Anthony Corcoran

Nephron-sparing management vs radical nephroureterectomy for low- or moderate-grade, low-stage upper tract urothelial carcinoma

To compare overall and cancer‐specific outcomes between patients with upper tract urothelial carcinoma (UTUC) managed with either radical nephroureterectomy (RNU) or nephron‐sparing measures (NSM) using a large population‐based dataset.

Active surveillance of small renal masses

The increased diagnosis of small renal masses (SRMs) poses the challenge of how best to manage patients with tumours that are not likely to progress and cause death during their lifetime. Concerns regarding overdiagnosis and overtreatment of patients with low-risk or indolent disease has led to the introduction of active surveillance as an alternative to immediate intervention in select candidates. However, differentiating between benign or low-grade lesions and high-grade aggressive phenotypes is difficult. Renal biopsy, radiographic assessment, and clinical nomograms have been used before surgery to evaluate the probability of whether an SRM will exhibit characteristics of an aggressive cancer. SRM growth trends have been studied over periods of observation but no characteristics have been found to correlate with aggressive growth kinetics. Stratification of patients with SRMs according to risk status is crucial when considering whether active surveillance might be an appropriate treatment option. Factors that should be taken into account include comorbidities, a history of malignancy, pre-existing chronic kidney disease, life expectancy and patient preference. Standardized active surveillance protocols are currently lacking, and clinical trials designed to randomize patients with SRMs to receive either active surveillance or immediate treatment are sorely needed to address the existing evidence gap.

When is Prior Ureteral Stent Placement Necessary to Access the Upper Urinary Tract in Prepubertal Children

PURPOSE We studied the possibility that age, height, weight and body mass index could be used to predict the likelihood of successful ureteroscopic access to the upper urinary tract without previous stent placement in prepubertal children. MATERIALS AND METHODS We retrospectively reviewed all ureteroscopic procedures for upper tract calculi in prepubertal children from 2003 to 2007. We compared age, height, weight and body mass index in patients who underwent successful primary flexible ureteroscopic access and in those who required initial stent placement to perform ureteroscopy. RESULTS Successful primary ureteroscopic access to the upper tract was achieved in 18 of 30 patients (60%). There was no difference in mean age (9.9 vs 9.5 years, p = 0.8), height (132 vs 128 cm, p = 0.6), weight (37 vs 36 kg, p = 0.86) or body mass index (19.3 vs 20.5 kg/m(2), p = 0.55) between patients with successful vs unsuccessful upper tract access. Locations that prevented access to the upper urinary tract were evenly distributed among the ureteral orifice, iliac vessels and ureteropelvic junction. CONCLUSIONS Age, height, weight and body mass index could not predict the likelihood of successful ureteroscopic access to the upper tract. Placement of a ureteral stent for passive ureteral dilation is not necessary for successful ureteroscopic access to the renal pelvis in prepubertal children. An initial attempt at ureteroscopy, with placement of a ureteral stent if upper tract access is unsuccessful, decreases the number of procedures while maintaining a low complication rate.

Management of Benign Ureteral Strictures in the Endoscopic Era

BACKGROUND AND PURPOSE During the past decade, endoscopic management has emerged as the first-line treatment of benign ureteral strictures. We reviewed our experience with the management of benign ureteral strictures to determine the success rate of endoscopic surgery in a contemporary series and assessed the viability of surgical reimplantation in the modern era. PATIENTS AND METHODS We identified 75 patients with a diagnosis of ureteral stricture between 2000 and 2005 via electronic medical records search and excluded those with completely obliterated, external compressive, malignant, or ureteroenteric strictures, ureteropelvic junction obstruction, and those with follow-up less than 2 months. RESULTS Thirty-four patients who were treated endoscopically (balloon dilation and/or holmium laser endoureterotomy) were identified. Mean stricture length in each patient was 1.6 +/- 1 cm (range 0.5-4 cm), and the mean number of procedures per patient was 1.7 +/- 0.8. Endoscopic success was achieved in 29 (85%), while 5 (15%) patients experienced endoscopic management failure and ultimately needed ureteral reimplantation. When comparing the endoscopically treated and reimplant groups, there was no significant difference in mean stricture length (1.38 +/- 1.13 vs 2 +/- 1.1 cm, P = 0.14), yet mean number of procedures performed (1.41 +/- 0.85 vs 3.6 +/- 1.5; P = 0.002) reached statistical significance. There were no clinical or radiographic signs of obstruction in 100% of patients who received endoscopic therapy only and 100% of patients who needed open surgical management at a mean follow-up of 25.2 +/- 19.3 and 7.7 +/- 3.2 months, respectively. CONCLUSIONS Endoscopic surgery is clearly a successful primary treatment modality in the management of benign ureteral strictures with minimal morbidity. In the modern era of endoscopic surgery, however, ureteral reimplantation remains a viable option in treating the small subset of patients with benign ureteral strictures for whom endoscopic management fails.

Effects of Focal Versus Total Cryotherapy and Minimum Tumor Temperature on Patient-Reported Quality of Life as Compared to Active Surveillance in Prostate Cancer Patients

OBJECTIVE To investigate the effects of focal (hemiablation) or total cryotherapy and minimum tumor temperature on patient-reported quality of life (QoL) in patients with prostate cancer. METHODS An Institutional Review Board-approved database was reviewed for patients who underwent cryotherapy or active surveillance (AS). QoL questionnaire responses were collected and scores were analyzed for differences between focal and total cryotherapy and between very cold (<-76°C) and moderate-cold (≥-76°C) minimum tumor temperatures. RESULTS A total of 197 patients responded to a total of 547 questionnaires. Focal and total cryotherapy patients had initially lower sexual function scores relative to AS (year 1 mean difference focal: -31.7, P <.001; total: -48.1, P <.001). Focal cryotherapy was associated with a more rapid improvement in sexual function. Both focal and total cryotherapy sexual function scores were not statistically significantly different from the AS cohort by postprocedural year 4. Very cold and moderate-cold temperatures led to initially lower sexual function scores relative to AS (year 1 very cold: -38.1, P <.001; moderate-cold: -30.7, P <.001). Moderate-cold temperature scores improved more rapidly than those of very cold temperature. Neither very cold nor moderate-cold temperatures had a statistically significant difference in sexual function scores relative to AS by postprocedural year 4. Urinary function and bowel habits were not significantly different between focal and total cryotherapy and between very cold and moderate-cold temperature groups. CONCLUSION Focal cryotherapy and moderate-cold (≥-76°C) temperature were associated with favorable sexual function relative to total cryotherapy and very cold temperature, respectively. No significant differences in urinary function or bowel habits were observed between groups.

Patient-reported quality of life progression in men with prostate cancer following primary cryotherapy, cyberknife, or active holistic surveillance

BackgroundTechnological advancements have led to the success of minimally invasive treatment modalities for prostate cancer such as CyberKnife and Cryotherapy. Here, we investigate patient-reported urinary function, bowel habits, and sexual function in patients following CyberKnife (CK) or Cryotherapy treatment, and compare them with active holistic surveillance (AHS) patients.MethodsAn IRB-approved institutional database was retrospectively reviewed for patients who underwent CK, Cryotherapy, or AHS. Quality of life (QoL) survey responses were collected every three months and the mean function scores were analyzed in yearly intervals over the 4 years post-treatment.Results279 patients (767 survey sets) were included in the study. There was no difference among groups in urinary function scores. The CyberKnife group had significantly lower bowel habit scores in the early years following treatment (year 2 mean difference: −5.4, P < 0.01) but returned to AHS level scores by year 4. Cryotherapy patients exhibited initially lower, but not statistically significant, bowel function scores, which then improved and approached those of AHS. Both CyberKnife (year 1 mean difference: −26.7, P < 0.001) and Cryotherapy groups (−35.4, P < 0.001) had early lower sexual function scores relative to AHS, but then gradually improved and were not significantly different from AHS by the third year post-treatment. A history of hormonal therapy was associated with a lower sexual function scores relative to those patients who did not receive hormones in both CyberKnife (−18.45, P < 0.01) and Cryotherapy patients (−14.6, P < 0.05).ConclusionsAfter initial lower bowel habits and sexual function scores, CyberKnife or Cryotherapy-treated patients had no significant difference in QoL relative to AHS patients. These results highlight the benefit of CyberKnife and Cryotherapy in the management of organ-confined prostate cancer.

PD36-09 INSTITUTIONAL VOLUME IS ASSOCIATED WITH REDUCED 90 DAY MORTALITY RATES FOR BOTH OPEN AND ROBOTIC RADICAL CYSTECTOMY

The association between PBT and oncological outcomes, as well as OCM was assessed using Cox and logistic regression analyses. Imbalances in clinicopathological features of patients receiving PBT vs. patients not receiving PBT were mitigated using conventional adjusting as well as inverse probability of treatment weighting (IPTW). RESULTS: The final population consisted of 525 patients with a median follow-up of 26 months (IQR: 21-30 months) of whom 275 patients (52.4%) received PBT. The two groups (PBT vs. no PBT) differed significantly with respect to most clinicopathological features including perioperative blood loss (median: 1000ml; IQR: 650-1600ml vs. median: 570ml; IQR: 400-800ml). Independent predictors of receipt of PBT in multivariate logistic regression analysis were sex (odds ratio (OR)1⁄44.66; 95% confidence interval (CI)1⁄4[2.34-9.29]; p<0.001), body mass index (OR1⁄40.92; 95% CI1⁄4[0.87-0.97]; p1⁄40.003), type of urinary diversion (OR1⁄40.40; 95% CI1⁄4[0.22-0.75]; p1⁄40.004), estimated blood loss (OR1⁄41.29; 95% CI1⁄4 [1.21-1.39]; p<0.001), and any complication within 30 days (OR1⁄43.00; 95% CI1⁄4[1.75-5.15]; p<0.001). Unweighted and unadjusted survival analyses revealed a significant increase in cumulative incidences of CSM and OCM in the two groups (p1⁄40.017 and p<0.001, respectively). After IPTW-adjustment, those differences no longer held true. PBT was not associated with RFS (HR1⁄40.92; 95% CI1⁄4[0.53-1.59]; p1⁄40.76), OS (HR1⁄41.07; 95% CI1⁄4[0.56-2.04]; p1⁄40.84), CSM (sub-HR1⁄41.09; 95% CI1⁄4[0.62-1.93]; p1⁄40.76) and OCM (sub-HR1⁄41.02; 95% CI1⁄4[0.27-3.84]; p1⁄40.95) in IPTW-adjusted Cox regression and competing-risks regression analyses. The same held true in conventional multivariate Cox and competing-risks regression analyses, where pathological tumor stage and lymphovascular invasion were the only independent predictors of CSM (HR1⁄43.71, 95% CI1⁄4[2.06-6.68], p<0.001 and HR1⁄42.49, 95% CI1⁄4 [1.43-4.33], p<0.001) aswell as disease recurrence (HR1⁄44.48, 95%CI1⁄4 [2.45-8.16], p<0.001 and HR1⁄42.76, 95% CI1⁄4[1.56-4.87], p<0.001). CONCLUSIONS: This study could not determine an adverse impact of PBT on oncological outcome and overall survival after adjusting for differences in patient characteristics.

MP70-04 3-T MULTIPARAMETRIC MRI CHARACTERISTICS OF PROSTATE CANCER PATIENTS SUSPICIOUS FOR BIOCHEMICAL RECURRENCE AFTER PRIMARY FOCAL CRYOSURGERY.

Source of Funding: This research was made possible through the NIH Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and generous contributions to the Foundation for the NIH by the Doris Duke Charitable Foundation (Grant #2014194), the American Association for Dental Research, the Colgate-Palmolive Company, Genentech, and other private donors. For a complete list, visit the foundation website at http://www.fnih. org.

PD56-09 PSA TRENDS FOLLOWING PRIMARY FOCAL CRYOSURGERY FOR EARLY STAGE PROSTATE CANCER

METHODS: Participants were eligible when diagnosed with intermediate risk, unilateral clinically significant localised prostate cancer, fit for either RP or PA. Pre-biopsy mpMRI and targeted biopsy or template guided biopsies were compulsory before randomization to either RP or PA. Target accrual for the feasibility phase was 80 patients over 18 months. Follow-up involved regular PSA measurements and, in the focal therapy arm, mpMRI and targeted biopsies of any suspicious areas. Quality of life data were measured at six weeks and three monthly intervals. RESULTS: The table below summarises recruitment data. Baseline demographics of men randomised to date are Mean age: 66.7yrs (48.4-78.2); BMI: 26.4 (22.0-32.3); PSA: 7.60 (2.5-16.20) and Gleason score: 3+41⁄47 75.6%, 4+31⁄47 24.4%. CONCLUSIONS: A randomised controlled trial of partial ablation of the prostate versus radical treatment with surgery is feasible. The full trial is being developed, and will provide key data to inform men when making the treatment decision for intermediate risk unilateral prostate cancer.

MP70-09 PREDICTORS OF BIOCHEMICAL RECURRENCE AFTER PRIMARY FOCAL CRYOTHERAPY FOR LOCALIZED PROSTATE CANCER: A MULTI-INSTITUTIONAL ANALYTIC COMPARISON OF THE PHOENIX AND STUTTGART CRITERIA

INTRODUCTION AND OBJECTIVES: The Phoenix (PD) and Stuttgart definitions (SD) are used to define biochemical recurrence (BCR) in patients after radiotherapy and High Intensity Focused Ultrasound treatment of organ-confined prostate cancer (PCa) respectively. However, these definitions have also been applied to follow patients who have undergone cryosurgery. We sought to identify predictors of BCR using the PD and SD criteria and evaluate each criterion0s ability to predict biopsy-proven recurrence in primary focal cryosurgery (PFC) patients. METHODS: We performed a retrospective review of patients who underwent PFC at two tertiary care centers. Patients were followed with serial prostate specific antigen (PSA) tests. PSA levels, preand post-PFC biopsy Gleason scores, number of positive cores, and BCR (defined as: PD 1⁄4 [PSA nadir + 2 ng/mL] and SD 1⁄4 [PSA nadir + 1.2 ng/ mL]) were recorded. Patients who experienced BCR were biopsied, monitored carefully or treated at the discretion of the treating urologist. Cox proportional regression and survival analyses were performed to assess time to BCR using the PD and SD criteria. RESULTS: Of 162 patients included [median (range) follow up: 36.6 (2.8-109.4) months] in the study, 64 (39.5%) and 98 (60.5%) experienced BCR based on PD and SD, respectively. On multivariate Cox regression analysis, the number of positive pre-PFC biopsy cores was an independent predictor of both PD (Hazard Ratio [HR]: 1.4, p1⁄40.001) and SD (HR: 1.3, p1⁄40.006) BCRs. Post-PFC PSA nadir was an independent predictor of BCR using the PD (HR: 2.2, p1⁄40.024) but not SD (HR: 1.4, p1⁄40.181) BCR. Survival analysis showed a 3-year BCR free survival of 55% and 36% for PD and SD respectively. Of those biopsied after BCR, 14/26 (53.8%) using the PD and 18/35 (51.4%) using the SD were found to have cancer (57.1% PD and 66.7% SD were clinically significant PCa). CONCLUSIONS: Both the PD and the SD showed about a 50% biopsy-proven rate of recurrence after PFC. The number of positive cores on pretreatment biopsy appears to be a significant predictor of failure after PFC. The ideal definition of BCR after PFC remains to be elucidated.