Barbara Ercole

A prospective trial assessing the effects of clamp ischemia during partial nephrectomy on renal function, biomarkers, and structure.

367 Background: Tolerance of the human kidney to clamp ischemia (CI) during partial nephrectomy (PN) has been considered to be limited to 20-30 min. We determined the utility of new biomarkers for following renal injury in this setting. METHODS 40 patients undergoing open PN without ( N=27, avg clamp time 32.3 min, range 15-53 min., 74% > 30 min.) or with cooling ( N=13 avg clamp 48 min. range 30-61 min.) had biopsies of uninvolved areas of the kidney preclamp, during clamping and 5 min. after clamp release, along with serial measurements of standard renal functional parameters plus measurement of serum cystatin C and NGAL, and of urine NGAL, cystatin C, NAG, LFABP, NGAL, KIM-1 and IL-18. RESULTS Serum creatinine transiently increased at 24 hours by 21.9±6.4% after warm CI and 27.2±7.9% after cold CI (Ps < .001), but serum cystatin C did not change and plasma NGAL was minimally affected. Urine biomarkers increased irrespective of whether they were factored for creatinine, with particularly large changes in KIM-1 and LFABP, but did not correlate with duration of CI, the change in creatinine at 24 hours, or the use of cold or warm CI. Ultrastructure and staining for actin, phosphotyrosine, B1 integrin, and ICAM-1 showed changes consistent with CI, but much milder than predicted from animal models. Creatinine has remained stable in the patient cohort at up to 18 months of follow-up. CONCLUSIONS The data indicate that the insult to the clamped kidney from 30-60 minutes of CI under conditions of open partial nephrectomy is well tolerated despite increases of urinary biomarkers, which may in part reflect local effects of the surgery itself, expand indications for PN in the management of renal cancers, and support the use of CI as opposed to more complex procedures for PN.

Preliminary results of perioperative outcomes and oncologic efficacy from a single-institution randomized controlled trial of open versus robotic-assisted radical cystectomy.

305 Background: In the past decade minimally invasive robotic assisted approaches have emerged as a viable option for the treatment of many urologic malignancies. Robotic-assisted radical cystectomy (RARC) for bladder cancer has been reported with the potential for lower blood loss, less transfusion requirement, and shorter hospital stay in prior studies. We present preliminary data from a single institution prospective randomized clinical trial of open radical cystectomy (ORC) versus RARC. METHODS Prospective randomized single institution series evaluating the feasibility of ORC versus RARC for consecutive patients was performed from July 2009 to June 2011. Oncologic efficacy was assessed based on the surrogates of total number of lymph nodes removed and positive surgical margins. Perioperative morbidity was assessed evaluating for estimated blood loss, transfusion requirements, length of stay and perioperative morbidity. RESULTS To date 46 patients have been randomized with data available on 39 patients for analysis. Each group was similar with regards to age, sex, race, BMI, comorbidities, and previous abdominal procedures, operative time, and final pathologic stage. We observed no significant difference between oncologic outcomes of positive surgical margins (5% vs 5.263%, p 0.48) or number of LN removed (11 vs 23, p 0.40) for the RARC versus ORC groups respectively. The RARC group was noted to have decreased estimated blood loss (400 mL vs 800 mL, p 0.008) and a trend towards decreased rate of excessive length of stay (>5 days) (65% vs 84%, p 0.17) for the RARC versus ORC groups. The robotic group had a trend towards decreased rate of transfusion however this was not statistically significant (40% versus 53%, p 0.26). CONCLUSIONS Our preliminary findings from a single institution randomized trial of RARC versus ORC indicates that RARC has equivalent oncologic outcomes as measured by positive surgical margins and total number of lymph node removed. RARC demonstrates Perioperative benefits of decreased blood loss, fewer excessive hospital stays, and a trend toward fewer transfusions that was not significant.

Degarelix in the Treatment of Prostate Cancer

Manipulation of the hypothalamic-pituitary-gonadal axis via androgen deprivation therapy has been in use since the 1940’s for the treatment of advanced prostate cancer. Androgen deprivation may be achieved via surgical castration or pharmacological castration. Pharmacological castration is preferred by patients due to its decreased psychological impact on body image and potential reversibility. Gonadotropin releasing hormone (GnRH) agonists have been a mainstay in androgen suppression. Recently degarelix, a GnRH antagonist, has been proven to be as effective and not inferior to GnRH analogues, such as leuprolide, in a phase III trial. Degarelix was found to have no initial testosterone surge, reach castrate levels of testosterone by day three, have no testosterone microsurges, have the ability to keep follicle stimulating hormone suppressed and have lower histaminogenic potency compared to its predecessor abarelix. A review of the pharmacokinetics, clinical trial findings, safety and ongoing debates as to the best application of degarelix is presented.

Minimally Invasive Therapy for Benign Prostatic Hyperplasia: Practice Patterns in Minnesota

BACKGROUND AND PURPOSE Benign prostatic hyperplasia (BPH) affects more than 50% of men by the age of 60 and 90% by age 85. Many of these men are not candidates for surgical procedures such as transurethral resection of the prostate (TURP), stimulating the development of less-invasive forms of therapy. We studied the utilization of these newer therapies by urologists practicing in Minnesota. MATERIALS AND METHODS An anonymous questionnaire was sent to 174 members of the Minnesota Urological Society, of which 58 were available for analysis. A case scenario was presented of a patient with BPH refractory to medical therapy. The options were traditional and minimally invasive therapies. The physician was asked to select whether he or she would offer each option and perform the procedure or refer the patient within or outside the practice. Statistical analysis was performed using chi-square and two-sample t-tests on Minitab software. The results were considered significant at P < 0.05. RESULTS While 59% of the respondents would offer both minimally invasive and traditional alternatives, 10% would offer only minimally invasive therapy, while 29% would offer only traditional therapy (P = 0.01). The most common minimally invasive therapies offered were transurethral microwave thermotherapy and (55%) and transurethral needle ablation (33%). If they offered a form of minimally invasive therapy, the majority of respondents would perform the procedure themselves. Rural urologists were less likely to offer minimally invasive therapy (43%) than metro physicians (81%; P = 0.035). There was no significant difference in the use of minimally invasive therapies by rural and urban urologists (P = 0.409) or urban and metropolitan urologists (P = 0.119). Urologists completing their training between 1960 and 1980 were less likely to offer minimally invasive therapy. There was no significant difference in the likelihood of offering traditional versus minimally invasive alternatives according to the percent of managed care in the practice. CONCLUSIONS Urologists closer to the completion of their residency training are more likely to include a minimally invasive technique in their treatment plan, while urologists practicing in rural Minnesota are less likely to offer minimally invasive procedures. Further emphasis should be placed on increasing the availability of minimally invasive techniques in rural settings.