MP84-20 CHANGING PRACTICE PATTERNS FOR THE MANAGEMENT OF UPPER TRACT UROTHELIAL CARCINOMA WITH NEPHROURETERECTOMY: A 10-YEAR POPULATION-BASED ANALYSIS

Abstract

INTRODUCTION AND OBJECTIVES: Nephroureterectomy (NU), is the standard treatment for upper tract urothelial carcinoma (UTUC). Minimally invasive (MI) laparoscopic or robotic-assisted approaches have been introduced in an effort to reduce morbidity. We performed a population-based study to assess contemporary trends in utilization, morbidity, and cost of competing approaches for NU in theUS. METHODS: Using the Premier Hospital Database (Premier, Inc., Charlotte, NC), a nationally representative discharge database collecting data from over 600 non-federal hospitals throughout the US, we captured all patients who underwent a NU (ICD9 55.51) with diagnoses of UTUC (ICD9 189.1, 189.2), from 2004 to 2013. We fit regression models, accounting for clustering by hospitals and sample weighting to estimate 90-day postoperative complications, length of stay (LOS), operating room time (OT), and direct hospital costs among open NU and MI NU. RESULTS: The weighted cohort included 17245 open, 13298 laparoscopic, and 3745 robotic NUs. MI NU increased from 36% to 54% from 2004 to 2013 while the annual number of NU’s decreased by nearly 20% during the same period (Figure 1); among the least healthy patients (CCI 2), robotic NU’s accounted for 31% in 2013 as compared to 2% in 2004. The overall 90-day mortality (Clavien 5) and major (Clavien 3-5) complication rates were 1.89% and 9.4% respectively with no statistically significant differences among surgical approach based on adjusted analysis. The LOS was decreased for laparoscopic NU (Incidence Risk Ratio [IRR]: 0.87, p <0.001) and robotic NU (IRR: 0.76, p <0.001) compared to open NUs. OT was 10.35 (p<0.05) and 56.35 (p<0.001) minutes longer for laparoscopic and robotic NU. Adjusted 90day median direct hospital costs were $1354 and $3533 higher for laparoscopic and robotic NU (p<0.001). CONCLUSIONS: During this contemporary 10-year study, the use of MI NUs increased to over half of procedures with a recent surge in robotic NU’s particularly in the higher comorbidity patients. The national reduction in total NUs performed in the US may reflect a growing enthusiasm for renal sparing options for UTUC. Comparable perioperative outcomes among the three approaches suggest that the morbidity profile may be driven primarily by patient-specific characteristics.