Belinda Li

Functional Implications of Renal Tumor Enucleation Relative to Standard Partial Nephrectomy

OBJECTIVE To compare the surgical precision for optimizing nephron-mass preservation of tumor enucleation (TE) vs standard partial nephrectomy (SPN), with primary focus on functional outcomes. TE is presumed to optimize preservation of parenchymal mass and function but this has not yet been rigorously studied and quantified. MATERIALS AND METHODS Robotic partial nephrectomy patients who had appropriate pre- and postoperative studies for analysis of parenchymal mass preservation specific to the operated kidney were included. Computed tomography or magnetic resonance imaging and estimated glomerular filtration rate were required to be <2 months prior and 4-12 months after surgery. Parenchymal mass preservation and surgical precision were estimated for each technique, with precision defined as actual postoperative parenchymal volume or predicted postoperative parenchymal volume, presuming loss of a 5 mm rim of parenchyma associated with tumor excision and reconstruction. RESULTS Analysis included 57 TE and 53 SPN. Median age, body mass index, and tumor size were comparable. Percent parenchymal mass preserved in the operated kidney with TE was 96% (interquartile range [IQR] = 90-100) vs 89% (IQR = 83-96) for SPN (P = .003). Precision of excision or reconstruction was 101% (IQR = 96-105) for TE vs 94% (IQR = 88-100) for SPN (P < .001). On multivariable analysis, only TE correlated with improved surgical precision (coefficient = 6.7, 95% confidence interval = 1.6-11.8, P = .01). Although preservation of global renal function also favored TE, the differences were marginal (96% vs 93%), and statistical significance was not observed (P = .2). CONCLUSION Our analysis, which specifically focuses on the functional implications of TE, demonstrates that TE maximally spares normal parenchyma compared to SPN. Thus far, functional differences remain marginal and not statistically significant. Clinical significance of these findings in various clinical settings will require further investigation.

CEVL interactive – Promoting effective teamwork to perform robot assisted laparoscopic pyeloplasty in pediatric urology☆

Performing pediatric robotic surgeries effectively and efficiently requires the pediatric urologist to “team” with the entire operating room staff. Yet members of this team often achieve competency through different training paths. Attending surgeons often train in a structured, hands-on skills course and then gradually advance to be observed by a mentor. Circulating nurses and surgical technicians typically train together at their home institutions with instructors or by immersion in the operating room. Urology trainees may have opportunity to prepare with review of video clips and a robotic simulator if available, but often do the majority of their learning through immersion in the operating room. Finally, training of anesthesiologists and radiology technicians typically is provided only as an afterthought. To address this situation, the authors created this “CEV-ule” based on their belief that improving the effectiveness of the entire surgical team performance could be achieved by providing the OR staff with a shared online interactive learning for all to use prior to and concurrent with the surgical case. Because pediatric robot-assisted laparoscopic pyeloplasty (RALP) is the most commonly performed pediatric robotic procedure, we chose it as the index case to test this hypothesis. Herein, we present a paradigm approach to RALP. We identified critical points of the procedure in which effective teamwork is essential (e.g., suture passing, instrument exchange). In this manner the surgical workflow may include troubleshooting these points.

The July Effect in Urologic Surgery: Myth or Reality?

Introduction: The July effect is the widely held belief that medical care is compromised at the beginning of the academic year due to transitioning medical trainees. We determined its impact on surgical outcomes in urological surgery. Methods: The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database and State Emergency Department Database for California were used for the years 2007 to 2011. Patients were identified who underwent surgery in July, August, April and May, and separated into early (July and August) and late (April and May) cohorts. Surgical outcomes for early vs late surgery were compared for academic centers. Adjusted multivariate models were fit to determine the effect of early surgery as a predictor of adverse outcomes. Results: For major urological surgery July/August timing had no impact on length of stay, 30-day readmission, 30-day emergency room visits, never events, perioperative complications or mortality (all values p >0.05). Similarly, for stone, groin, bladder outlet and cystoscopic bladder procedures, July/August surgery had no impact on rates of urinary retention, emergency room visits within 30 days, clot evacuations within 30 days, perioperative complications or 30-day readmissions (all values p >0.05). At the end of the year cystectomies had increased odds of intraoperative complications (OR 0.63, 95% CI 0.4–0.97) while nephrectomies had higher odds of major complications (OR 0.69, 95% CI 0.53–0.89). Conclusions: Surgical outcomes are not compromised by having surgery at the beginning of the academic year, despite resident turnover, representing appropriate oversight during this potentially vulnerable time.

MP45-13 POST-OBSTRUCTIVE BLADDER SMOOTH MUSCLE REMODELING IS DEPENDENT ON BLADDER STEM CELLS

INTRODUCTION AND OBJECTIVES: Smooth muscle contraction in the hyperplastic prostate may drive urethral obstruction and subsequent lower urinary tract symptoms. Consequently, inhibition of contraction is an important strategy for medical therapy, but available options show insufficient efficacy. Development of novel options with higher efficacy requires adequate understanding of contractile mechanisms and identification of new targets. Recently, a possible role of polo-like kinase 1 (PLK1) has been suggested for smooth muscle contraction outside the lower urinary tract. Here, we examined effects of PLK1 inhibitors on contraction of human prostate tissue. METHODS: Prostate tissues were obtained from radical prostatectomy (n1⁄4122 patients). Smooth muscle contractions were studied in an organ bath, where they were induced by adrenergic and nonadrenergic agonists or electric field stimulation (EFS) after addition of solvent (control) or PLK inhibitor (SBE13, cyclapolin 9, TAK960, Ro3280). RT-PCR, Western blot and immunofluorescence were performed for detection of PLK isoforms. RESULTS: Noradrenaline and the a1-agonists phenylephrine and methoxamine (each 0.1-100 mM) induced concentration-dependent contractions of human prostate strips, which were significantly inhibited by SBE13 (1 mM) and cyclapolin 9 (3 mM). This inhibition was significant for different agonist concentrations, and between groups for nearly all agonist/inhibitor combinations (p<0.01, p<0.002, p<0.002 between SBE13 and control for noradrenaline, phenylephrine, methoxamine; p<0.002, p<0.02 for cyclapolin vs. control for noradrenaline, methoxamine). EFS induced frequence-dependent contractions, which were significantly inhibited by SBE13 (1 mM), cyclapolin 9 (3 mM), TAK960 (100 nM), and Ro-3280 (100 nM) (p<0.02 for SBE13 vs. control, p<0.03 for cyclapolin vs. control, p<0.006 for TAK960 vs. control, p<0.04 for Ro-3280 vs. control). Endothelin-1 (0.1-3 mM) and U46619 (0.1-30 mM) induced concentration-dependent contractions of prostate strips, which were not changed by SBE13 or cyclapolin 9. RT-PCR, Western blot, and immunofluorescence suggested expression of PLK1 in smooth muscle cells of the human prostate. CONCLUSIONS: PLK inhibitors inhibit a1-adrenergic and neurogenic smooth muscle contractions in the prostate. A PLKdependent signalling pathway may confer divergent regulation of adrenergic and non-adrenergic contraction in the human prostate.

Thirty-day hospital revisits after prostate brachytherapy: who is at risk?

Background Transperineal prostate brachytherapy is a common outpatient procedure for the treatment of prostate cancer. Whereas long-term morbidity and toxicities are widely published, rates of short-term complications leading to hospital revisits have not been well described. Materials and methods Patients who underwent brachytherapy for prostate cancer in an ambulatory setting were identified in the Healthcare Cost and Utilization Project State Ambulatory Surgery Database for California between 2007 and 2011. Emergency department (ED) visits and inpatient admissions within 30 days of treatment were determined from the California Healthcare Cost and Utilization Project State Emergency Department Database and State Inpatient Database, respectively. Results Between 2007 and 2011, 9,042 patients underwent brachytherapy for prostate cancer. Within 30 days postoperatively, 543 (6.0%) patients experienced 674 hospital encounters. ED visits comprised most encounters (68.7%) at a median of 7 days (interquartile range 2–16) after surgery. Inpatient hospitalizations occurred on 155 of 674 visits (23.0%) at a median of 12 days (interquartile range 5–20). Common presenting diagnoses included urinary retention, malfunctioning catheter, hematuria, and urinary tract infection. Logistic regression demonstrated advanced age {65–75 years: odds ratio [OR], 1.3 [95% confidence interval (CI) 1.06–1.60, P = 0.01]; >75 years: OR 1.5 [95% CI 1.18–1.97, P = 0.001]}, inpatient admission within 90 days before surgery [OR 2.68 (95% CI 1.8–4.0, P < 0.001)], and ED visit within 180 days before surgery [OR 1.63 (95% CI 1.4–1.89, P < 0.001)] as factors that increased the risk of hospital-based evaluation after outpatient brachytherapy. Charlson comorbidity score did not influence risk. Conclusions ED visits and inpatient admissions are not uncommon after prostate brachytherapy. Risk of revisit is higher in elderly patients and those who have had recent inpatient or ED encounters.

Management of Renal Cell Carcinoma with Inferior Vena Caval Tumor Thrombus

Direct intraluminal extension of tumor into the renal vein and inferior vena cava may be seen in up to 10% of patients with renal cell carcinoma. Accurate preoperative assessment of the cephalad extent of the tumor thrombus allows for a planned controlled operative intervention. Adjunctive techniques drawn from vascular, hepatobiliary, and cardiac surgery may be necessary. Long-term survival is possible with an aggressive surgical approach.

Advising on the care of the uncircumcised penis: A survey of pediatric urologists in the United States

BACKGROUND Parents of uncircumcised boys often report confusion regarding the proper care and hygiene practices for the uncircumcised penis. The lack of guidance from healthcare providers may be due to a lack of consensus on the proper care of the prepuce. OBJECTIVE The aim of this study was to determine whether or not there exists consensus among pediatric urologists on the care of the uncircumcised penis and on the advice they provide to parents. METHODS An electronic survey was delivered to 514 members of the Society for Pediatric Urology (SPU). The survey contained demographical and clinical questions which were analyzed using descriptive statistics. RESULTS Of 261 SPU members who opened the e-mail invitation, a total of 204 responses were received for a response rate of 78% (overall response rate 40%). Nine responses were excluded for members practicing outside of the United States or whose locations were not disclosed for a final number of responses of 195. Overall, pediatric urologists reported a high level of confidence in providing advice to parents with a median confidence score of 10 (scale 1-10, IQR 9-10). Only 66% reported providing advice to parents on when to begin retracting the foreskin, with 48% basing their advice on the patients age and 19% on the patients toilet training status (Figure). Respondents who based their advice on age, advised beginning retraction at 2-5 years (61%), 6-11 years (17%), less than 2 years (12%), and greater than 12 years (10%). For frequency of retraction before toilet training, 50% recommended no retraction, 25% with cleaning or baths, 10% with each diaper change, and 13% provided no advice. After toilet training, 48% of respondents recommended retracting the foreskin with cleaning or baths, 41% with each void, and 19% recommended no retraction. The majority of respondents agreed that problems with voiding (77%), infection (74%), and hygiene (64%) were indications for treatment of phimosis. In asymptomatic cases, 47% believed that phimosis required treatment if persisting beyond a specific age, the most common being greater than 12 years of age (40%). CONCLUSIONS Although pediatric urologists reported being highly confident in advising parents on the care of the uncircumcised penis, there is not a clear consensus among these subspecialists on when to begin and how often to retract the foreskin, or when phimosis requires treatment. These findings offer insight into current practice patterns to better inform primary care providers and parents.

Pushing Boundaries: Robotic Nephrectomy of an Auto-transplanted Kidney for Recurrent Renal Cell Carcinoma

Advances in robotic technology continue to expand the boundaries of minimally invasive approaches in transplant surgery. A single report has previously described the use of the robotic approach in transplant nephrectomy for a failed allograft. Our objective is to describe our technique and experience for the first reported robotic nephrectomy of an auto-transplanted solitary kidney for a recurrence of renal cell carcinoma (RCC). We highlight technical considerations during allograft mobilization and hilum dissection with the additional demands of a previously operated auto-transplant kidney.

V3-10 ROBOTIC-ASSISTED LAPAROSCOPIC NEPHRECTOMY OF AN AUTO-TRANSPLANTED KIDNEY FOR RECURRENT RENAL CELL CARCINOMA

INTRODUCTION AND OBJECTIVES: To perform nephronsparing surgery, arterial clamping is often required. Operative bleeding control is difficult in laparoscopic techniques. We imagined a novel technique for “zero ischemia” nephron-sparing surgery using a hybrid opearating room: clampless laparoscopic partial nephrectomy was performed after superselective tumoral embolization. Our objective is to describe this new technique. METHODS: The patient is a 46 year old patient with no prior medical history, who had a 3 cm large localized renal tumor on the convexity of the left kidney. The lesion was heterogeneous, medial, partially endophytic and of moderate complexity (RENAL 8p). The procedure was realized in a hybrid operating room by a double team: interventional radiologist and urologist. RESULTS: A first renal arteriography was made to visualize the arterial vascularization of the left kidney. With a guidance software, the tumoral artery was catheterized superselectively. The tumor and its arteries were embolized by microspheres and coils. A 3D arteriography showed the exclusion of the tumor from the renal vascularization. Then, the patient was positionned for laparoscopic partial nephrectomy, thas was performed without dissecting the renal pedicule, nor clamping of the renal artery. Operative bleeding was insignificant. No suture was necessary. A final control 3D arteriography showed no arterial bleeding and preservation of healthy renal parenchyma. Follow-up was uneventful. Preoperative renal function was maintained. The tumor was a clear cell renal carcinoma. Surgical margins were negative. CONCLUSIONS: This is the first experience of superselective tumoral embolization followed immediately by laparoscopic partial nephrectomy in a hybrid operating room. Resection of a localized renal cancer of moderate complexity was performed clampless, sutureless and without intraoperative bleeding. Source of Funding: none

MP04-11 OBESITY MAY BE A RISK FACTOR FOR URETEROENTERIC ANASTOMOTIC STRICTURES AFTER RADICAL CYSTECTOMY WITH URINARY DIVERSION

INTRODUCTION AND OBJECTIVES: Bladder Cancer (Bca) is significantly associated with aging. However, the correct management of BCa in the elderly remains controversial. The aim of the study is to analyse predictive factors of early death in a group of patients >70y, with Bca, at 100 days after a geriatric comprehensive assessment (CGA), in order to help in therapeutic decision making. METHODS: 112 patients with Bca were enrolled. This is a multicentric and prospective cohort study approved by an ethics committee. A standardized comprehensive geriatric assessment (CGA) was done before the treatment decision and different geriatric data were collected: MMSE, MNA, BMI, Grip hand grip strength, ADL, IADL, GIRSg, Gait speed, QLQC30, Charlson, G8 and Balducci classification. Characteristics of cancer, social and demographic data were also collected. During a 100-days follow up, the rate of death, treatments made and geriatric interventions were collected. RESULTS: A total of 112patientswere enrolled, including 25,9% of women and a mean age of 82y [70-96]. 26,8% (n1⁄430) of patients died within the 100-days follow up. 34,8%(n1⁄439) of patients had metastatic cancers. The most common proposed treatments, by the surgeron or the oncologist, were surgery (radical cystectomy) (44,6%) and chemotherapy (41,6%). In 35,7% of cases, CGA has modified the therapeutic decision, in favor to palliative care in 57,5%.In univariate analyzes, metastatic cancers (HR1⁄4 2,7 [ 1,3-5,5],p1⁄40,008), cognitive deficit (MMSE<24) (HR1⁄43;2[1,5-7],p1⁄40,003), confusion (HR1⁄42,2 [1,1-4,5],p1⁄40,032), under nutrition (MNA<17) (HR1⁄46,9 [2,1-22],p<0,001), lower gait speed (HR1⁄45,6 [2,4-12,9],p<0,001), social isolation (HR1⁄44,5 [2,1-9,6], p<0,001), and loss of autonomy in ADL (HR1⁄42,7 [1,1-6,2],p1⁄40,023) and IADL (HR1⁄42,7 [1,1-6,5],p1⁄40,032) had significantly more risk of dying. The predictive factors of early death, in multivariate analyzes, were the metastatic cancers (HR1⁄43,5 [1,6-7,5], p1⁄40,002), the lower gait speed (HR1⁄43,1 [1,2-7,7], p1⁄40,015), social isolation (HR1⁄4 2,6 [1,2-5,9], p1⁄40,02)and loss of autonomy in ADL (HR1⁄43,3 [1,2-9,2],p1⁄40,022). CONCLUSIONS: This study confirms that some geriatric data could be predictive of worse outcome. These results can help the geriatrician, the surgeon and the oncologist in decision making. But these data also encourage to propose targeted geriatric interventions to improve the patients’s prognosis, especially customize their perioperative care.