Vol. 193, No.
4S, Supplement, Saturday, May 16, 2015
experience prolonged, difficult recoveries after surgery. There is
growing interest in identifying ways to improve recovery after RC. To
date, studies on this topic have focused on inpatient length of stay
(LOS) as the primary outcome measure. Given that many patients
suffer complications after discharge and require readmission to the
hospital, LOS may not be the most useful measure to determine effi-
cacy of recovery improvement efforts. We propose a novel composite
endpoint e “Poor Recovery” e as a more encompassing measure of
outcomes after RC.
METHODS: A comprehensive perioperative multidisciplinary
algorithm called the Optimized Surgical Journey (OSJ) has been in
development at our institution over the last 18 months. We selected
50 patients who underwent RC with the OSJ algorithm and 50 patients
who underwent RC with usual care during the same time period. Poor
Recovery was defined by inpatient LOS > 7 days or hospital read-
mission within 30 days. Statistical analyses included the Wilcoxon rank-
sum test for continuous variables and Fisher’s exact test for categorical
variables.
RESULTS: Patients in the OSJ group had significantly shorter
times to flatus, bowel movement, first ambulation and resumption of
regular diet as compared to the Non-OSJ group (Table). There were no
differences between the groups in operative time, blood loss, analgesia
or rate of ICU admission. Mean LOS was significantly shorter in the OSJ
group (5.6 vs. 8.5 days, p < 0.01). Poor Recovery was experienced by
18% of patients in the OSJ group and 60% of patients in the Non-OSJ
group (p < 0.01).
CONCLUSIONS: We define a novel composite endpoint e
Poor Recovery e that can help measure outcomes after RC. For
future prospective studies of accelerated recovery pathways, the poor
recovery endpoint may be a useful metric by which to determine the
efficacy of various interventions.
Table 1 Post-Operative Recovery
OSJ Non-OSJ P-Value
Recovery - mean POD (SD)
Ambulation 1.3 (0.5) 1.9 (1.4) 0.01
Flatus 2.9 (1.3) 4.3 (1.4) < 0.01
Bowel movement 3.8 (1.4) 5.2 (1.6) < 0.01
Regular diet 3.4 (1.5) 6.5 (3.2) < 0.01
Length of stay 5.6 (1.5) 8.5 (4) < 0.01
Source of Funding: None.
MP26-15
TREND IN TA STAGE UROTHELIAL CARCINOMA OF THE
BLADDER: SHIFT TO HIGHER GRADING?
Shane Barney*, George Wayne, Elizabeth Nagoda, Mark Soloway,
Juan Acuna, Miami, FL
INTRODUCTION AND OBJECTIVES: Bladder cancers are
treated differently based on histological grade. Studies have shown
pathologist grading to vary significantly. This study examines a possible
trend towards higher grading of Ta staged Transitional Cell Carcinoma
(TCC) of the bladder, given the new WHO grading criteria in 2004 and
other changes.
METHODS: We studied a subset of the SEER (Surveillance,
Epidemiology, and End Results) database for an association between
year and likelihood of a high-grade classification on pathologic analysis
of Ta stage bladder cancer. 36,422 cases of clinically ambiguous Ta-
staged TCC were identified between 1997 and 2011. Join-point and
Multivariate Logistic regressions tested the hypothesized trend towards
higher grading.
RESULTS: Join-point regression identified an increasing trend
in proportion of high-grade Ta TCC bladder cancer from 1997-2011.
However, we found no significant points of inflection in the slope of such
an association. Specifically, there was no significant change in the trend
coinciding with the 2004 change in WHO grading systems. Logistic
THE JOURNAL OF UROLOGYâ e299
regression found a 16% (unadjusted OR¼1.16, 99% CI: 1.15-1.18) in-
crease in the odds of high-grade designation for each passing year.
This result did not change when adjusted for possible confounders
(adjusted OR¼1.17, 99% CI: 1.15-1.20). Other significant determinants
of grade included age, gender, and tumor size (AOR¼1.02, 1.5, 1.35
respectively).
CONCLUSIONS: The likelihood of high-grade assignment on
pathologic assessment of Ta-staged TCC is increasing with time at a
gradual rate, which is unlikely caused by a singular event such as the
2004 WHO change in grading recommendations. Multiple factors e
demographics, technology, pathologist variability e likely contribute to
this trend. Future studies will be needed to further understand and
contextualize such a trend.
Source of Funding: none
MP26-16
NEUTROPHIL TO LYMPHOCYTE RATIO, A NEW PROGNOSTIC
FACTOR IN NON MUSCLE INVASIVE BLADDER CANCER
Vincenzo Favilla, Tommaso Castelli, Daniele Urzì, Sebastiano Cimino,
 , Giorgio Ivan Russo*,
Salvatore Privitera, Eugenia Fragala
Giuseppe Morgia, Catania, Italy
INTRODUCTION AND OBJECTIVES: An elevated neutrophil
to lymphocyte ratio (NLR) was associated with a worse overall and
disease free survival in a variety of different malignancies, including
muscle invasive bladder cancer. The predictive value of NLR in non
muscle invasive bladder cancer (NMIBC) has not been well prospec-
tively studied. The aim of our study was to evaluated whether NLR
predict disease recurrence and progression in NMIBC.
METHODS: The NLR, defined as the absolute neutrophil
count divided by the absolute lymphocyte count, was prospectively
evaluated in 178 consecutive, newly diagnosed, patients with NMIBC
treated with transurethral resection of the bladder tumor (TURB), be-
tween the years 2009 and 2013. Patients with hematologic disorders or
conditions that may have influenced blood cell lines such as autoim-
mune disease, presence of an active infection and/or immunodeficiency
virus infection at the time of surgical intervention, prior or concomitant
intravescical therapy with BacilleCalmettee Gue rin (BCG), prior blood
transfusion, and the presence of other cancer types or prior chemo-
therapy were excluded. Cutoff points for NLR were tested separately
for recurrence and progression using the standardized cutoff-finder
algorithm. Univariate and multivariate Cox regression analyses were
used to evaluated the association between NLR and disease recur-
rence and progression
RESULTS: The study cohort comprised 148 male and 30 fe-
male patients. The median age of all 178 patients enrolled in the study
was 69.27, with a median follow-up of 53 months (IQR: 33.0-76.25).
e300 THE JOURNAL OF UROLOGYâ
Median NLR was 2.55 (IQR: 1.90-3.62) Patients with NLR <3 were
older (74.45 vs. 67.94; p¼0.02) and exhibited significant differences in
term of pathological stage (p¼0.03) and no. of tumours (p¼0.04) if
compared with those with NLR 3. During the follow-up study, 14
(23.3%) and 44 (37.9%) (p¼0.04) patients respectively with NLR <3
and 3 experienced recurrence and 2 (3.3%) and 14 (11.9%) experi-
enced progression (p¼0.06). At the multivariate Cox regression anal-
ysis, NLR < 3 was associated with low disease recurrence (HR: 0.34
[IQR: 0.17-0.68]; p<0.01). Pathological stage pT1 (p<0.01), high grade
(p<0.01), no. of tumours (p<0.01) and smoking status (p<0.01) were
independently predictors of disease recurrence. No association was
found between NLR  3 and disease progression at the multivariate
Cox regression analysis. The 5 years recurrence free survival was 49%
and 62% in patients with NLR  3 and < 3 (p¼0.04). The 5 year pro-
gression free survival was 77% and 93% in patients with NLR  3 and
< 3 (p¼0.69).
CONCLUSIONS: NLR is an independent predictor of disease
recurrence but no of progression in patients with newly diagnosed
NMIBC. These findings could offer a new contribution to find new bio-
markers of recurrence in NMIBC patients.
Source of Funding: None
MP26-17
T1 HIGH-GRADE (G3) TRANSITIONAL CELL CARCINOMA OF
THE URINARY BLADDER: DELAYED RADICAL CYSTECTOMY
IS CORRELATED TO A WORSENED OUTCOME
Birte-Swantje Schneevoigt*, Tobias Grimm, Alexander Buchner,
Alexander Kretschmer, Maria Apfelbeck, Markus Grabbert,
Christian Stief, Alexander Karl, Munich, Germany
INTRODUCTION AND OBJECTIVES: To assess cancer spe-
cific survival (CSS) in patients with primary pT1 high-grade bladder
cancer (BC) depending on the time interval between diagnosis and
performance of radical cystectomy (RC).
METHODS: Between 2004 and 2013, 175 of 920 patients who
underwent RC presented with the initial diagnosis of pT1 high-grade
transitional cell carcinoma (TCC) of the bladder at our institution.
Median follow-up was 27 months. 90% (n¼158) of these patients un-
derwent RC within two years from diagnosis, 10% (n¼17) after
that period. From the group of patients undergoing RC within two
years, 64% (n¼101) were treated within three months after initial
diagnosis.
RESULTS: There was no difference in CSS between patients
undergoing RC within three months, three to twelve months or
twelve to 24 months after initial diagnosis (p¼0.864). However CSS
was significantly worsened when the time interval between initial
diagnosis and the performance of RC was more than two years
(p¼0.006). Overall, an up- and downstaging in the RC specimen
was found in 57% and 22%, respectively. There was a significant dif-
ference in T-stages between patients undergoing RC within two years
and after two years from diagnosis (p¼0.003). Significantly more pa-
tients had stage T3 and T4 in the RC group after two years (59%
vs. 30%).
CONCLUSIONS: Our data suggest that patients with the initial
diagnosis of T1 high-grade TCC of the urinary bladder have an
increased risk for a worsened CSS when RC is performed more than
two years after the primary tumor diagnosis.
Source of Funding: none
Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015
MP26-18
MULTI-ISTITUTIONAL CONTROLLED STUDIES DO NO REFLECT
THE PATIENT’S COMPLIANCE TO BCG ENCOUNTERED IN
CLINICAL PRACTICE. RESULTS ON 411 PATIENTS
Vincenzo Serretta*, Cristina Scalici Gesolfo, Vincenza Alonge,
Fabrizio Di Maida, Palermo, Italy; Lorenzo Rocchini, Marco Moschini,
Andrea Gallina, Renzo Colombo, Milan, Italy
INTRODUCTION AND OBJECTIVES: BCG maintenance for at
least one year is advocated by urological guidelines as the best intra-
vesical regimen in high-risk non muscle invasive bladder cancer
(NMIBC), conservatively treated. Noteworthy, a relevant percentage of
patients does not complete the planned treatment. The aim of this study
was to analyze the reasons for treatment interruption and low
compliance.
METHODS: Consecutive patients affected by T1HG NMIBC
undergoing conservative management with adjuvant BCG entered the
study. The Connaught BCG strain was administered intravesically ac-
cording to the South West Oncology Group schedule for one year,
81mg diluted in 50 ml of saline solution, starting 21-30 days after TUR.
Toxicity and causes of treatment interruption were recorded.
RESULTS: Between 2000 and 2012, intravesical BCG with
1-year maintenance regimen was proposed to 411 patients. Out of
them, 380 (92,5%) completed the induction cycle and 308 (81%) started
the maintenance. A total of 215 (52.3%) completed the scheduled one-
year treatment. Toxicity requiring treatment interruption was recorded in
25 (6.1%) patients only. In 60 patients (14.6%) a delay of one or more
instillations was necessary. Grade-I toxicity, not requiring therapy
interruption or delay, was recorded in 193 (46.9%) cases. In our
experience, the patient’s compliance registered during the induction
cycle reached 92%, confirming the low toxicity and the good patients’
acceptance of the 6-week induction. However, between the end of the
induction course and the first maintenance instillation, 50 patients (13%)
became reluctant to treatment for many personal reasons unrelated to
toxicity and 22 (6%) were excluded for suspicious bladder lesion at
cystoscopy. Moreover, patients’ compliance to maintenance decreased
from 81% at 3 months to 56.6% at 12 months. Surprisingly, the rate of
drop-out (15%) remained stable at 6 and 12 months. Mild toxicity and
social discomfort were the mean reasons for dropout during mainte-
nance (60%).
CONCLUSIONS: Severe toxicity caused BCG interruption in a
limited amount of cases. Almost 60% of treatment interruptions was
attributable to low grade toxicity, inadequately considered by the urol-
ogists. The personal difficulties related to the prolonged treatment and
the limited patients’ awareness of the therapeutic value of maintenance
were other important reasons. A structured periodical counseling and a
timely recognition and therapy of mild but persistent symptoms, might
significantly ameliorate patients’ acceptance of BCG maintenance.
Source of Funding: none
MP26-19
A PROSPECTIVE STUDY ON THE INFLUENCE ON RECURRENCE
OF QUITTING CIGARETTE SMOKING AT DIAGNOSIS OF PRIMARY
NON MUSCLE INVASIVE BLADDER CANCER
Cristina Scalici Gesolfo*, Francesco D’Amato, Dario Fontana,
Francesco Sommatino, Palermo, Italy; Lorenzo Rocchini,
Marco Moschini, Renzo Colombo, Andrea Gallina, Milan, Italy;
Vincenzo Serretta, Palermo, Italy
INTRODUCTION AND OBJECTIVES: Cigarette smoking is a
known risk factor for bladder cancer (BC). Even if there is evidence that
quitting decreases the incidence of BC it is still object of debate if
quitting at first diagnosis could influence the outcome of primary non
muscle invasive bladder cancer (NMIBC) reducing the risk of further
recurrence. The aim of the present prospective study is to evaluate the
outcome of smokers affected by primary NMI-BC in relation to their
smoking habit after diagnosis.