Charles U. Nottingham

The Impact of Minimally Invasive Surgery on Major Iatrogenic Ureteral Injury and Subsequent Ureteral Repair During Hysterectomy: A National Analysis of Risk Factors and Outcomes

OBJECTIVE To identify risk factors for ureteral injury during hysterectomy and to assess outcomes of concurrent minimally invasive vs converted to open repairs. METHODS We queried the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2013 to identify abdominal hysterectomy (AH), minimally invasive hysterectomy (MIH), or vaginal hysterectomy. Ureteral injury was identified based on intraoperative or delayed management. Multivariate logistic regression was performed to assess the effect of hysterectomy approach on risk of ureteral injury while controlling for covariates. For patients with ureteral injury during MIH, we compared 30-day outcomes following minimally invasive vs converted open repairs. RESULTS There were 302 iatrogenic ureteral injuries from 96,538 hysterectomies, with 0.18%, 0.48%, and 0.04% from AH, MIH, and vaginal hysterectomy, respectively. Patients who underwent MIH were younger and had decreased comorbidities compared to patients who underwent AH (all P < .001). MIH resulted in lower overall complications (6.6% vs 14.8%, P < .001) but higher ureteral injury rate (0.48% vs 0.18%, P < .001) compared to AH. On multivariate analysis, the minimally invasive approach was associated with increased risk of ureteral injury (odds ratio 4.2, P < .001). Patients undergoing minimally invasive ureteral repairs (89%) during MIH had shorter operating room time and length of stay but similar overall perioperative complications compared to those with converted open repairs (11%). CONCLUSION Using a large national series, we show that the minimally invasive approach for hysterectomy is an independent risk factor for iatrogenic ureteral injuries. During MIH, concurrent minimally invasive ureteral repairs resulted in comparable 30-day outcomes compared to converted to open repairs.

The Effect of Obesity on Perioperative Outcomes for Open and Minimally Invasive Prostatectomy

OBJECTIVE To compare the impact of obesity on perioperative outcomes between open radical prostatectomy (ORP) and minimally invasive prostatectomy (MIP). METHODS Using the National Surgical Quality Improvement Program public use files for 2008-2013, we identified patients undergoing prostatectomy using Current Procedural Terminology codes. Those without body mass index (BMI) or comorbidity information were excluded. BMI was treated as a categorical variable according to the World Health Organization classification. Demographic and comorbid conditions were compared between BMI groups, and multivariable logistical regression was used to identify independent predictors of adverse perioperative events. RESULTS We identified 17,693 MIP and 4674 ORP for analysis. Of the entire cohort, only 18.7% had a BMI within the normal range (18.5-24.9), whereas the remaining 81.3% were at least overweight (BMI > 25). Class I, II, and III obesity accounted for 25.0%, 7.0%, and 2.3% of the cohort, respectively. Overall, complications were higher with ORP (19.0%) than with MIP (5.3%), which held true across all BMI categories. The rate of wound, renal, thromboembolic, infectious, neurologic, Clavien grade III-V, and overall complications among MIP were directly related to BMI. Only wound and renal complications were related to BMI in ORP. In multivariable analysis, obesity was found to be an independent predictor of wound, renal, and thromboembolic complications. CONCLUSION Obesity has a larger impact on morbidity for MIP compared to ORP. Overall morbidity, however, remains lower for MIP across all BMI groups.

30-Day Morbidity and Reoperation Following Midurethral Sling: Analysis of 8772 Cases Using a National Prospective Database

OBJECTIVE To determine 30-day complications, risk of readmission, and reoperation for midurethral slings (MUS). METHODS The National Surgical Quality Improvement Program database from 2006 to 2013 was queried for MUS alone by excluding concurrent reconstructive, urologic, or gynecologic procedures. We assessed baseline characteristics, 30-day perioperative outcomes and 30-day readmission. Logistic regression analysis identified risk factors for the frequent complications. RESULTS There were 8772 women who underwent MUS, of which 3830 (43.7%) and 4942 (56.3%) were performed by urologists and gynecologists, respectively. Patients of urologists were older, had higher frailty, and were more likely diabetic (all P < .05). Patients of gynecologists were more likely to have resident involvement compared to urologists (16.4% vs 11.2%, P < .001). Mean operative time was shorter for urologists compared to gynecologists (35.6 ± 29.2 minutes vs 38.1 ± 34.3 minutes, P < .001). The overall 30-day rate of any complication was 3.52%. Urinary tract infection (UTI) occurred in 2.2% vs 3.5% of the urologic and gynecologic patients, respectively (P=.001). After adjusting for frailty, body mass index, steroid use, age, operative time, and residency involvement, gynecologic performed surgery incurred an increased risk of UTI (OR 1.67, 95% CI 1.27-2.19; P=.001). Sixty-five (0.90%) patients were readmitted within 30 days, most commonly due to urinary symptoms. Sling revision for urinary obstruction occurred in 15 patients; 10 underwent repair of the bladder, urethra, or vagina. CONCLUSION To our knowledge, we present the largest American cohort of MUS 30-day outcomes to date, stratified by specialty of performing surgeon. Overall, morbidity is low. UTI is the most common complication, and occurs at increased frequency for patients of gynecologists.

Open Vs Minimally Invasive Adult Ureteral Reimplantation: Analysis of 30-day Outcomes in the National Surgical Quality Improvement Program (NSQIP) Database

OBJECTIVE To examine 30-day outcomes of robotic-assisted and pure laparoscopic ureteral reimplantation (LUR) vs open ureteral reimplantation (OUR) in adult patients for benign disease. METHODS We identified adult patients undergoing LUR or OUR by urologists between 2006 and 2013 using the American College of Surgeons National Surgical Quality Improvement Program database, excluding those with concomitant partial cystectomy or ureterectomy. Multivariable regression modeling was used to assess for the independent association of minimally invasive surgery (MIS) with 30-day complications, reoperations, or readmissions. RESULTS Of 512 patients identified, 300 underwent LUR and 212 underwent OUR. Baseline characteristics including age, race, body mass index, and cardiovascular comorbidities were similar between LUR and OUR (all P > .05). Patients who underwent LUR had higher median preoperative serum creatinine (1.1 mg/dL vs 1.0 mg/dL, P = .03), increased presence of a resident (51% vs 34%, P < .01), and shorter hospitalization (1 [interquartile range 0-3] days vs 4 [interquartile range 3-6] days, P < .01) compared to patients who underwent OUR. LUR had lower overall complications (9% vs 28%, P < .01), especially with regard to transfusions (1% vs 11%, P < .01), superficial wound infections (0% vs 5%, P < .01), and urinary tract infections (5% vs 11%, P = .03). On multiple regression analyses, MIS was an independent predictor of lower overall complication rate (odds ratio [OR] 0.24 [0.14-0.40], P < .01), but was not predictive of readmission (OR 0.93 [0.44-1.98], P = .16) or reoperation (OR 2.09 [0.90-4.82], P = .10). CONCLUSION In the largest current series assessing the impact of MIS on adult ureteral reimplantation, data from the National Surgical Quality Improvement Program demonstrate that LUR results in decreased 30-day complications.

Upstaging of nonurothelial histology in bladder cancer at the time of surgical treatment in the National Cancer Data Base

PURPOSE To determine patient and pathologic characteristics as well as outcomes for patients with clinically localized, nonurothelial histology bladder cancer. MATERIALS AND METHODS Using the National Cancer Data Base, we identified patients between 2000 and 2010 diagnosed with bladder cancer as their only malignancy undergoing definitive surgical management. Patients were characterized as urothelial (n = 13,442), squamous (n = 789), small cell (n = 124), adenocarcinoma (n = 789), or other histology (n = 499). Patient and pathologic characteristics were compared across histologic subtypes. We also evaluated for incidence of T and N upstaging. Survival analysis was performed using the Kaplan-Meier method. Multivariate survival analysis was performed to identify predictors of adverse overall survival. RESULTS Patients with nonurothelial histology were more likely to be African-American, treated at academic medical centers, and of younger age (all P<0.05). Among those with nonurothelial histology, 55.4% of patients presenting with clinical stage T1 or less had their tumor upstaged during definitive surgical treatment compared to 42.7% of those with urothelial carcinoma. Squamous histology incurred the highest upgrading rate of 61.8%. Five-year survival varied by subtype, with universally decreased survival for those upstaged. Among nonurothelial histology, overall 5-year survival was 32.4% (95% CI: 28.8%-36.2%) vs. 46.0% (95% CI: 42.3%-49.6%) for those upstaged and not upstaged, respectively. Neoadjuvant therapy is used infrequently in this population. CONCLUSION We present the largest survival analysis of various rare subtypes of bladder cancer to date. Patients with nonurothelial bladder cancer have significantly higher rate of upstaging at cystectomy and with this a worsened overall survival. Aggressive treatment should be strongly considered for nonurothelial cancers when identified.

Giant Multilocular Cystadenoma of the Prostate: AIRP Best Cases in Radiologic-Pathologic Correlation

Editor’s Note.—RadioGraphics continues to publish radiologic-pathologic case material selected from the American Institute for Radiologic Pathology (AIRP) “best case” presentations. The AIRP conducts a 4-week Radiologic Pathology Correlation Course, which is offered five times per year. On the penultimate day of the course, the best case presentation is held at the American Film Institute Silver Theater and Cultural Center in Silver Spring, Md. The AIRP faculty identifies the best cases, from each organ system, brought by the resident attendees. One or more of the best cases from each of the five courses are then solicited for publication in RadioGraphics. These cases emphasize the importance of radiologic-pathologic correlation in the imaging evaluation and diagnosis of diseases encountered at the institute and its predecessor, the Armed Forces Institute of Pathology (AFIP).

No Effect of Music on Anxiety and Pain During Transrectal Prostate Biopsies: A Randomized Trial

OBJECTIVE To investigate the effect of ambient music on anxiety and pain in men undergoing prostate biopsies. MATERIALS AND METHODS Between September 2015 and June 2016, men undergoing office transrectal prostate biopsy at our institution were randomly assigned to music (n = 85) or control (n = 97) groups. We examined clinical characteristics, pathologic variables, and baseline anxiety using the Trait Instrument of State-Trait Anxiety Inventory. Primary outcomes included anxiety assessed by State Instrument of STAI (STAI-S) and pain using a visual analog scale. RESULTS There were no significant differences in baseline characteristics between the music and control groups, including median age, prostate-specific antigen, use of magnetic resonance imaging-guided biopsies, or Trait Instrument of State-Trait Anxiety Inventory. The majority (93%) of patients indicated they desired music in their prebiopsy survey. There were no significant differences in STAI-S (33.7 ± 8.9 vs 34.4 ± 9.9, P = .6), pain score (2.3 ± 2.1 vs 2.0 ± 2.1, P = .3), or vital signs between the music and control groups, respectively. There were also no differences in STAI-S, visual analog scale, or vital signs between groups when stratified by age, prostate-specific antigen, or number of previous biopsies. Men who received music were more likely to request music for future prostate biopsy, compared to men who did not (93% vs 83%, P = .07, respectively). CONCLUSION This randomized study showed no difference in anxiety or pain scores for patients who had ambient music during transrectal prostate biopsy. Future studies are needed to discern the influence of details including method of music delivery, music type, and utilization of adjunct relaxation tools.

Clinical and Radiographic Predictors of Great Vessel Resection or Reconstruction During Retroperitoneal Lymph Node Dissection for Testicular Cancer

OBJECTIVE To evaluate whether specific clinical or radiographic factors predict inferior vena cava (IVC) or abdominal aortic (AA) resection or reconstruction (RoR) at the time of postchemotherapy retroperitoneal lymph node dissection (RPLND) for germ cell tumors of the testicle. MATERIALS AND METHODS Two hundred seventy-seven patients undergoing postchemotherapy RPLND at two institutions between 2005 and 2015 were identified. Preoperative imaging was reviewed with radiologists blinded to operative details. Univariable and multivariable logistic regressions were performed, and a model was created to predict the need for great vessel RoR using radiographic and clinical factors. RESULTS Of 97 patients with preoperative imaging and clinical data available, 16 (17%) underwent RoR at RPLND. On univariable analysis dominant mass size, degree of circumferential vessel involvement, and vessel deformity were associated with RoR (all P <.05). No patients with clinical stage IIA or IIB disease at diagnosis required RoR. In the multivariable model, mass involvement of the IVC >135° (odds ratio 65.5, 7.8-548, P <.01) and involvement of the AA >330° (odds ratio 29.0, 3.44-245, P <.01) were predictive for RoR. These thresholds yielded a PPV of 48% and 50% and a NPV of 92% and 97% for IVC and AA RoR, respectively. CONCLUSION Degree of circumferential involvement of the great vessels is an independent predictor for resection or reconstruction of the IVC or AA at postchemotherapy RPLND. Patients at high risk of great vessel reconstruction should be informed accordingly and have the proper teams available for complex vascular reconstruction.

MP61-02 MINIMALLY INVASIVE VERSUS OPEN URETERAL REIMPLANTATION: IS THERE A DIFFERENCE IN RATES OF REOPERATION? COMPARISON FROM A LARGE NATIONAL DATABASE

and SR-RCC23 cells exhibited significantly higher resistance to sunitinib treatment compared with that of these sunitinib sensitive cells. Microarray analysis was performed comparing ACHN vs SRACHN and RCC23 vs SR-RCC23, respectively, to evaluate the miRNA profiles of each cells. In SR-ACHN and SR-RCC23 cells as compared with ACHN and RCC23 cells, the CT values of miR-575, -642b-3p and -4430 have significantly increased, while the CT values of miR-18a-5p, -29b-1-5p, -431-3p and -4521 have significantly decreased with real-time RT-PCR. CONCLUSIONS: We created sunitinib resistant cell lines SRACHN and SR-RCC23 and identified microRNAs considering related with sunitnib resistant by performing microarray. By regulating these microRNAs may contribute to the improvement of sunitinib resistance.

MP64-15 ROBOTIC ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY IN ISUP GRADE 5 PROSTATE CANCER: ONCOLOGICAL OUTCOMES

INTRODUCTION AND OBJECTIVES: We present here oncological outcome for patients with International Society of Urological Pathology (ISUP) Grade 5 prostate cancer (PC) who underwent primary treatment with robotic assisted laparoscopic radical prostatectomy (RALP). METHODS: Using a prospectively collected institutional registry, we identified patients with clinically organ confined and locally advanced (cT1-T3N0M0) ISUP Grade 5 PC who underwent RALP with bilateral pelvic lymphadenectomy as primary treatment between 2005 and 2013. RESULTS: We included 106 patients with median age of 65 years (IQR 58.5-68). The majority of patients had clinically organconfined disease (90%). Following surgery, 71 patients (67%) were upstaged to pT3 and 40 patients (38%) were downgraded to Gleason score 8 or 7. With median follow-up of 63.5 months (IQR 34-85), 50 patients (48%) had biochemical failure: 24 patients (23%) had PSA persistence and 26 patients (24%) had biochemical recurrence (BCR). Adjuvant and salvage RT were administered to 12 (11%) and 34 (32%) patients, respectively; adjuvant and salvage ADT were given to two (2%) and 31 (29%) patients, respectively; 9 patients (8%) received subsequent therapies. Eleven patients (10%) had systemic failure and 10 patients (9.5%) died: 3 (3%) from prostate cancer and 7 (7%) from other causes. Using Kaplan-Meier estimate, the 5-year overall, disease specific, metastasis-free and disease-free survivals are 91%, 96%, 88%, and 59% respectively. Using univariate analysis, pre-operative PSA, number of cores involved with ISUP grade 5 PC on biopsy, percentage of positive cores on biopsy, and pathological T stage were all correlated with both biochemical and systemic failure. CONCLUSIONS: The disease volume on pre-operative biopsy and specifically the amount of Gleason 5 pattern predicted both biochemical and systemic failure. RALP in ISUP grade 5 PC is a viable treatment option in the multimodality management of PC, it affords local control and might improve long-term oncologic outcomes. Source of Funding: none