Christopher Lebeis

Advanced laparoscopic techniques significantly improve function of peritoneal dialysis catheters.

BACKGROUND Continuous ambulatory peritoneal dialysis (CAPD) catheters provide a preferred alternative to hemodialysis in a growing population with chronic kidney disease. However, CAPD catheters traditionally have been associated with a high rate of nonfunction with both open and laparoscopic procedures. New advanced laparoscopic techniques using rectus sheath tunneling and omentopexy have been reported to improve catheter function. STUDY DESIGN This study retrospectively reports the Cleveland Clinic experience during the transition from basic to advanced laparoscopic techniques from June 2002 to July 2008. A total of 197 patients were identified: 68 who underwent insertion with basic techniques and 129 who received catheters with advanced techniques. Primary nonfunction, procedural complications, and overall nonfunction rate were analyzed using the most recent follow-up to June 2008. RESULTS Primary nonfunction occurred in 25 of 68 (36.7%) patients in the basic group; this occurred in only 6 of 129 patients (4.6%) in the advanced group (p < 0.0001). The overall rate of complications including nonfunction from primary and secondary sources, peritoneal leak, peritonitis, port-site hernia, and bleeding occurred in 31 of 68 (45.6%) patients in the basic group and 21 of 129 (16.28%) patients in the advanced group (p < 0.0001). CONCLUSIONS These data clearly show a significant improvement in CAPD catheter function using omentopexy and rectus sheath tunneling. These advanced laparoscopic techniques should become the preferred method of CAPD catheter insertion.

Novel Technique Prevents Lymphoceles After Transperitoneal Robotic-assisted Pelvic Lymph Node Dissection: Peritoneal Flap Interposition

INTRODUCTION To determine the efficacy of our novel technique to prevent lymphocele formation after pelvic lymph node dissection (PLND) after robotic-assisted radical prostatectomy (RARP) using the existing peritoneum of the bladder. TECHNICAL CONSIDERATIONS We evaluated 155 consecutive patients undergoing RARP with PLND over 24 months. Group A included the first 77 patients with PLND using standard technique (no peritoneal flap). Group B included the subsequent 78 patients (1 patient excluded) with PLND and peritoneal interposition flap. The peritoneal interposition flap is created by rotating and advancing the peritoneum around the lateral surface of the ipsilateral bladder to the dependent portion of the pelvis and fixing it to the bladder itself. A cystogram was performed in 91% of the patients 7-14 days after the surgery. Lymphocele formation rates were compared (based on symptoms, cystogram findings, and radiographic confirmation). RESULTS The 2 groups were statistically equivalent in terms of prostate-specific antigen, age, blood loss, body mass index, Gleason score, prostate size, pathology, or heparin use. Lymphocele formation occurred in 9 of 77 (11.6%) group A patients and in 0 of 77 group B patients (P = .003). Mean time to lymphocele detection in group A was 30.4 days. Mean follow-up in groups A and B were 383.97 and 379 days, respectively (P = .91). CONCLUSION Strategic rotation and fixation of a peritoneal flap around the lateral aspect of the bladder during transperitoneal RARP with PLND is a novel technique to prevent lymphocele formation. Given the sample size and single institutional study, a prospective, randomized, multi-institutional trial is planned.

Durable Results of Mitomycin C Injection with Internal Urethrotomy for Refractory Bladder Neck Contractures: Multi-institutional Experience

Introduction: We evaluated our intermediate term experience with radial urethrotomy and intralesional mitomycin C injection in patients with recurrent bladder neck contractures. Recurrent bladder neck contractures in which previous endoscopic treatment failed pose a difficult management dilemma. Methods: Prospectively collected data were reviewed in a retrospective manner of patients presenting with recurrent bladder neck contractures from January 2007 to June 2014. All patients had at least 1 prior failed incision of a bladder neck contracture and many had additional dilations or catheter dependence. Radial cold knife incisions of the bladder neck were performed followed by injection of 0.3 to 0.4 mg/ml mitomycin C at each incision site. All surgeons performed the incision technique and injection in a reproducible fashion. Results: A total of 40 patients underwent urethrotomy with mitomycin C injection. At a median followup of 20.5 months 30 patients (75.0%) had a stable bladder neck after 1 procedure. An additional 5 patients required 2 procedures to obtain a stable patent bladder neck (87.5%). Of the 40 patients 14 (35.0%) presented in retention on catheter drainage and all had a stable, patent bladder neck. No recurrence was detected in the original 18 patients in the pilot study with patent bladder necks. Rigorous followup revealed no long‐term complications. Conclusions: Urethrotomy with mitomycin C injection for the management of recurrent bladder neck contractures is safe and efficacious. The addition of an antifibrotic agent in conjunction with internal urethrotomy offers a definitive solution to a problem that would otherwise be managed with repeat urethral incision/dilation, catheter dependence or open bladder neck reconstruction.

MP61-07 SERUM MICRORNA ANALYSIS: A MINIMALLY INVASIVE ASSAY CORRELATED WITH UPGRADING IN PATIENTS WITH LOW-RISK PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: Pathologic upgrading from biopsy to prostatectomy occurs in approximately 30% of prostate cancer cases. PSA, a nonspecific protein, has previously been the primary serum marker for prostate cancer. Markers that more accurately assess risk of aggressiveprostate cancer at the timeof screening are critical for the future management of this disease. The aim of this study was to identify a panel of microRNA (miRNA) from serum that could differentiate patients with low-risk (Gleason 6) prostate cancer on TRUS biopsy specimenswho were either the same grade or upgraded at the time of prostatectomy. METHODS: Total RNA was isolated from serum of patients who had Gleason Sum (GS) 6 prostate cancer at the time of TRUS guided prostate biopsy. These patients were divided into groups with GS 6 that remained GS 6 (same grade) at prostatectomy and those who were upgraded to GS7 (upgrade) at the time of prostatectomy. For the discovery phase, sample pools from each group were profiled via miRNA PCR array (Exiqon). Validation of miRNA expression levels was performed on 29 same and 31 upgrade samples by qRT-PCR. RESULTS: Array analysis of 751miRNA identified34miRNAwith 2-fold differential expression between patients who had Gleason upgrading between biopsies and prostatectomy compared to patients who were same grade. Of these, 20 miRNA were down-regulated and 14 were up-regulated in theupgradedgroup.Additionally, 3miRNAwereexpressed in the upgrade groupwhich were not detected in the same grade group. 17 miRNA were further validated by qRT-PCR on individual samples. miR425-5pandmiR-146-5pwere found tobesignificantlydifferent between the same grade and upgraded groups. ROC curve of logistic regression analysis of theses two showed an area under the curve of 0.691. CONCLUSIONS: Serum samples demonstrated different miRNA expression levels between samples that were same grade or upgraded from Gleason 6 at prostatectomy. This minimally invasive assay could provide an adjunct to PSA and prostate biopsies to better counsel patients on management of low-risk prostate cancer and monitor patients on active surveillance.