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PREOPERATIVE AND OPERATIVE FACTORS ASSOCIATED WITH COMPLICATIONS FOLLOWING RADICAL NEPHROURETERECTOMY
Kari Bailey, Jay Raman, Kuan Lin, Erik Lehman, , Laura-Maria Krabbe, Vitaly Margulis, Tobias Klatte, Shahrokh Shariat, Alex Arnouk, Costas Lallas, Edouard Trabulsi, Gregory Bozzini, Pierre Colin, Sarah Drouin, Morgan Roupret, Benoit Peyronnet, Karim Bensalah, David Canes

Introduction:
Radical nephroureterectomy (RNU) is the gold standard for managing upper-tract urothelial carcinoma (UTUC). Perioperative complications may be significant given their impact on survival outcomes as well as delivery of adjuvant therapies when necessary. Identifying variables associated with adverse post-procedure events may guide patient counseling, expectations, and operative and post-operative management. Owing to its rarity, such data are lacking for radical nephroureterectomy (RNU). We review preoperative, operative and pathologic characteristics of a multi-institutional, international cohort of patients undergoing RNU to identify factors associated with perioperative complications.

Methods:
A retrospective review of medical records of 732 patients undergoing RNU at 8 academic centers in the United States and Europe were reviewed. Data on preoperative clinical, demographic, comorbidity indices , operative, and pathologic data were collected. Complications within 30-days of surgery were graded using the modified Clavien-Dindo scale. Univariate and multivariate analyses determined the association between preoperative, operative, and pathologic variables and the presence of complications.

Results:
371 men and 361 women with median age of 70 years and BMI of 27 were included. Three-quarters of the cohort was Caucasian. Measurement of comorbidity indices noted median Charlson score of 4 (range, 1 14), while 44% had ASA ? 3 and 11% had ECOG status ? 2. Leading comorbid medical conditions included hypertension (55%), hyperlipidemia (41%), coronary artery disease (24%), diabetes (17%), and pulmonary disease (14%). Median baseline eGFR (CKD-EPI) was 58 ml/min/1.73m2 with 50% having CKD stage > III. 73% of cases were performed via a minimally invasive approach and 36% had a lymph node (LN) dissection. Median OR duration was 200 minutes (range, 60977) with a median EBL of 165cc (range, 105000). 12% of patients received an intraoperative transfusion. Final pathology noted that 56% of tumors were located in the kidney/renal pelvis, 50% were muscle invasive, 68% were high grade, 10% had positive lymph nodes, and 6% had positive surgical margins.
Overall, 270 patients (37%) experienced a post-operative complication including 54 with Clavien III or greater events. On univariate analysis, age, race, baseline eGFR, comorbidities (DM, hyperlipidemia, HTN) all comorbidity indices (Charlson, ECOG, ASA), EBL, OR duration, intraoperative transfusion, tumor location, pathologic stage, and surgical margin status were associated with complications. Conversely, surgical approach and LN dissection were not associated with post-RNU complications. In a multivariate model including preoperative variables, only patient age (OR 4.0, 95% CI 1.76.3, p=0.05), Charlson index (OR 4.5, 95% CI 2.16.8, p=0.03) and eGFR (OR 7.8, 95% CI 3.412.1, p=0.005) were independently associated with post-operative complications. For operative and pathologic data, on multivariate analysis only OR time (OR 8.3, 95% CI 3.610.8, p=0.004) and intraoperative transfusion (OR 6.8, 95% CI 2.48.7, p=0.009) were associated with post-RNU complications.

Conclusion:
Almost 40% of patients in our international cohort experienced a complication within 30 days of RNU. Increasing age, higher Charlson score, and lower baseline eGFR were independently associated with patients developing complications. Additionally, longer OR duration and intraoperative transfusion requirement were associated with post-RNU complications. Other operative (surgical approach, LN dissection) and pathologic factors (stage, grade) did not predict complications following surgery. These data can be used for preoperative patient counseling as well as modification of clinical pathways after RNU.


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