1. Urinary Diversion: Does RARC learning curve affect diversion choice in urothelial carcinoma PG O’Malley 1, B Al Hussein Al Awamlh 1, DP Nguyen 1, BM Faltas 2, R Lee 1, DS Scherr 1 1 Department of Urology and 2 Department of Medical Oncology, Weill Cornell Medical College I NTRODUCTION AND O BJECTIVES Contra-indications for continent diversion include abnormal glomerular filtration rate (GFR) and advanced age. The introduction of new techniques such as Robotic assisted radical cystectomy (RARC) however may introduce confounding selection and other biases into choice of diversion. This study examined if choice of diversion changed with the introduction of RARC ABSTRACT IRB approved, retrospective chart review was performed on 383 non-metastatic patients who underwent definitive treatment with either open radical cystectomy (ORC) or RARC for urothelial carcinoma. Surgery was performed at a single tertiary care centre between 2001-2014 by a single, fellowship trained, urological oncologist.. COHORTS: Cohorts consisted of ORC (n=118, 1 cohort), and consecutive RARC (n=257) cohorts of 50 patients (Cohort 1: 1-50, Cohort 2: 51-100, etc). Eight patients underwent conversion from RARC to ORC during 2006-2014, these patients were excluded from analysis prior to construction of the cohorts OUTCOMES: Primary outcome was defined as continent (orthotopic ileal neobladder, or Indiana pouch) versus non-continent diversion, ie ileal conduit. Pre-op variables: age, gender, obesity (BMI >30), GFR ( 60 mL/min/1.73 m2), ASA status (1-2 vs. 3-4), clinical stage based on trans urethral resection of bladder tumor (TURBT), and history of previous pelvic radiation were examined on univariable analysis. Multivariable logistic regression analysis was performed using significant variables and cohort. RESULTS METHODS Table 1. Demographics and Baseline characteristics of ORC and RARC cohorts 1-5. RESULTS Table 3: Univariable and multivariable logistic regression analysis CONCLUSIONS Multivariable analysis demonstrated that only age and renal function (GFR) determined choice of diversion despite the introduction of robot-assisted technique for radical cystectomy T he data suggests that while the introduction of new techniques such as RARC have altered the operation it has not altered the choice of optimal diversion for appropriate candidates and classic determinants such as age and renal function continue to drive this clinical decision Table 2: Pathology, Diversion choice and operative parameters CohortOverallORC RARC 1 (1-50) RARC 2 (51-100) RARC 3 (101-150) RARC 4 (151-200) RARC 5 (201-257) Age*72 (64-78)68.5 (63-75)71 (63-80)74.5 (68-79)70 (63-79)75 (68-81)72 (65-78) Gender (Female) 87 (23%) 31 (26%) 10 (20%)14 (28%)5 (10%)10 (20%)17 (30%) Obese (BMI>30) 91 (24.3%) 30 (25%) 11 (22.0%)12 (24%)17 (34%)10 (20%)11 (19%) BMI (med, IQR) 27 23-29 27 23-30 26.5 24-2927 24-2928 24-3126 24-2926 23-29 GFR62.4 (45.8-79.3) 64.0 (45.3-80.4) 63.7 (42.7-74.7) 61.2 (41.2-75.5) 62.6 (42.6-87.9) 58.0 (50.3-70.5) 61.5 (50.7-79.4) GFR 40-60102 (29.6%) 29 (26%) 13 (26%)15 (30%)13 (26%)21 (43.8%)11 (32.4%) GFR >60185 (53.6%) 64 (56.6%) 27 (54%)25 (50%)28 (56%)21 (43.8%)20 (58.8%) ASA (3-4)*186 (51.5%) 57 (52.3%) 17 (34%) 28 (57.1%)26 (52%)33 (66%)25 (47.2%) TURBT Stage (MIBC) 217 (60.1%) 64 (59.8%) 29 (58%) 29 (59.2%)27 (55.1%)36 (73.5%)32 (61.4%) Previous XRT35 (9.3%) 10 (8.5%) 4 (8.0%) 10 (20.0%)3 (6.0%)2 (4.0%)6 (10.5%) CohortOverallORCRARC IRARC 2RARC 3RARC 4RARC 5 T Stage: NMIBC T2 T3 T4 p=0.187 177 (47.2) 57 (15.2) 87 (23.2) 54 (14.4) 46 (39.0) 21 (17.8) 27 (22.9) 24 (20.3) 28 (56.0) 3 (6.0) 14 (28.0) 5 (10.0) 21 (42.0) 11 (22.0) 14 (28.0) 4 (8.0) 28 (56.0) 6 (12.0) 11 (22.0) 5 (10.0) 26 (52.0) 11 (22.0) 8 (16.0) 5 (10.0) 28 (49.1) 5 (8.8) 13 (22.8) 11 (19.3) N Stage: N0 N+ Nx p=0.326 284 (75.7) 77 (20.5) 14 (3.7) 83 (70.3) 31 (26.2) 4 (3.4) 39 (78) 9 (18) 2 (4) 41 (82) 6 (12) 3 (6) 42 (84) 8 (16) 0 (0) 39 (78) 7 (14) 4 (8) 40 (70.2) 16 (28.1) 1 (1.8) Diversion: Continent Conduit None p=0.528 155 (41.3) 217 (57.9) 3 (0.8) 54 (45.8) 63 (53.4) 1 (0.9) 19 (38.0) 31 (62.0) 0 (0) 20 (40.0) 30 (60.0) 0 (0) 20 (40.0) 30 (60.0) 0 (0) 14 (28.0) 34 (68.0) 2 (4.0) 28 (49.1) 29 (50.9) 0 (0) EBL –cc (Median, IQR) p<0.001 500 (300-800) 900 (600-1400) 350 (250-500) 325 (200-600) 400 (300-800) 400 (300-600) 300 (245-500) OR Time -mins (Median, IQR) 350 (300-420) 338 (276-420) 362 (330-450) 360 (300-400) 397 (330-465) 334 (285-399) 333 (286-375) Variable UNIVARIABLEMULTIVARIABLE OR95% CIP-valueOR95% CIP-value Age 0.840.81 - 0.88<0.0010.840.80 - 0.88< 0.001 Gender (ref – female) 0.890.55 - 1.460.65-- Obese 1.000.62 - 1.620.98-- GFR: (ml/min/1.73m 2 ) 40-60 >60 4.51 8.03 1.86 - 10.93 3.46 - 18.62 0.001 <0.001 3.35 4.67 1.10 - 10.17 1.63 - 13.38 0.033 0.004 ASA 0.290.19 - 0.45<0.0010.610.34 - 1.100.098 TURBT stage 0.930.61 - 1.430.75-- Previous XRT 0.450.21 - 1.000.049-- RARC cohort 1.72.36 - 1.410.330.630.25 - 1.570.322 20.780.40 - 1.520.461.450.60 - 3.540.411 30.780.40 - 1.520.460.670.27 - 1.650.380 40.480.23 - 0.990.0460.820.32 - 2.080.671 51.130.60 - 2.120.712.300.82 - 6.430.114 Dr. P O’Malley supported by The Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust and by the Ferdinand C. Valentine Fellowship Award from the New York Academy of Medicine.