Charles Metcalfe

Positive surgical margins are a risk factor for significant biochemical recurrence only in intermediate‐risk disease

Study Type – Therapy (case series)

Reliability Assessment of International Grading System for Vesicoureteral Reflux

PURPOSE The International Reflux Committee proposed a grading system for vesicoureteral reflux in 1985 which has been used extensively in everyday practice and research studies. Despite widespread use, based mainly on face validity, the interrater and intrarater reliability of this tool are not known. A tool cannot be considered valid unless it is reliable. Therefore, we estimated the interrater and intrarater reliability of the international grading system for vesicoureteral reflux. MATERIALS AND METHODS A series of 28 voiding cystourethrogram studies were selected. The images were assembled in an electronic presentation in random fashion. Four pediatric radiologists, 5 pediatric urologists and 4 senior urology residents graded the studies. The images were then shuffled in a random fashion and re-rated after 7 days (total 728 observations). Cohen weighted kappa statistics were used to determine interrater and intrarater reliability. Subgroup analysis was then performed comparing the variability among the 3 groups of raters and different grades. RESULTS The average interrater reliability was 0.53 (95% CI 0.52-0.55, p <0.0001). Agreement in subgroups was 0.61 for urologists, 0.59 for residents and 0.56 for radiologists. The lowest agreement was shown in grade III (0.36) and the highest in grade I (0.98). The intrarater reliability was 0.86 (95% CI 0.77-0.95, p <0.001). CONCLUSIONS The international grading system for vesicoureteral reflux shows low interrater reliability for moderate degrees of vesicoureteral reflux whereas the intrarater reliability is high. Modification of this system may improve its reproducibility.

Long-term Results of Surgical Techniques and Procedures in Men with Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is one of the most common conditions associated with the aging male. Surgical management of lower urinary tract symptoms attributed to BPH has progressed over time as urologic surgeons search for more innovative and less invasive forms of treatment. Transurethral resection of the prostate (TURP) has long been the “gold standard” to which all other forms of treatment are compared. There are several different methods of surgical treatment of BPH, including whole gland enucleation/intact removal, vaporization, and induction of necrosis with delayed reabsorption as well as hybrid techniques. As with any form of surgical intervention, long-term results define success. Long-term follow-up consists of examining overall efficacy with attention to associated adverse events. TURP has the luxury of the longest follow-up, while less invasive forms of treatment starting to acquire long-term data. There are several surgical options for BPH; newer methods do show promise, while the “gold standard” continues to demonstrate excellent surgical results.

Three primary testicular tumours: Trials and tribulations of testicular preservation.

Balancing recurrence risk, side effects and patient preference in the treatment of multiple metachronous testicular tumours can be challenging. We present the case of a young male patient who developed 3 different primary testicular neoplasms over an 8-year period, each associated with retroperitoneal lymphadenopathy requiring chemotherapy. The first tumour at age 19 was managed with radical orchiectomy. Four years later, a partial orchiectomy was performed to remove 2 small lesions. Another 4 years later, a complete orchiectomy was required for an additional tumour. This case highlights the caveats of testis-sparing surgery for testis cancer and the need for careful surveillance in these patients.

PD34-05 5-ALPHA REDUCTASE INHIBITORS IN PATIENTS ON ACTIVE SURVEILLANCE FOR PROSTATE CANCER: IMPACT ON DISEASE PROGRESSION AND CURATIVE INTERVENTION

INTRODUCTION AND OBJECTIVES: To report pathologic progression (PP) and curative intervention (CI) in 361 men on active surveillance (AS) in comparison between with and without use of 5alpha reductase inhibitors (5-ARI). METHODS: Total 361 patients were grouped: with use of 5-ARI (n1⁄4 119, 33%) or without use of 5-ARI (No 5-ARI), n1⁄4242 (67%). All the patients had at least two years of follow up and the median follow up time was 5.1 years for 5-ARI vs 5.3 years for No 5-ARI (p1⁄40.6). The AS protocol included PSA (6 monthly), multi-parametric transrectal ultrasound (TRUS) annually, and surveillance biopsy (2-3 yearly, or as indicated). PP was defined as upgrade on Gleason score, increase in cancer core length (>4mm) or percent (>25%), or clinical progression on the follow up. CI was defined as discontinuing AS to undergo any kind of curative or hormonal therapy. Clinical variables were compared between the two groups. Kaplan-Meier method was conducted to estimate survivals for PP and CI, and multivariable Cox regression for predictors of PP. RESULTS: At the entry, the two groups were similar: age (63 vs. 61yrs, p1⁄40.1), PSA (4.8 vs. 4.8ng/ml, p1⁄40.5), prostate volume on TRUS (41cc vs. 35cc, p1⁄40.1), clinical stage T1c/T2a (85%/13% vs. 90%/9%, p1⁄40.06), biopsy Gleason score (6/3þ4/4þ3 1⁄4 88%/10%/2% vs. 87%/11%/2%, p1⁄40.9), biopsy cancer core length (1.5mm vs. 1mm, p1⁄40.37) and percent (10% vs. 8.5%, p1⁄40.2) of index cancer, and number of positive cores (1 vs. 1, p1⁄40.1), respectively for 5-ARI vs No 5-ARI groups. Predictors of PP were: not taking 5-ARI (p1⁄40.017), entry PSA > 4ng/ml (p1⁄40.009) and Gleason pattern 4 in biopsy (p<0.001). In regression analyses, 5-ARI-group had lowered the risk of PP by 41%. Estimated probability of PP-free survival (Fig 1) and CI-free survival (Fig 2) are shown: CONCLUSIONS: The use of 5-ARI for selected patients on AS delayed PCa progression and curative intervention. Source of Funding: None

PD9-07 EARLY AND LATE COMPLICATIONS OF ROBOTIC RADICAL CYSTECTOMY AND INTRA-CORPOREAL URINARY DIVERSION

INTRODUCTION AND OBJECTIVES: To evaluate long-term clinical outcome and complications of patients with Urothelial Bladder Cancer (UBC) who underwent radical cystectomy (RC) and orthotopic neobladder (ONB) diversion with minimum of 15 years follow-up. METHODS: Using our IRB approved institutional bladder cancer database, we identified 1,964 patients who underwent RC for UBC at our institution between 1971 and 2008. 121 patients who underwent RC and ONB (Kock pouch to the urethra) with more than 15 years follow-up were subjects of this study. We reviewed the clinicopathological variables, long-term complications and outcome of this cohort. Detailed follow-up were found in 96/121 patients (79.3%). eGFR analysis was done on 32 patients with information available on BMI, pre-op Cr, and at least 2 Cr reading of 3,6,10, 15 years with 1 of the readings being at least 10 years. RESULTS: Of the 121 patients, 118 were male (97.5%). Mean age at cystectomy was 59.3 years with a median follow-up of 18.3 years (range 15.1 23). Pathologic stage at cystectomy was <1⁄4pT1 (70, 57.9%), pT2 (32, 26.4%), pT3 (14, 11.6%) and pT4 (5, 4.1%) and pNþ (11, 9.1%) with N1 (4, 3.3%) and N2 (7, 5.8%). Neoadjuvant chemo, radiation and adjuvant chemo were used in 9 (7.4%), 2 (1.7%) and 33 (27%) cases, respectively. There were 6 patients with recurrences (3 urethral, 1 pelvis, 1 distant, and 1 upper tract) at median of 9.23 years (range 1.2 e 17.2) after cystectomy. Only 1 of the patients died of the disease (at 16.3 years); 27 died of non-cancer cause (mean 18.2; 15.223.0), 5 died of secondary cancer (17.1; 15.4-20.0), 3 died of unknown cause (15.3; 15.1-15.4), and 85 are alive without evidence of disease (18.5; 15.1-23.0). CONCLUSIONS: The most common complications in ONB patients with more than 15 yrs follow-up were pouch-related, with afferent limb stenosis and pouch stones contributing the most. A gradual decrease in GFR over time was seen throughout the patient population, thus making renal insufficiency a prevalent complication in long-term survivors with ONB.