Avinash Chennamsetty

Electrosurgical Management of Hunner Ulcers in a Referral Center's Interstitial Cystitis Population

OBJECTIVEnTo characterize electrocautery (EC) as a valid treatment option in interstitial cystitis (IC) patients with Hunner ulcers (HUs).nnnMETHODSnFrom 1997 to 2013, a single urologists IC population was retrospectively reviewed to identify HU patients as well as their demographics, operative characteristics, and response to a 2-page questionnaire evaluating parameters of their experience with EC. Descriptive statistics, Pearson chi-square test, Student t test, and Pearson coefficient were used.nnnRESULTSnTwo hundred fourteen EC procedures were performed in 76 patients (87% women; mean age, 66 ± 1.67 years). Fifty-one patients (69%) who underwent multiple EC had mean initial bladder capacity of 438.62 ± 27.90 mL and final bladder capacity of 422.40 ± 30.10 mL. Mean number of EC procedures was 2.98 ± 0.25 (range, 1-11). Mean time between sessions was 14.52 ± 1.34 months (range, 1-121 months). Fifty-two patients (68%) completed our questionnaire, with 13.54 ± 1.28 years of symptoms and 10.66 ± 0.96 years since diagnosis. Ranking IC treatments, 37 patients (84%) reported EC most beneficial. On a 0-10 (none to worst possible) scale before and after EC, frequency improved from 9.04 ± 1.30 to 3.65 ± 2.75 (P <.001), urgency from 8.40 ± 2.38 to 3.28 ± 2.71 (P <.001), and pain from 8.62 ± 2.36 to 2.68 ± 2.55 (P <.001). Overall, 89.6% of patients noted some degree of symptom improvement after EC; 56.3% of patients had marked improvement. A total of 98% of patients would undergo EC again.nnnCONCLUSIONnEC of HU is an effective and safe procedure with high patient satisfaction that does not diminish bladder capacity.

Contemporary diagnosis and management of Fournier's gangrene.

Fournier’s gangrene, an obliterative endarteritis of the subcutaneous arteries resulting in gangrene of the overlying skin, is a rare but severe infective necrotizing fasciitis of the external genitalia. Mainly associated with men and those over the age of 50, Fournier’s gangrene has been shown to have a predilection for patients with diabetes as well as people who are long-term alcohol misusers. The nidus for the synergistic polymicrobial infection is usually located in the genitourinary tract, lower gastointestinal tract or skin. Early diagnosis remains imperative as rapid progression of the gangrene can lead to multiorgan failure and death. The diagnosis is often made clinically, although radiography can be helpful when the diagnosis or the extent of the disease is difficult to discern. The Laboratory Risk Indicator for Necrotizing Fasciitis score can be used to stratify patients into low, moderate or high risk and the Fournier’s Gangrene Severity Index (FGSI) can also be used to determine the severity and prognosis of Fournier’s gangrene. Mainstays of treatment include rapid and aggressive surgical debridement of necrotized tissue, hemodynamic support with urgent resuscitation with fluids, and broad-spectrum parental antibiotics. After initial radical debridement, open wounds are generally managed with sterile dressings and negative-pressure wound therapy. In cases of severe perineal involvement, colostomy has been used for fecal diversion or alternatively, the Flexi-Seal Fecal Management System can be utilized to prevent fecal contamination of the wound. After extensive debridement, many patients sustain significant defects of the skin and soft tissue, creating a need for reconstructive surgery for satisfactory functional and cosmetic results.

Predictors of Incisional Hernia after Robotic Assisted Radical Prostatectomy

Introduction. To explore the long term incidence and predictors of incisional hernia in patients that had RARP. Methods. All patients who underwent RARP between 2003 and 2012 were mailed a survey reviewing hernia type, location, and repair. Results. Of 577 patients, 48 (8.3%) had a hernia at an incisional site (35 men had umbilical), diagnosed at (median) 1.2 years after RARP (mean follow-up of 5.05 years). No statistically significant differences were found in preoperative diabetes, smoking, pathological stage, age, intraoperative/postoperative complications, operative time, blood loss, BMI, and drain type between patients with and without incisional hernias. Incisional hernia patients had larger median prostate weight (45 versus 38 grams; P = 0.001) and a higher proportion had prior laparoscopic cholecystectomy (12.5% (6/48) versus 4.6% (22/480); P = 0.033). Overall, 4% (23/577) of patients underwent surgical repair of 24 incisional hernias, 22 umbilical and 2 other port site hernias. Conclusion. Incisional hernia is a known complication of RARP and may be associated with a larger prostate weight and history of prior laparoscopic cholecystectomy. There is concern about the underreporting of incisional hernia after RARP, as it is a complication often requiring surgical revision and is of significance for patient counseling before surgery.

Treatment of Urethral Strictures from Irradiation and Other Nonsurgical Forms of Pelvic Cancer Treatment

Radiation therapy (RT), external beam radiation therapy (EBRT), brachytherapy (BT), photon beam therapy (PBT), high intensity focused ultrasound (HIFU), and cryotherapy are noninvasive treatment options for pelvic malignancies and prostate cancer. Though effective in treating cancer, urethral stricture disease is an underrecognized and poorly reported sequela of these treatment modalities. Studies estimate the incidence of stricture from BT to be 1.8%, EBRT 1.7%, combined EBRT and BT 5.2%, and cryotherapy 2.5%. Radiation effects on the genitourinary system can manifest early or months to years after treatment with the onus being on the clinician to investigate and rule-out stricture disease as an underlying etiology for lower urinary tract symptoms. Obliterative endarteritis resulting in ischemia and fibrosis of the irradiated tissue complicates treatment strategies, which include urethral dilation, direct-vision internal urethrotomy (DVIU), urethral stents, and urethroplasty. Failure rates for dilation and DVIU are exceedingly high with several studies indicating that urethroplasty is the most definitive and durable treatment modality for patients with radiation-induced stricture disease. However, a detailed discussion should be offered regarding development or worsening of incontinence after treatment with urethroplasty. Further studies are required to assess the nature and treatment of cryotherapy and HIFU-induced strictures.

Office-Based Ultrasound Guided Renal Core Biopsy is Safe and Efficacious in the Management of Small Renal Masses.

OBJECTIVEnTo evaluate the safety and efficacy of ultrasound (US)-guided percutaneous renal mass biopsy (RMB) performed in the office setting by urologists.nnnMATERIALS AND METHODSnThis is a retrospective study involving patients who underwent office-based US-guided percutaneous RMB between April 2010 and October 2015. Baseline vital signs and US were performed prior to the procedure. Patients were then observed for 1xa0hour after the procedure and repeat vital signs and US were performed. Hemodynamically stable patients who did not develop hematoma were discharged.nnnRESULTSnIn 108 patients, 70 (64.8%) were male, median age was 69.5 years, and median mass size was 3.3u2009cm (interquartile range: 2.5-4.6). Biopsy yield was as follows: 72 (66.7%) had renal cell carcinoma, 14 (13.0%) had benign renal parenchyma, 11 (10.2%) had oncocytoma, 6 (5.6%) had angiomyolipoma, 2 (1.9%) had lymphoma, and 3 (2.8%) had other disease. The initial nondiagnostic rate was 14 of 108 (13.0%). There were 28 of 108 (25.9%) patients observed whereas 79 of 108 (73.2%) received surgery or ablative therapy. Final pathology was concordant with biopsy results in 66 of 68 (97.1%) cases. Three patients experienced a grade I Clavien-Dindo surgical complication, all of which were managed conservatively.nnnCONCLUSIONnOffice-based US-guided RMB is safe and efficacious in the management of appropriately selected SRM. It potentially offers improved dynamic characterization of solid renal mass, greater convenience to patients, as well as cost savings. Further studies are needed to evaluate this promising technique.

Advances in diagnosis and treatment of interstitial cystitis/painful bladder syndrome.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a prevalent chronic condition that can be challenging not only to diagnose but also to treat. We review recent diagnostic markers and therapies for IC/BPS from non-medication-based therapies, oral therapies, intravesical therapies, and surgical treatments.

Removal of a Penile Constriction Device with a Large Orthopedic Pin Cutter

Penile strangulation is an infrequent clinical condition that has widely been reported. It usually results following placement of a constriction device to enhance sexual stimulation. Early treatment is essential to avoid potential complications, including ischemic necrosis and autoamputation. We describe the use of a Large Orthopedic Pin Cutter to remove a metal penile constriction device in the Emergency Department (ED). This case report describes the relatively safe technique of using an instrument available in many hospitals that can be added to the physicians arsenal in the removal of metal constriction devices.

MP64-07 LYMPH NODE YIELD AND POSITIVITY RATE BY LOCATION IN 1000 ROBOTIC PROSTATECTOMY PATIENTS THAT UNDERWENT EXTENDED PELVIC LYMPH NODE DISSECTIONS AT A SINGLE INSTITUTION

INTRODUCTION AND OBJECTIVES: The current evidence for lymphadenectomy (LND) at the time of radical prostatectomy (RP) for Gleason 7 intermediate-risk prostate cancer (PCa) is not as robust as for high-risk prostate cancer. Current guidelines defer to various nomograms regarding the risk of lymph node involvement to dictate the need for LND. The objective of this study was to examine utilization trends and survival data for patients who underwent LND for Gleason 7 PCa. METHODS: The SEER database was queried for all patients with either Gleason 3+4 (G34) or 4+3 (G43) PCa from 2004-2013, limited to patients with no evidence of metastatic disease or prior radiotherapy. Distributions and trends of LND, cancer-specific survival (CSS) and overall-survival (OS) were calculated. Memorial-Sloan Kettering Cancer Center (MSKCC) nomogram was applied to stratify patients based on risk of nodal disease at time of RP (<5% risk or >5% risk). Finally, multivariate logistic regression analyses (MVA) were performed to determine covariates associated with the likelihood of receiving LND. RESULTS: A total of 78641 patients with either G34 or G43 PCa underwent RP (59194 and 19447, respectively) with mean followup of 57.9 months. Of these patients, 61.2% of G34 and 73.5% of G43 patients underwent LND. During this time, the proportion of G43 patients undergoing LND remained relatively stable. The proportion of G34 patients undergoing LND varied between 55.9% in 2008 and 67.9% in 2013 despite decreasing RP rates in that same time frame. On MVA, the primary contributor to the variability in LND completion was socioeconomic status (SES): patients with higher SES were less likely to receive LND when indicated (OR 0.82, p < 0.05) and more likely to receive LND when not indicated (OR 1.15, p < 0.05). Age, race and insurance status were not significant predictors of LND. The incidence of pN+ disease was 1.5% and 5.2% in the <5% and >5% risk groups, respectively. Completion of LND at time of RP did not significantly change CSS in patients with G34 PCa (99.50% with LND and 99.59% without LND, p 1⁄4 0.14.) In G43 patients, however, CSS was better in patients who did not undergo LND (98.81% with LND and 99.33% without LND, p 1⁄4 0.002), the difference primarily driven by pN1 patients. CONCLUSIONS: The role of LND for Gleason 7 prostate adenocarcinoma is not yet standardized, as indicated by the variability of LND dissection rates over an 11-year period in the United States. SES was the primary predictor of LND completion at time of RP. As CSS was not affected by completion of LND for G34 PCa, further evaluation of oncologic benefit in this patient population is warranted.

MP03-16 UTILITY OF MULTI-PARAMETRIC MRI/ULTRASOUND FUSION: COGNITIVE NOT INFERIOR TO TARGETED SOFTWARE-BASED PROSTATE BIOPSIES

INTRODUCTION AND OBJECTIVES: Prostate cancer (PCa) remains the only solid organ tumor that is diagnosed by a non-targeted sampling method. Recently, multi-parametric MRI (MP-MRI) in conjunction with an MRIultrasound (US) fusion guided biopsy (bx) has demonstrated improved PCa detection. Unfortunately, this technology has been limited to tertiary care centers. Therefore, we sought to compare cognitive versus targeted software to assess the ability of cognitive registration to disseminate more readily into the community. METHODS: Consecutive patients underwent an MRI-US fusion prostate bx for elevated PSA, abnormal DRE, active surveillance or prior negative bx with a persistently elevated PSA. All subjects underwent pre-bx MP-MRI and lesions visible on MRI were graded using the PI-RADS version 2 classification system. The UroNav bx tracking system was used to fuse the stored MR images with real-time US generating a 3D model, which was then used to sequentially perform cognitive, targeted, and standard 12 core systematic biopsies in an office setting under local anesthesia. Descriptive statistics included patient characteristics and univariate analysis was done using logistic regression analysis to detect the associations between presence of cancer, clinically significant cancer, demographic variables, and bx method. Signed rank test was used for paired comparisons amongst bx method. RESULTS: 44 patients (median age 66 yrs, median PSA 6.4) underwent an MRI-US fusion bx between July 2014 and October 2015 with an overall CDR of 59%. Cognitive CDR was 40.9% with 25% being clinical significant disease. The targeted CDR was 27.3% with 22.7% being clinically significant disease. Overall, the cognitive approach had a sensitivity of 69.2% (95% CI: 50%, 88%) whereas the targeted approach had sensitivity of 46.2% (95% CI: 26%, 67%). Furthermore, the targeted approach missed 8 cancers when compared to the cognitive approach, whereas, the cognitive approach missed 2 cancer when compared to the targeted approach. The difference in sensitivity is most pronounced when comparing standard and targeted methods (p1⁄40.02) and approaches significance when comparing cognitive and targeted methods (p1⁄40.11). CONCLUSIONS: MRI-US fusion targeted software when compared to the cognitive platform, was not found to have higher cancer detection rate nor sensitivity. We believe this highlights the importance of the MRI itself, rather than the platform used.