Amir H. Lebastchi

The Role of Transurethral Resection in Trimodal Therapy for Muscle-Invasive Bladder Cancer.

While radical cystectomy (RC) with pelvic lymph node dissection (PLND) represents the accepted gold standard for the treatment of muscle-invasive bladder cancer, this treatment approach is associated with significant morbidity. As such, bladder preservation strategies are often utilized in patients who are either deemed medically unfit due to significant comorbidities or whom decline management with RC and PLND secondary to its associated morbidity. In a select group of patients, meeting strict criteria, bladder preservation approaches may be employed with curative intent. Trimodal therapy, consisting of complete transurethral resection of bladder tumor (TURBT), chemotherapy, and radiation therapy has demonstrated durable oncologic control and long-term survival in a number of studies. The review presented here provides a description of trimodal therapy and the role of TURBT in bladder preservation for patients with muscle-invasive bladder cancer.

The Urology Applicant: An Analysis of Contemporary Urology Residency Candidates

OBJECTIVE To better understand todays urology applicant. METHODS All 2016 Urology Residency Match applicants to the study-participating institutions were provided a survey via email inquiring about their paths to urology, their career aspirations, how they evaluate a training program, and how they perceive residency programs evaluate them. RESULTS Of a possible 468 applicants registered for the match, 346 applicants completed the survey. Only 8.7% had a mandatory urology rotation, yet 58.4% believed that a mandatory urology rotation would influence their career decision. Most applicants (62.1%) spent more than 8 weeks on urology rotations, and 79.2% completed 2 or more away rotations. Applicants were attracted to urology by the diversity of procedures, prior exposure to the field, and the mix of medicine and surgery, with mean importance scores of 4.70, 4.52, and 4.45 of 5, respectively. Female applicants were more likely to be interested in pediatric urology, trauma or reconstructive urology, and female pelvic medicine and reconstructive surgery. Significant differences in survey results were noted when applicants were separated by gender. Three-fourths of respondents (75.7%) applied to more than 50 residency programs. Applicants ranked operative experience, interactions with current residents, and relationships between faculty and residents as the most important criteria when evaluating training programs. Of the subspecialties, 62.1% of applicants expressed most interest in urologic oncology. At this stage in their career, a significant majority (83.5%) expressed interest in becoming academic faculty. CONCLUSION This study provides new information that facilitates a more comprehensive understanding of todays urology applicants.

Robotic-assisted Thoracoscopic Transdiaphragmatic Adrenalectomy (RATTA) for Metastatic Renal Cell Carcinoma

OBJECTIVE Robotic-assisted thoracoscopic transdiaphragmatic adrenalectomy (RATTA) represents a novel surgical approach for the management of adrenal pathology in patients with a history of extensive transperitoneal or retroperitoneal procedures. METHODS Here we report the first described case of RATTA in a 56-year-old woman with metastatic renal cell carcinoma to the left adrenal gland and right lung. With the assistance of cardiothoracic surgery, this patient underwent robotic-assisted thoracoscopic pulmonary wedge resection and RATTA. In brief, after completion of the pulmonary wedge resection by thoracic surgery the diaphragm was incised starting at the left crus and extending laterally through the diaphragmatic muscle, exposing the retroperitoneal space and fat. The adrenal gland with mass was identified, dissected from surrounding structures, and extracted. The diaphragm was then closed using Ethibond suture with polytetrafluoroethylene felt pledgets. A 22-Fr chest tube was placed in the thoracic cavity. RESULTS Operative and postoperative courses were uncomplicated. The patient was discharged on postoperative day 4. Pathology confirmed metastatic clear cell renal cell carcinoma in both the left adrenal and the right lung nodules with negative surgical margins. CONCLUSION The case described here highlights the surgical technique and ideal patient population in which RATTA serves as a feasible and safe alternative to conventional laparoscopic approaches in the treatment of adrenal pathologies.

MP55-06 PRE-OPERATIVE PREDICTORS OF INCIDENTAL PT3A UPSTAGING FOLLOWING PARTIAL NEPHRECTOMY FOR CLINICAL T1 RENAL CELL CARCINOMA

multi-center study and compared to radical nephrectomy (RN) performed in the same centers for tumors of comparable diameter and VTT. Demographics, perioperative complications, functional, and oncologic outcomes were compared between the two groups. Mean, median, standard deviation, and interquartile range (IQR) were used to report continuous variables, as appropriate. Survival analysis were used to assess recurrence free survival (RFS), cancer specific survival (CSS) and overall survival (OS). Univariable (UVA) and multivariable (MVA) analyses were used to evaluate variables predicting complications, OS, CSS and RFS, and end-stage renal disease (ESRD, eGFR<30). RESULTS: Overall, 63 cases and 176 control were enrolled in the study. VTT was unsuspected pre-operatively in 46 (73%) of PN cases. Any grade and high grade postoperative complications were recorded in 41.9% and 22.2% for PN patients, respectively, and in 21.7% and 7.9% for RN patients, respectively (p values <0.05). Once adjusted for covariates, PN was associated with a significantly higher risk of any grade postoperative complications (OR 0.4; p1⁄40.026), whereas only a non-significant trend was identified for high grade complications (OR 0.3; p1⁄40.05). Median followup duration of the patients alive and disease free was 26.6 mo (IQR 8.7-39 mo) and 30 mo (IQR 13 64 mo) in the PN and RN group, respectively (p1⁄40.5). The two-year RFS, CSS and OS survival estimates were 91.8%, 94.0%, 88.1%, for PN, respectively, and 95.8%, 94.6%, 92.9% for RN, respectively. PN site of recurrence were: local in 3 (4,9%), nodal in 3 (4,9%) and distant in 11 (18%). No differences in RFS, CSS and OS survival estimates were found between PN and RN, both in UVA and MVA analyses, where only the classic pathological variables were independent predictors of RFS, CSS, and OS. Preoperative eGFR was similar in both groups, with roughly 3% of the patients presenting with ESRD at initial diagnosis. At follow-up, eGFR was similar in both groups, whereas the prevalence of ESRD was significantly higher in the PN group (32.7% vs 13.2%, p<0.01). However, in MVA analyses, baseline eGFR was the only independent predictor of ESRD (HR 1.0; p<0.01), whereas only a non-significant trend was identified for the type of surgery (HR 0.5; p1⁄40.07). CONCLUSIONS: PN in tumors with concomitant intraparenchymal vein branches thrombosis is feasible but it is associated with higher risk of complications. RFS, CSS and OS were similar in the two groups. Finally, we found a non-statistically significant trend in favor of PN for ESRD prevention.

MP08-12 MULTI-INSTITUTIONAL EVALUATION OF MRI AND FUSION BIOPSY IN CONFIRMATORY BIOPSY FOR ACTIVE SURVEILLANCE

INTRODUCTION AND OBJECTIVES: To provide standardization as prostate MRI becomes increasingly utilized, the Prostate Imaging-Reporting and Data System (PIRADS) was developed and has been modified to its latest version (v2). Using biopsy outcome as the standard, we examined the predictive accuracy of a PIRADS 4 or 5 read for clinically significant (Gleason 7+) PCa in a blinded fashion. METHODS: We reviewed our prospectively maintained database of consecutive men who underwent prostate MRI prior to biopsy between September 2014 and December 2015. A proportionally representative sample (based on the original clinical PIRADS v2 interpretation) was selected for re-examination (n1⁄432). The prostate MRIs for these patients were de-identified and were loaded by a blinded third party. Four radiologists of varying levels of experience independently interpreted all prostate MRI, blinded to all clinical information. An 00overread00 was defined as a PIRADS 4 or 5 read with biopsy result of benign prostate or Gleason 6 PCa. An 00under-read00 was defined as a PIRADS 1-3 read with resulting biopsy result of Gleason 7+ PCa. RESULTS: The distribution of accuracy is provided in Table 1. Accurate interpretation ranged from 56% (18/32) to 75% (24/32), and the differences among the radiologists were not significant (p1⁄40.48). The improvement of accuracy with a 00majority read00, as defined by two or more accurate radiologists0 blinded interpretations, over the original clinical read trends toward significance (p1⁄40.16). No clinical variable was predictive of an incorrect 00majority read00, including age, PSA, family history, use of 5-alpha reductase inhibitors, prostate volume, or previous biopsy history. CONCLUSIONS: In a blinded assessment of radiologists at our institution, we find that the predictive accuracy of PIRADS 4 or 5 for clinically significant PCa varies among radiologists independent of experience level. A 00majority read00 performed better than the original clinical interpretation, suggesting that consensus interpretation of prostate MRI may improve predictive accuracy.

PD07-03 MICHIGAN PROSTATE SCORE (MIPS): AN ANALYSIS OF A NOVEL URINARY BIOMARKER PANEL FOR THE PREDICTION OF PROSTATE CANCER AND ITS IMPACT ON BIOPSY RATES

INTRODUCTION AND OBJECTIVES: The Michigan Prostate Score (MiPS) is a validated and commercially available early detection test for prostate cancer combining serum PSA with urinary PCA3 and T2:ERG expression. This novel biomarker reports individual patient risk estimates for biopsy detection of any MiPS and of high-grade (Gleason score >6) prostate cancer HG MiPS. We investigated the impact of MiPS on clinical decision-making and prostate biopsy frequency rates and correlated MiPS and HG MiPS with final biopsy pathology results. METHODS: MiPS testing was offered to men referred for initial or repeat prostate biopsy at a single, tertiary institution as an alternative to proceeding directly to a biopsy between October 2013 and January 2015. Patient characteristics, PSA, PCA3, T2:ERG, and biopsy pathology were analyzed to see how MiPS and HG MiPS risk prediction models affected the decision for prostate biopsy as well as biopsy pathology. One-way ANOVA was used to correlate MiPS scores with biopsy rates and clinical outcomes. RESULTS: 149 men underwent MiPS testing, of whom 67.8% had not undergone a prior prostate biopsy. Median age was 65.2, and median PSA was 9.5 ng/ml. The mean predicted risks for detection of any and high-grade cancer were 41.5% and 26.0%, respectively. The 73 men (49%) who proceeded to prostate needle biopsy had higher MiPS (52.7% vs. 30.7%, p<0.001) and HG MiPS scores (35.2% vs. 18.2%, p<0.001) than those who did not undergo biopsy. Among those biopsied, MiPS, HG MiPS, PCA3, and T2:ERG were significantly higher in those with cancer (all p<0.05) found on biopsy. PSA alone was not associated with cancer diagnosis (p1⁄40.82). CONCLUSIONS: The combination of urinary PCA3 and T2:ERG in a test panel for prostate cancer reduced the use of prostate biopsy by 51% among men referred for prostate biopsy. MiPS and MiPS HG were closely correlated with the presence of any cancer and highgrade cancer, respectively. These findings support the clinical utility and validity of MiPS for stratifying prostate cancer risk and guiding high-yield biopsy utilization.

V6-06 ROBOTIC-ASSISTED THORACOSCOPIC TRANSDIAPHRAGMATIC ADRENALECTOMY: A NOVEL SURGICAL APPROACH

INTRODUCTION AND OBJECTIVES: Early allograft dysfunction (EAD) can be caused by a number of technical factors including vascular complications such as thrombosis and kinking. Retroperitoneal compartment syndrome (RACS) is an under-recognized vascular cause of EAD with potentially devastating consequences, and may even result in a lost graft. The graft can be salvaged with early recognition and intervention through a mesh hood fascial closure (MHFC) technique. METHODS: Here we describe, in video, a 23-years-old male recipient diagnosed with renal failure secondary to chronic reflux. He has a 6months history of peritoneal dialysis and is currently on hemodialysis. The patient received an anonymous living-donor right kidney from our paired exchange program. His BMI is 22. The graft had a single renal artery and single renal vein. A standard anastomosis was performed and subsequent urine output was brisk. The fascia was closed without tension. However, urine production ceased after the fascia was fully closed. A case of RACS was suspected and intraoperative Doppler ultrasound showed no blood flow in the graft. Immediately re-exploration revealed the graft to be abnormal in color and turgor. RESULTS: These abnormalities resolved after pressure was relieved. The kidney was then placed in the optimal position within the iliac fossa and a large ellipsoid piece of polypropylene mesh was draped loosely and without tension over the graft. The mesh was attached to the posterior fascial edges using interrupted #1 polypropylene sutures. Skin closure then was completed over a closed suction drain placed in the retroperitoneal space lateral to the kidney. Doppler ultrasound after skin closure showed good flow and the postoperative course was unremarkable. CONCLUSIONS: RACS could be associated with small android pelvis and lack of compliance in the retroperitoneal cavity secondary to peritoneal dialysis. Suspected RACS require prompt intervention to prevent irreversible graft dysfunction. We have shown that MHFC is an effective and safe method to treat EAD secondary to RACS.

Using Imaging to Predict Treatment Response in Genitourinary Malignancies

CONTEXT Over the previous2 decades, there have been numerous advancements in the diagnostic evaluation, therapeutic management, and postoperative assessment of genitourinary malignancies. OBJECTIVE To present a review of current and novel imaging modalities and their utility in the assessment of therapeutic response in the systemic management of renal, testicular, and prostate cancers. EVIDENCE ACQUISITION A PubMed/Medline search of the current published literature inclusive of prospective and retrospective original research, systematic reviews, and meta-analyses was conducted evaluating imaging modalities for renal cell carcinoma, prostate cancer, and testicular cancer. All relevant literature was individually reviewed and summarized to provide a concise description of the currently available imaging modalities and their efficacy in assessing treatment response of the genitourinary malignancies targeted in this review. EVIDENCE SYNTHESIS Conventional imaging techniques play a pivotal role in predicting the treatment response of genitourinary malignancies and have, therefore, been incorporated into clinical guidelines. Advancements in imaging technology have led to increased utilization for prognostication of a genitourinary cancers response to therapy. CONCLUSIONS A good understanding of current recommended imaging techniques to evaluate treatment response in genitourinary malignancies is of paramount importance for todays clinician, who faces increasing treatment modalities. PATIENT SUMMARY In this review, we summarize available imaging modalities in the evaluation of treatment response in kidney, prostate, or testicular tumors. We believe that a good understanding of current imaging modalities is of paramount importance for healthcare providers treating these cancers.