Carrie Mlynarczyk

Impact of Histologic Subtype on Cancer-specific Survival in Patients with Renal Cell Carcinoma and Tumor Thrombus

BACKGROUND Although different prognostic factors for patients with renal cell carcinoma (RCC) and vena cava tumor thrombus (TT) have been studied, the prognostic value of histologic subtype in these patients remains unclear. OBJECTIVE We analyzed the impact of histologic subtype on cancer-specific survival (CSS). DESIGN, SETTINGS, AND PARTICIPANTS We retrospectively analyzed the records of 1774 patients with RCC and TT who underwent radical nephrectomy and tumor thrombectomy from 1971 to 2012 at 22 US and European centers. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariable ordered logistic and Cox regression models were used to quantify the impact of tumor histology on CSS. RESULTS AND LIMITATIONS Overall 5-yr CSS was 53.4% (confidence interval [CI], 50.5-56.2) in the entire group. TT level (according to the Mayo classification of macroscopic venous invasion in RCC) was I in 38.5% of patients, II in 30.6%, III in 17.3%, and IV in 13.5%. Histologic subtypes were clear cell renal cell carcinoma (cRCC) in 89.9% of patients, papillary renal cell carcinoma (pRCC) in 8.5%, and chromophobe RCC in 1.6%. In univariable analysis, pRCC was associated with a significantly worse CSS (p<0.001) compared with cRCC. In multivariable analysis, the presence of pRCC was independently associated with CSS (hazard ratio: 1.62; CI, 1.01-2.61; p<0.05). Higher TT level, positive lymph node status, distant metastasis, and fat invasion were also independently associated with CSS. CONCLUSIONS In our multi-institutional series, we found that patients with pRCC and vena cava TT who underwent radical nephrectomy and tumor thrombectomy had significantly worse cancer-specific outcomes when compared with patients with other histologic subtypes of RCC. We confirmed that higher TT level and fat invasion were independently associated with reduced CSS.

Impact of Synchronous Metastasis Distribution on Cancer Specific Survival in Renal Cell Carcinoma after Radical Nephrectomy with Tumor Thrombectomy

PURPOSE Metastatic renal cell carcinoma can be clinically diverse in terms of the pattern of metastatic disease and response to treatment. We studied the impact of metastasis and location on cancer specific survival. MATERIALS AND METHODS The records of 2,017 patients with renal cell cancer and tumor thrombus who underwent radical nephrectomy and tumor thrombectomy from 1971 to 2012 at 22 centers in the United States and Europe were analyzed. Number and location of synchronous metastases were compared with respect to patient cancer specific survival. Multivariable Cox regression models were used to quantify the impact of covariates. RESULTS Lymph node metastasis (155) or distant metastasis (725) was present in 880 (44%) patients. Of the patients with distant disease 385 (53%) had an isolated metastasis. The 5-year cancer specific survival was 51.3% (95% CI 48.6-53.9) for the entire group. On univariable analysis patients with isolated lymph node metastasis had a significantly worse cancer specific survival than those with a solitary distant metastasis. The location of distant metastasis did not have any significant effect on cancer specific survival. On multivariable analysis the presence of lymph node metastasis, isolated distant metastasis and multiple distant metastases were independently associated with cancer specific survival. Moreover higher tumor thrombus level, papillary histology and the use of postoperative systemic therapy were independently associated with worse cancer specific survival. CONCLUSIONS In our multi-institutional series of patients with renal cell cancer who underwent radical nephrectomy and tumor thrombectomy, almost half of the patients had synchronous lymph node or distant organ metastasis. Survival was superior in patients with solitary distant metastasis compared to isolated lymph node disease.

Correlation between serum gastrin and cellular proliferation in Barrett’s esophagus

Background: Patients with Barrett’s esophagus (BE) are commonly treated with proton-pump inhibitors (PPIs) to minimize the exposure of esophageal mucosa to stomach acid. However, the use of these medications can lead to significant hypergastrinemia in a subset of patients, which is concerning due to the known tumorigenic and proliferative effects of gastrin. The present pilot study aims to investigate a potential correlation between serum gastrin and cellular proliferation in BE. Methods: We performed a cross-sectional analysis of patients with nondysplastic BE on PPI therapy. Fasting serum gastrin was measured on the same day as esophageal biopsies were obtained. These biopsies were then stained with Ki-67 nuclear antibody. Pearson’s correlation coefficient was calculated to assess the relationship between Ki-67 index and ln(gastrin). Results: A total of 10 patients were included in the study. The mean age was 62.6 (±8.4) years and 5 patients were male. The median serum gastrin level was 45.2 pM (interquartile range [IQR] 33–113) and the median Ki-67 index was 49.6% (IQR 23–64). We found a statistically significant positive correlation between Ki-67 index and ln(gastrin) (r = 0.64; p = 0.05). Conclusions: In nondysplastic BE patients on PPI therapy, serum gastrin levels were significantly correlated with cellular proliferation. These pilot data lend support to a potential causal effect of gastrin on neoplastic progression in BE. Longitudinal studies of patients with BE are needed to determine whether hypergastrinemia is a risk factor for the development of dysplasia and adenocarcinoma or could be used as a biomarker for disease progression.

MP56-15 BEYOND CURVATURE: PREVALENCE AND CHARACTERISTICS OF PENILE VOLUME LOSS DEFORMITIES IN MEN WITH PEYRONIE'S DISEASE

any significant difference in negative relationship effects based on penile curvature, calcification, hourglass deformity, or stretched penile length. CONCLUSIONS: Several patient-reported variables including penile shortening and partner pain with intercourse are associated with a higher-reported rate of negative impact on sexual relationships in patients with PD, while longer relationship durations may be protective.

MP79-14 PENILE FRACTURE INCIDENCE AND PHYSICIAN COMPLIANCE WITH UROTRAUMA GUIDELINES IN NEW YORK STATE

INTRODUCTION AND OBJECTIVES: The importance of psychosocial and sexual outcomes for patients after glansectomy or partial penectomy cannot be overstated. Penile lenght preservation and a good cosmetic apearence are essential for good functional outcomes. Despite the popular use of different skin flaps to cover the distal penile shaft, the use of grafts have been increasing during the last years. The objective of this study is to evaluate the experience with skin graft glanuloplasty. METHODS: The charts of 17 patients submitted to a total glansectomy or a partial penectomy and to a glanuloplasty with a skin graft were analysed. The age of the patients ranged from 58 to 76 years (mean of 67 years). The mean follow-up time was 16 months (minimal follow-up of 6 months). The group included 15 patients with diagnosis of penile cancer (stages I or II) and 02 patients with complications after malleable penile implants. In all patients with penile cancer the disassembly technique principle (proposed to treat distal penile deformities) was used to achieve themaximumpenile lenght preservation (organ sparing surgery). After the mobilization of the complex urethra, glans, tumor, skin and dorsal plexus, a partial penectomy was performed in 4/15 patients (26,7%) and a total glansectomy in 11/15 (73,3%). After the oncological ressection, the glanuloplasty was performed. First, a corporoplasty to modify the shape of the distal penile shat ( to become more cylindrical) . After, the fixation of the spatulated urethra on the top penile shaft, the dorsal plexus and the penile skin creating an area for neoglans . A splitticknessskin grafts harvest from the thighwasused to the glanuloplasty in 14/17 patients ( 82,3%) and a full tickness skin graft in 3/17 cases (17,7%) Additional cosmetic procedures was used in 5 patients (29,4%) suspensory ligament release, ventral phaloplasty, and suprapubic lipectomy. RESULTS: None patients had local recurrences during the follow-up period. None urethral complications (meatal stenosis) were observed. All patients are able to urinate in a standing position. Erection was preserved in 12/17 patients (70,6%) and 8/12 (66,7%) refered sexual intercourse. The patients satisfaction was excellent and all patients were satisfied with the cosmetic results and considered that they expected a penile lenght lower and a worse cosmetic result than was observed in the postoperative period. CONCLUSIONS: The use skin graft glanuplasty in the scenario of the organ sparing glasectomy or partial penectomy seems to be a safe option for the treatment of penile cancer with involvement of the distal portion of the penile shaft, offering the high functional and cosmetic outcomes.

V9-01 THREE-DIMENSIONAL PHOTOGRAPHY AS A TOOL FOR CHARACTERIZATION OF PENILE DEFORMITY IN PEYRONIE's DISEASE

INTRODUCTION AND OBJECTIVES: Non-curvature penile deformities are prevalent and bothersome manifestations of Peyronie’s disease (PD) that can result in functional impairment and psychological distress. The quantitative metrics that are currently used to describe these deformities are inadequate and non-standardized, which has historically been a barrier to clinical research and patient care. Our aim is to introduce three-dimensional photography as a technique to improve the evaluation of patients with PD, partially by the measurement of erect penile volume (EPV) and percent erect penile volume loss (EPVL), and to assess the reliability of measurements acquired by 3D photography. METHODS: Six penis models were constructed using computer-assisted design software, and physical models were produced using a 3D printer. 3D photographs of each model were captured in triplicate by 4 observers using an inexpensive 3D camera (Structure Sensor, Occipital, San Francisco, CA). Computer software (Blender, Amsterdam, Netherlands) was used to generate automated measurements of EPV, penile length, minimum circumference, and maximum circumference. 3D images were then digitally reconstructed to restore each image to a non-deformed shape. Percent EPVL was calculated for each model as the percent difference between the EPV of the original model and the EPV after digital reconstruction. The automated measurements were then statistically compared to measurements obtained using water displacement experiments and a tape measure. RESULTS: On average, 3D photography was accurate to within 0.1% for measurement of penile length. It overestimated maximum and minimum circumference by averages of 5.0% and 1.8%, respectively; overestimated EPV by an average of 8.6%; and underestimated percent EPVL by an average of 1.9%. All inter-test, inter-observer, and intraobserver ICC values were greater than 0.75, reflective of excellent methodological reliability. CONCLUSIONS: Erect penile volume and percent EPVL are novel, highly descriptive metrics that may be useful in describing all variants of non-curvature, volume-loss deformities resulting from PD. These metrics can be quickly, accurately, and reliably determined using computational analysis of 3D photographs. Clinical research using 3D photography for assessment of EPV and percent EPVL will empower clinicians and researchers to better understand the clinical impact of penile volume-loss deformities and to study how these deformities respond to therapy.

MP26-13 PHYSIOLOGIC FACTORS THAT DETERMINE VOLUNTARY DETRUSOR CONTRACTION DURATION IN MALES

INTRODUCTION AND OBJECTIVES: Motor unit number estimation (MUNE) techniques estimate the number of functioning motor units (MUs) in a muscle, and serve as a biomarker for neuromuscular and muscular atrophy. Application of current MUNE techniques to the pelvic floor is impractical because of the need for either multiple stimulations or invasive needle electrodes. The objective is to propose a novel MUNE technique applicable to pelvic floor muscles, by combining a high-density surface EMG (HD-sEMG) decomposition approach with pudendal nerve stimulation, negating the need for invasive needles or multiple stimulations. METHODS: All procedures were approved by UH IRB. The pudendal nerve was stimulated transrectally with a St. Mark0s electrode mounted on the operator0s glove. HD-sEMG recordings were acquired from the puborectalis muscle with a vaginal EMG probe (Figure 1b) during supramaximal stimulation and three maximal voluntary contractions of pelvic floor muscles. Firstly, single motor unit action potentials (SMUPs) were decomposed from EMG recordings during muscle contraction using our recently developed K-Means Clustering Convolution Kernel Compensation (KmCKC) Algorithm. All SMUPs were grouped into left or right side by visually checking their innervation zone locations following an established procedure. Next, mean SMUPs were derived for both sides by averaging all HD-sEMG profiles of grouped SMUPs. Last, MUNE was calculated as the weighted average of compound muscle action potential (CMAP) size to mean SMUP size ratios for both sides. RESULTS: Left and right branches of the pudendal nerve were simulated. Four SMUPs were decomposed from HD-sEMG signals (left: 3 and right: 1). MUNE for the left and right sides were 22.8 and 27.0, respectively. CONCLUSIONS: This pilot study proves the feasibility of a novel MUNE technique for muscles in the pelvic floor region. The KmCKC algorithm enables a non-invasive collection of SMUPs, negating the need for repeated electrical stimulation or invasive needle electrodes. Results from more subjects will be available from our ongoing subject recruitment. Source of Funding: This study was supported by NIH DK082644, Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction, and the University of Houston.

V2-07 FEMALE URETHROPLASTY WITH BUCCAL MUCOSAL GRAFT FOR STRICTURE DISEASE

INTRODUCTION AND OBJECTIVES: Female urethral strictures are rare and occur in less than 1% of women. Common causes are trauma, iatrogenic injury, inflammatory diseases or idiopathic. Diagnosis is suspected when a patient reports obstructive symptoms, urodynamics shows outlet obstruction and/or cystourethroscopy reveals urethral narrowing or fibrosis. Surgical treatment depends on location and length of the stricture, and the optimal approach is not well established. In this video, the technique for female urethroplasty with a dorsal onlay buccal mucosal graft is demonstrated. METHODS: A 48-year-old female patient presented with longstanding, symptomatic urethral stricture disease. She previously failed conservative management with urethral dilations and elected to pursue urethroplasty with buccal mucosal graft. Following informed consent, video recording of intraoperative surgical procedure was performed. Video editing and narration was standardized to highlight key steps of the procedure. RESULTS: The patient was taken to the OR for urethroplasty with a dorsal onlay buccal mucosal graft. First, a cystoscopy was performed and a suprapubic tube was placed to allow for sufficient postoperative healing. The buccal mucosal graft was harvested, defatted and soaked in normal saline. Circumferentially around the urethral meatus hydrodissection is used with care taken to avoid the clitoral tissue and nerves. The urethra was dissected to the level of the bladder neck and the full extent of the stricture was identified then incised. Stay sutures were placed in the superior and inferior apices to facilitate placement of the graft. Superior apical sutures were threaded through the graft and additional interrupted sutures were placed circumferentially. The graft was trimmed to size, threaded with the inferior apical stay sutures and secured in place. The surgical bed and graft were joined to enhance revascularization. The patient did well postoperatively, with no recurrence of stricture and healthy buccal mucosa graft on cystoscopy. CONCLUSIONS: Urethroplasty with dorsal buccal mucosal graft placement can be a feasible and effective treatment for female urethral strictures.

PD58-09 THE IMPACT OF A TEACHING HOSPITAL ON FUNDAMENTAL GENERAL UROLOGIC PROCEDURES: DO RESIDENTS HELP OR HURT?

(OCTAVE-Anas) score was created by combining PRO urinary function score changes at 3-months post-RARP, percentage of patients having a urethral catheter duration >16 days, percentage of patients readmitted, and blinded peer-review Global Evaluative Assessment of Robotic Skill (GEARS) scores of videos of the anastomosis technique. Similarly, for nerve sparing (NS), OCTAVENS score was created based on differences in erectile function at 6months post-RARP, percentage of organ-confined patients with positive margin, and GEARS assessment of NS technique. All component measures were standardized to represent number of standard deviations better (positive values) or worse (negative values) than population averages, and the OCTAVE score was calculated as the sum of these standardized values. RESULTS: From 4/2014 through 4/2016, 20 surgeons from 14 different practices (2,774 total patients) sent video clips of their surgical techniques and had at least 50% of their patients participating in MUSIC PRO. OCTAVE-Anas scores ranged from -6.4 to 3.5, while OCTAVENS scores ranged from -3.7 to 3.5. Construct validity was demonstrated with moderate correlation between OCTAVE and the video assessment scores (Anas r1⁄40.59, NS r1⁄40.56, Figure 1). CONCLUSIONS: OCTAVE successfully incorporates multidimensional assessments to reliably determine better performing surgeons for the anastomosis and nerve-sparing aspects of RARP. This method may be used to identify surgeons to provide peer surgical skill quality improvement, with the aim to advance care for prostate cancer patients in the state of Michigan.

What's in a Number? Examining the Effect of a Dedicated Research Year on H-Index and Fellowship Decision-making

OBJECTIVE To assess the effect of a dedicated research year on the h-indices of residents and the pursuit of fellowship within a heterogeneous group of urology programs. We previously demonstrated that urology residents with a dedicated research year produce more than 2 times the number of publications than their counterparts in 5-year programs. However, we did not give consideration to the impact of these publications. MATERIALS AND METHODS We obtained information on the publication output and pursuit of fellowship of graduates from the New York Section urology residency programs from 2009 to 2013. Data on peer-reviewed publications were obtained by PubMed query and h-index was documented from the Scopus database. RESULTS During the 5-year study period, 148 individuals (116 M, 32 F) graduated from New York Section urology programs. The mean h-index was 4.6 for residents in 5-year programs compared with 8.1 for those in 6-year programs (P < .001). Residents with a dedicated research year were more likely to pursue fellowship training (79.3% vs 58.8%, P = .023) with no difference in the pursuit of accredited fellowship programs. Those residents who went on to fellowship training had a significantly higher h-index (6.2 vs 3.6, P = .001). CONCLUSION Urology residents with a dedicated research year have almost 2 times the h-indices of their counterparts. Residents who pursue fellowship training also have higher h-indices. Residents who completed a dedicated research year were more likely to pursue fellowship training, although the accreditation status of these programs was variable.