Carlos Fay

Robotic salvage retroperitoneal and pelvic lymph node dissection for 'node-only' recurrent prostate cancer: technique and initial series.

To describe the technique of robot‐assisted high‐extended salvage retroperitoneal and pelvic lymphadenectomy (sRPLND+PLND) for ‘node‐only’ recurrent prostate cancer.

Active Surveillance for Small Renal Masses in Young Patients

We certainly agree with active surveillance for small renal masses 9SRMs). However, it must be in appropriate patients, the elderly and the infirm, in whom the comorbidity risks outweigh the oncologic risks. Evidence to support active surveillance for SRMs in the young is lacking.

Robotic Ureteral and Bladder Reconstruction

The incidence of iatrogenic ureteral injury has been increasing as the widespread of endoscopic procedures and laparoscopy, especially urological, gynecological and colorectal procedures [1, 2]. Ureteral strictures are most commonly secondary to previous surgeries, radiotherapy, malignancy, infection, endometriosis, trauma [3]. Surgical management of ureteral injuries depends not only on the length, location and etiology of the injury, but on the urologist’s surgical experience on open or minimally invasive approaches.

MP77-01 11C-CHOLINE VERSUS 68GA-PSMA PET/CT SCAN FOR THE DETECTION OF NODAL RECURRENCE FROM PROSTATE CANCER: RESULTS FROM A LARGE, MULTI-INSTITUTIONAL SALVAGE LYMPH NODE DISSECTION SERIES

with uncomplicated UTIs (OBGYNs: OR 21.01, p< 0.001; urologists: OR 2.37, p1⁄4 0.044) compared to internists. Of those who correctly selected a first-line agent, 29.8% prescribed a longer than recommended duration of therapy. IDSA guideline awareness was not associated with physicians’ practices in managing women with bacteriuria. CONCLUSIONS: Most physicians surveyed were unfamiliar with guidelines related to managing ASB and uncomplicated UTIs in women, likely contributing to overscreening and overtreatment of ASB and the use of inappropriate antibiotic regimens in treating uncomplicated UTIs. However, superior antibiotic stewardship was not associated with knowledge of IDSA guidelines, suggesting that guideline dissemination alone may not alter practice patterns among physicians managing women with bacteriuria.

V12-03 ROBOTIC UTERETAL REIMPLANTATION FOR URETERO-ENTERIC ANASTOMOTIC STRICTURES

tumor identification and characterization. Given their respective strengths and complementary characteristics, we postulate that combining wide-field (PDD and NBI) with microscopic (CLE) imaging technologies will further enhance TURBT. Towards that goal, we report our preliminary experience with multimodal enhanced cystoscopy. METHODS: The study received IRB approval. PDD was performed using hexaminolevulinate (Photocure) in combination with blue light cystoscope (Storz). NBI (Olympus) was performed with an NBIenabled camera head attached to the standard resectoscope. Probebased CLE was performed with fluorescein as the contrast agent along with 2.6 or 0.85 mm endomicroscopes (Cellvizio, Mauna Kea Technologies). Following TURBT with PDD or NBI, the resection bed was imaged with CLE. Imaging features of the resection bed were characterized by 3 urologists and achieved consensus. RESULTS: To date, 10 subjects have undergone multimodal imaging. No adverse events were noted due to the combination of instruments or imaging agents used. Confocal imaging features of the resection bed including elastin fibers (network of thin, interwoven strands), muscle fibers (sheets of straight, connected columns) and perivesical fat (collection of dark, round globules) were observed. Muscularis propria was present in the resected tissue on pathology assessment, confirming adequate resection. Patients are currently undergoing follow-up for cancer recurrence. CONCLUSIONS: We report real-time microscopic inspection of the resection bed to assess for adequate depth of resection with CLE in combination with the macroscopic imaging technologies PDD and NBI. Further studies are needed to determine if multimodal enhanced cystoscopy results in improved TURBT with adequate depth and margins of resection and decreased recurrence rate, which may eventually translate to a decreased need for repeat TURBT.

PD38-10 FACTORS INFLUENCING INTRAOPERATIVE CONVERSION FROM PLANNED ORTHOTOPIC TO NON-ORTHOTOPIC URINARY DIVERSION DURING RADICAL CYSTECTOMY

physical therapy (PFPT). METHODS: Under IRB approval, we identified 1269 patients that underwent open RC from 2002 to 2015 (ONB 74%, 85% male). From 2012, patients were prospectively followed with a validated, pictorial pad usage questionnaire. A subgroup of patients received PFPT as an intervention to assist their continence. Interventions focused on improving pelvic floor muscle strength and coordination. Manual, visual and surface EMG biofeedback training were incorporated to improve neuromuscular re-education of the pelvic floor as well as behavioral modifications for bladder re-training, timed voiding and general bladder and bowel health. Frequency of visits started from 1x/ week over 4-6 sessions, and longer thereafter. RESULTS: A total of 153 male patients with available pad usage questionnaires were followed from September 2012 to August 2015. Daytime continence rates increase from 59% at <3 months to 92% by 12-18 months postoperatively. Nighttime continence rates increased to 51% by 18-36 months postoperatively. Overall catheterization rate was 13.1%. 17 patients underwent PFPT during this period, with a median age of 70 yrs. There was no significant difference between groups for age, BMI, or Charlson comorbidity index. Univariate analysis showed there is a shorter median time to first daytime continence in PFPT group compared to non-intervention group (89 days vs 182 days respectively; p1⁄40.06), while this was not significant for the nighttime continence (median 134 vs 311; p1⁄40.12). Kaplan Meier curves also showed higher continence rates in PFPT group at 1 year (0.710.13) compared to non-PFPT ones (0.60.04), although the difference was not significant (p1⁄40.25) (figure 1). CONCLUSIONS: Following ONB, continence improves significantly by 6 months, and plateaus with 92% of patients achieving daytime continence by 12-18 months. Those who received PFPT tend to have faster return to daytime continence in the first year. Further research with bigger sample size is needed to support the value of PFPT in continence after RC and ONB.

PD15-09 IDENTIFYING THE OPTIMAL CANDIDATE FOR SALVAGE LYMPH NODE DISSECTION FOR NODAL RECURRENCE OF PROSTATE CANCER: RESULTS FROM A LARGE, MULTI-INSTITUTIONAL ANALYSIS

Nicola Fossati*, Nazareno Suardi, Giorgio Gandaglia, Armando Stabile, Milan, Italy; Michele Colicchia, R. Jeffrey Karnes, Rochester, NY; Friederike Haidl, David Pfister, Daniel Porres, Axel Heidenreich, Cologne, Germany; Christian Gratzke, Annika Herlemann, Christian Stief, Munich, Germany; Antonino Battaglia, Wouter Everaerts, Steven Joniau, Hein Van Poppel, Leuven, Belgium; Alexey V. Aksenov, Daniar K. Osmonov, Klaus-Peter Juenemann, Kiel, Germany; ADL Abreu, Fabio Almeida, Phoenix, AZ; C. Fay, Inderbir Gill, Los Angeles, CA; Alexandre Mottrie, Aalst, Belgium; Francesco Montorsi, Alberto Briganti, Milan, Italy

MP03-19 DIFFERENCE BETWEEN THE PZ AND THE TZ IN DIAGNOSTIC ACCURACY OF MAGNETIC RESONANCE IMAGING (MRI) 5-POINT LIKERT SCORING SYSTEM EVALUATED BY THE RESULT OF MRI/ULTRASONOGRAPHY FUSION TARGETED BIOPSY OF THE PROSTATE

INTRODUCTION AND OBJECTIVES: To evaluate the impact of urologist learning curve (LC) for mpMRI-TRUS fusion biopsy on clinically significant PCa (sPCa) detection rate. METHODS: Data from 291 patients who underwent mpMRITRUS transperineal/transrectal targeted (TB) and systematic transrectal biopsy (SB) for suspicion of PCa were prospectly collected at a single institution. For mpMRI-TRUS fusion-guided prostate biopsy, the BioJet fusion system (D&K Technologies, Germany) was used; biopsies were performed in a transrectal or transperineal setting according to the location of the primary lesion on the mpMRI. All the procedures were performed by two urologists who had already experience with TRUS guided random prostate biopsies. mpMRI studies were reported by different experienced radiologists. The cohort was divided into six groups representing consecutive times during the study period. Overall PCa detection rate (CDR) and csPCa detection rate (csCDR), defined with Epstein criteria, were reported and stratified according to progression groups. Sensitivity, specificity, negative predictive value and accuracy of MRI-TRUS TB were calculated. Linear regression analyses were performed to evaluate the learning curve of the procedure. RESULTS: Overall PCa detection rate was 42.6% (n1⁄4124) and csPCa detection rate was 28% (n1⁄481). CDR at target biopsy was 38% (n1⁄4111). Considering CDR stratified according to PIRADS, we reported 16.7% (n1⁄41), 21% (n1⁄422), 50.7% (n1⁄474) and 75% (n1⁄427) for PIRADS 2, 3, 4 and 5 respectively(p<0.01). Cancer detection rate increased from 38.8% to 42.6% from group A to group F (R21⁄40.06). csCDR and target biopsy CDR increased from 22% to 42% (R21⁄40.002) and from 38.8% to 39.5% (R21⁄40.7) respectively. Sensitivity, specificity, NPV and accuracy of TB in detecting PCa was 79% (CI: 0.68-0.89), 73% (CI: 0.66-0.78), 93 % (0.89-0.96) and 74% (0.680.79) respectively. Sensitivity, specificity, NPV and overall accuracy of TB in detecting csPCa was 93% (CI: 0.86-0.98), 83% (CI :0.77-0.87), 96% (CI:0.94-0.99) and 85% (CI: 0.81-0.89) respectively. When the LC impact was assessed, overall diagnostic accuracy on PCa and csPCa of TB did not show a significant increasing trend (R21⁄40.5 and R21⁄40.09). CONCLUSIONS: We failed to demonstrate a statistically significant impact of LC for PCa and csPCa detection. mpMRI-TRUS-TB seems to be an easy, reliable and feasible procedure in the hands of experienced urologists. Our findings represent a starting point for faster widespread of the technique in the urological practice.

V4-07 CONTRAST-ENHANCED ULTRASOUND (CEUS): EVALUATION OF HIGH INTENSITY FOCUSED ULTRASOUND (HIFU) ABLATION OF THE PROSTATE

INTRODUCTION AND OBJECTIVES: PCNL is the first-line therapy for large and complex renal calculi. To perform PCNL safely and effectively, the most important step is the formation of a nephrostomy tract and tract dilatation. Furthermore, as fine a nephroscope as possible is required for micro PCNL. In this clinical study, renal puncture using 20 G all-seeing needle and 4.8 Fr micro PCNL were performed for large renal stone using a micro-optic disposable scope. METHODS: The f0.65 mm scope with the High Definition Image Guide (HDIG) system reported in previous WCE held in Taiwan (2014) was adopted. The scope consists of an integrated light lead and the micro fiber optic including a f0.5 mm precise object lens and optical glass fiber, where real-time HD images can be seen through the digital image processing device. The scope can be set inside a 20 G puncture needle or 4.8 Fr metal sheath which can simultaneously include the micro-optic scope, 0.018 inch guidewire and 200 mm laser fiber. These devices are developed as part of a collaborative research with Takei Medical & Optical Co. Ltd. (Tokyo, Japan) and Sumita Optical Glass Inc. (Saitama, Japan) funded by Utsukushima Next-Generation Medical Industry Agglomeration Project between 2012 and 2014. After evaluating safety, optical quality and operation performance in an animal study, the clinical study authorized by the ethical committee of Okayama University Hospital was carried out from June 2013. The procedures of micro PCNL are as follows; ultrasound-guided renal puncture using 20 G all-seeing needle, removal of the scope followed by insertion of 0.018 inch guidewire, dilatation by metal introducer, insertion of 4.8 Fr metal sheath into renal calyx, insertion of the HDIG scope into the sheath, complete fragmentation of calculi by Ho-YAG LASER without removal of the fragments. RESULTS: A 68-year old male with renal calculi 21 mm in diameter in left lower calyx once underwent the puncture and the micro PCNL. After the operation, spontaneous discharge of fragmented calculi through lower urinary tract was observed and abdominal X-ray on POD 21 showed no fragment in his left kidney. No adverse event was occurred except slight elevation of serum creatinine during only a week postoperatively. CONCLUSIONS: The micro-optic disposable scope with the HDIG system is extremely useful for safer puncture and finer PCNL. We are now planning to adopt it to percutaneous procedure for urothelial carcinoma in upper urinary tract.

MP100-14 HIGH INTENSITY FOCUSED ULTRASOUND KIDNEY ABLATION: PRE-CLINICAL SAFETY AND EFFICACY EVALUATION IN A PORCINE MODEL USING A 15MM LAPAROSCOPIC PROBE

INTRODUCTION AND OBJECTIVES: Irreversible Electroporation (IRE) is an emerging ablative modality for patients with renal tumors that are not candidates for surgery or conventional thermal ablation. This study aims to evaluate technical success, safety, and outcomes for IRE treated complicated renal tumors. METHODS: A single institution retrospective review of all renal tumors treatedwithComputed Tomography (CT) guided IREbetweenMay 2013 and February 2016 was performed. A total of 17 patients underwent IRE with NanoKnife (AngioDynamics, Queensbury, New York) for primary or secondary renal malignancies. Technical success was defined as delivery of all planned pulses during ablation and verifying complete ablation by immediatepost-procedureCT imaging. Local recurrencewasdefinedas residual enhancement or increased tumor size following technical success. Follow-up imaging was scheduled at 1, 3, 6, 12, 18, and 24 months. Complications were defined using Clavien-Dino (CD) classification. RESULTS: IRE was performed on 18 complicated renal tumors with median RENAL score of 6.5 ( 1st quartile 6, 3rd quartile 9) and median tumor size of 2.2 cm (1st quartile 2.0, 3rd quartile 3.1). Most were clear cell renal cell carcinomas (n1⁄413). Technical success was achieved in 17/18 tumor treatments (94.4%). One (5.6%) case was aborted due to bleeding (CD grade IIIb) requiring embolization. Minor CD grade one or two complications were present in 7/18 cases (38.9%), including post-procedural urinary retention (4/18, 22.2%), hypoglycemia (1/18, 5.6%), hematuria (1/18, 5.6%), and back pain (1/18, 5.6%). Patients lost to follow up were excluded (n1⁄43) from follow-up analysis. Median follow-up was 392 days, 1st quartile 203, 3rd quartile 696). Two local recurrences (14.2%) occurred on days 320 and 230 post-procedure with RENAL Scores of 9 and 8, respectively. Both cases were successfully treated with cryoablation and follow up showed no residual tumor at 723 and 617 days post cryoablation, respectively. CONCLUSIONS: IRE appears to be a safe and efficacious option for the treatment of renal tumors in patients that are not candidates for surgery or thermal ablation techniques. Further research is warranted with larger sample sizes and continued follow up.