total of 3,713 90-day complications. Median (IQR) age was 70 (62-77) years, 1,507 (80.1%) were male, 1,527 (81.2%) underwent open RC, 1,210 (64.3%) underwent orthotopic urinary diversion, and 411 (21.9%) had neoadjuvant chemotherapy. After reclassification, the minor (grade < II) complication rate was higher in the proposed system (89.2% vs 86.3%) (Table 1). Reclassification with the proposed system resulted in more grade I complications but fewer grade II, III, and IV. When predicting prolonged LOS, the proposed system achieved a higher AUC than the Clavien system (AUC 0.63 vs 0.54). While no individual grade was a predictor of prolonged LOS or readmission in the Clavien system, specific grades in the proposed system significantly increased risk of prolonged LOS and 30-day and 90-day readmission (p<.05).

Conclusion: 

Our proposed cystectomy-specific classification system is comparable to the CD system in capturing complication severity. The proposed system, however, simplifies the grading schema, offers a supplemental index of complications to standardize complication reporting, and more accurately predicts prolonged LOS and readmission.

Objectives

Efforts to mitigate significant variations in bladder tumor recurrence rates have focused on improving documentation of operative findings using a surgical checklist. The intent is to enhance surgeon attention to important technical aspects of the procedure, resulting in higher quality transurethral resection of bladder tumor (TURBT). We performed a longitudinal study evaluating documentation before and after implementation of a 10-item checklist for TURBT quality assessment in a community practice setting.

Methods

TURBT operative notes were reviewed prior to checklist education, followed by prospective data collection after education. Education included providing physicians with a laminated 10-point TURBT operative checklist with the goal of maximizing operative note documentation. A repeat educational intervention was performed 4 months later. Trained data analysts manually reviewed charts from 269 patients. The data were entered into a data collection tool for analysis. Primary outcome was assessment of documentation practices prior to and after checklist implementation. Secondary measures were assessing documentation trends over time post intervention.

Results

A total of 269 TURBTs were performed: 127 before intervention, 79 after first intervention, and 63 after second intervention. No significant difference was found when comparing mean items recorded prior to (4.4) and after intervention (4.7, p=0.08). However, ANOVA testing revealed a significant difference in the three periods where the mean item increases immediately after intervention followed by a decline after the second intervention (4.4 prior, 5.1 after first intervention, 4.37 after second intervention, p=0.049). There was a significant trend of decreased item reporting at a rate of 0.0056 items/day after intervention (p=0.016).

Conclusions

While a checklist embedded into operative reports has been demonstrated to improve documentation of critical components of a quality TURBT, passive education with a reference card does not have the same impact. Although documentation improved immediately following implementation, physicians reverted to prior habits of documentation over time. Shaping physician behavioral practices remain a challenging endeavor in the community setting, and structural changes including EMR embedded templates should be implemented whenever possible. Other implementation science interventions including audited feedback, comparative physician performance and Pay-for-Performance are likely to be more successful in achieving the desired outcomes.

Introduction: Partial cystectomy (PC) may be offered in select patients with cT2 muscle invasive bladder cancer (MIBC) utilizing Neoadjuvant Chemotherapy (NAC) and pelvic lymphadenectomy (PLND). We investigated utilization and survival outcomes of PC in a large contemporary cohort.

Methods:  Propensity matching was used to compare pathological and surgical outcomes in non-metastatic MIBC patients in the National Cancer Database undergoing PC or Radical cystectomy (RC). Multivariate logistic regression was used to determine predictors of NAC, LND, peri-operative morbidity and mortality outcomes. This analysis was repeated in the subset with cT2 MIBC.

Results: In 31,306 T2-T4N0M0 patients, 1543 (4.9%) underwent PC. PC use was higher in older patients and mostly (85%) performed for cT2 disease. PC patients were less likely to receive NAC (11.4 vs 27.9%, p<0.001) and PLND (58.7 vs 92.5%, p<0.001) than RC patients. Pathological ≥T3 disease (pT3) was found in 39.4% and positive nodes in 6.9% of PCs. Positive margins were higher in PC, 15.7 vs 10.6%, p<0.001.

PC patients had shorter inpatient stay (4.2 vs 8.7 days, p<0.001), lower 30-day readmission (6.7 vs 9.6%, p<0.001), and decreased 30- and 90-day mortality (1.3 vs 1.8%, p<0.001 & 4.8 vs 4.9%, p=0.04). On multivariate analysis, PC remained an independent predictor of lack of NAC and PLND, shorter LOS, lower readmissions, and improved 30- and 90- day mortality.

In cT2 patients undergoing PC, 32% were ≥pT3 and 6.6% were node pos. Utilization of PLND and NAC remained less likely than in RC (p<0.001).

In both full cohort and cT2 subset, PC was associated with slight improvement in time to mortality and overall survival (OS) (OR 1.44, p<0.001).

Conclusions:  PC is rarely used in treatment of MIBC and despite guidelines, NAC and PLND are underutilized. Care is required in selecting patients for PC as one third of cT2 patients have ≥pT3. PC may have lower peri-operative mortality and comparable OS to RC.  Further investigation is required to determine optimal candidates for PC.  

Objectives:

Current guidelines recommend neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) for muscle invasive bladder cancer (MIBC). NAC has been shown to confer a survival benefit across all ages yet is not offered to many elderly patients. Our objective was to evaluate age-based disparity in treatment and outcomes of MIBC.

Methods:

Using the National Cancer Database, we identified patients with MIBC from 2006-2017. First, use of different treatments, RC, RC and adjuvant chemotherapy, NAC with RC (“gold standard treatment”), chemo-radiation, and no treatment, was compared between age groups. A second analysis was performed in the cohort of elderly patients, ≥70, undergoing cystectomy. Peri-operative and mortality outcomes were compared in patients receiving NAC vs. no NAC. Propensity score weighting (PSW) based on patient and disease characteristics was used to account for confounders.

Results: 

In 70,911 patients with non-metastatic MIBC, use of NAC with RC was lower in patients ≥70, 7.2 vs. 20.9%, p<0.001. On multivariate analysis, patients receiving NAC and RC were younger, had private insurance, higher high school completion, recent diagnosis, lower CCI, higher stage disease, treatment at an academic center, and more likely to undergo pelvic lymph node dissection (p<0.001 for all).

In patients ≥70 undergoing RC, NAC was associated with shorter inpatient stay (LOS) (8.5 vs 9.7 days, p<0.001), decreased 30-day readmission (8.6 vs 10.6%, p=0.003), and lower 30- and 90-day mortality (1.5 vs 3.1%, p=0.01 and 4.9 vs 7.7%, p=0.004, respectively). Multivariate logistic regression with PSW found NAC as an independent predictor of shorter LOS (Beta= -0.66 days, 95% CI [-1.08- -0.24], p=0.002), lower 30-and 90-day mortality (OR=0.62, 95% CI [0.46-0.83], p=0.002 and OR=0.72, CI [0.60-0.87], p<0.001), and improved overall survival (OR=1.25, 95% CI [1.13-1.38], p<0.001).

Conclusions:

Despite increased omission of NAC in patients ≥70, elderly patients receiving NAC and RC had comparable peri-operative morbidity and mortality to those undergoing RC alone. Patients of advanced age who are candidates for RC, should be offered NAC.

Introduction: Neoadjuvant chemotherapy provides a survival benefit compared to cystectomy alone in muscle invasive bladder cancer (MIBC), but only in those who respond at least partially to the treatment. Herein, we explore the feasibility of a urine-based DNA methylation test to monitor response to neoadjuvant therapy (NAT).

Methods: Urine samples were collected from MIBC patients undergoing NAT (chemotherapy or immunotherapy) under an IRB approved protocol at baseline and after each therapy cycle. Samples were analyzed with Bladder CARE (Pangea Laboratory), a urine-based assay that measures methylation levels of 3 bladder-cancer specific biomarkers (TRNA-Cys, SIM2, and NKX1-1) and two internal control loci using methylation-sensitive restriction enzymes coupled with qPCR. Results are reported as Bladder CARE Index (BCI) score and categorized as “positive”, “high-risk”, or “negative”. Changes in BCI score and surgical pathology were reviewed to determine association. 

Results: Of 35 enrolled patients, 18 completed NAT and underwent restaging transurethral resection of bladder tumor (n=3) or cystectomy (n=15). Gemcitabine/Cisplatin (GemCis) was used in 13/18 patients (Table 1). A decrease in BCI was seen in 13/18 (72%) patients. Of the patients with a decrease in BCI, 12 (92%) showed at least partial response to NAT. Only one patient with complete response on final pathology had a negative BCI at baseline and throughout NAT (#7). Final BCI was correlated with final pathology in 12/18 (67%) patients (positive/high-risk BCI in patients with residual disease post NAT or negative BCI in pT0). One patient with clinical T3 disease had positive BCI (>2000) at baseline, which remained positive over the NAT. This patient was restaged with TURBT but did not undergo cystectomy as they developed lung metastasis after NAT (#29).

Conclusion: We present a novel urine based epigenetic assay that may have utility in monitoring response to NAT in patients with MIBC. Further studies are underway to evaluate the utility of this test.

Introduction

The use of blue light cystoscopy (BLC) with hexaminolevulinate (HAL/Cysview) has been shown to improve the detection of both carcinoma-in-situ (CIS) and papillary bladder tumors. However, previous studies found that the sensitivity and false positive rate of BLC could vary between genders, due to inflammatory conditions or difference in urothelium structure. Herein, we aim to evaluate heterogeneity in characteristics of BLC for detection of malignant lesions among various races. 

Methods

Clinicopathologic information was collected from adult patients undergoing transurethral resection of bladder tumor or biopsy who were enrolled in the multi-institutional Cysview registry between April 2014 and February 2021. The primary outcome was detection of any malignant lesion on final pathology. Sensitivity, negative and positive predictive values for detection of malignant lesions was calculated for BLC, white light cystoscopy (WLC), and the combination of both modalities. Fisher’s exact test was used to assess differences between various races. 

Results

Overall, 2,379 separate samples were identified from 1292 patients, of whom, 1095 (85%) were White/Caucasian, 96 (7%) Black/African American, 51 (4%) Asian and 50 (4%) Hispanic. The median (IQR) age was 71 (35 – 93) years. In all races, the sensitivity of BLC was higher than that of WLC, except the Hispanic population (Table 1). Addition of BLC to standard WLC increased the detection rate by 10% for any malignant lesion in total cohort, although this increase was 18% in Asian patients. Additionally, positive predictive value of BLC was the highest in Asian population (94.4%), while Hispanics had the highest negative predictive value for BLC (86.4%). 

Conclusions

Regardless of race, BLC increased the detection of bladder cancer when combined with WLC. However, the difference was more pronounced in White and Asian patients. Further research is warranted to elucidate the etiology of this observation which may ultimately alter interpretation of lesions detected by BLC.

Introduction:

Platinum based chemotherapy is considered standard of care in treating clinical stage (CS) II and III testis cancer. The response, measured by change in size of the retroperitoneal (RP) disease, has prognostic and management implications. We examined the magnitude of change in cross-sectional size and volume of RP masses and its clinical and prognostic implications.

Methods:

A retrospective review of our IRB approved database was conducted for patients diagnosed with CS-II and CS-III non-seminoma between 2010-2019. Patients with a mediastinal primary tumor or without RP involvement were excluded. A single experienced radiologist (TT) examined pre and post-chemo CT imaging to record the dimensions of all RP masses.

Results:

Of 497 patients evaluated, 126 patients were included with a median (IQR) age of 27 (23-33) years. 72 (48%) patients were CS-II at diagnosis. The median (IQR) pre-chemo long axis size was 7 (3.8-11.5) cm and the median (IQR) post-chemo reduction in tumor volume was 80% (47%-92%). Following Induction chemo, 67 (53%) patients had a post-chemo retroperitoneal lymph node dissection (PC RPLND) and 26 (21%) required multiple treatment modalities. The rate of PC-RPLND as a first treatment following induction chemo was >50% across all size categories (figure 1A), while the lifetime need for PC-RPLND was 74%. At the time of PC-RPLND rates of viable tumor were similar irrespective of pre-chemo mass size (Figure 1C). The percent reduction in mass volume did not reliably predict fibrosis. Post chemotherapy tumor size had a direct correlation with the risk of recurrence (figure 1D) and patients with <70% tumor volume reduction showed higher recurrence rates (HR 5.7, p<0.001). Patients with a pre-chemo mass size >3 cm had a significantly higher risk of recurrence (HR 3, p <0.001).

Conclusion:

Following induction chemotherapy, more than half of patients required PC-RPLND irrespective of pre-chemo tumor size or post-chemo volume reduction. This illustrates the value of a multidisciplinary treatment approach and early engagement of surgical expertise during the treatment course. 

Objectives: Numerous scientific publications show improved postoperative recovery with enhanced recovery after surgery (ERAS) protocols in various surgical fields. However, there is nonexistent data on the use of ERAS in retroperitoneal lymph node dissection (RPLND) for testicular cancer. We implemented an ERAS protocol for RPLND patients at our institution in 2019 and report the early clinical outcomes in a cohort of post-chemotherapy RPLND patients.

Materials and Methods: We performed a retrospective cohort study comparing clinical outcomes of the first 20 patients who underwent an open post-chemotherapy RPLND with an ERAS protocol in 2019-2020 to the last 20 patients managed with a standard protocol in 2018-2019. The ERAS protocol included well-established items (eg. early mobilization) as well as items specifically tailored for RPLND (eg. early low-fat diet and urinary catheter removal under epidural analgesia).

Results: The median age at the time of operation was 30 years (range, 19-60) and postoperative follow-up time11.0 months (3-29). The groups were similar in comorbidities, operative details and type of testicular cancer (Table 1). The median postoperative hospitalization time was 4.0 days (3-12) in the ERAS group and 4.5 days (3-7) in the Standard group (p=0.4016). ERAS patients were able to tolerate solid oral diet sooner than patients in the standard group (1.0 [1 – 11] vs. 3.0 [2-5]; p<0.001). The 90-day complication rate was 25 % in the ERAS group and 15 % in the Standard group (p=0.429). The postoperative readmission rate was 5 % in each group.

Conclusions: Early results demonstrate that ERAS protocol is feasible and safe in patients undergoing RPLND for testicular cancer and provides fast postoperative recovery. 

Source of Funding: None

Table 1.

Objectives: Limited data is available regarding the role and necessity of delayed orchiectomy in patients with testicular cancer following chemotherapy. The aim of this study is to evaluate the clinicopathological findings of patients undergoing delayed orchiectomy and post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND). 

Materials and Methods: Using our IRB-approved testis cancer database, a retrospective analysis was performed on patients who underwent delayed (post-chemotherapy) orchiectomy and PC-RPLND for metastatic testicular cancer. Patients’ characteristics, pathologic findings of orchiectomy and retroperitoneal specimens, as well as oncological outcomes were reviewed.

Results: A total of 30 patients with a median (IQR) age of 30 (26-38) years were included in this study. All patients received 3-4 cycles of first-line platinum-based chemotherapy, of whom 9 cases treated with salvage chemotherapy as well. Delayed orchiectomy was performed simultaneously with PC-RPLND in 24 and as a separate procedure in 6 patients. A testicular prosthesis was placed in 10 patients without complications. Final pathology of the orchiectomy specimens revealed no viable germ cell tumor in 20 (65%), pure teratoma in 7 (23%), intratubular germ cell neoplasia in 1 (6%), and residual viable tumor in 2 (6%) (Table-1). The last group included: (1) one patient with residual (30%) seminoma who had negative preoperative tumor markers and negative PC-RPLND pathology; (2) a patient with mixed yolk sac (20%) and teratoma (10%) components who had elevated AFP and similar PC-RPLND pathology. The pathology of the orchiectomy and PC-RPLND specimens was concordant in 19 (63%) patients. In a median (IQR) follow-up of 17 (7.5-56) months, 5 patients developed recurrence, all of whom underwent systemic chemotherapy ± surgery. Among 20 patients with available hormonal panel, newly diagnosed hypogonadism (Testosterone < 300 ng/dL) was detected in 4 (20%) patients.

Conclusion: Residual testicular viable cancer and/or teratoma can be seen in about one-third of patients who undergo PC-RPLND and delayed orchiectomy. Systemic therapy does not obviate the need for orchiectomy in these patients. 

Objectives: Oncologic outcomes of post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) for testicular tumors depend invariably on thorough resection of the retroperitoneal template that may embrace adjuvant vascular procedures including resection with or without reconstruction. The goal of this study is to describe the incidence, feasibility and perioperative outcome of vascular resection during PC-RPLND.  

Methods: Using our IRB-approved testis cancer database, we retrospectively reviewed the records of consented patients who underwent PC-RPLND for testicular germ cell tumors between 1998 and 2020. Patients’ clinico-pathologic features, surgical data and 90-day complications were reviewed. Multivariable logistic regression (MVA) was used to evaluate independent factors associated with vascular resection. 

Results:  A total of 241 patients underwent PC-RPLND, of which 48 (20%) required vascular resections. Inferior vena cava or abdominal aorta resection with or without reconstruction was performed in 41 patients. Other vascular procedures included renal (#5) and iliac (#2) vessel resection, of which 3 needed reconstruction (Table 1). Graft was used for all aortic reconstructions plus one case with left common iliac artery resection.  Fifteen (28%) patients underwent another adjuvant procedure as well (Table 1). MVA showed that pre-operative RP mass size (OR=1.1, 95%CI: 1 – 1.2, P=0.002), right-sided primary testis cancer (OR=2.5, 95%CI: 1.2 – 5, P=0.008), and salvage chemotherapy prior to PC-RPLND (OR=5.3, 95%CI: 2.3 – 12.3, P<0.001) were significantly associated with increased rate of vascular resections. No intra-operative complication was reported. 90-day complication rate was 33%, most of which were low grade (Table 2). 

Conclusions: Vascular resections are required in a significant proportion of patients undergoing PC-RPLND. Preoperative retroperitoneal mass size, salvage chemotherapy, and right-sided testis cancer are associated with higher rate of adjuvant vascular resections.