Daniel Wollin

Guideline of Guidelines: Imaging of Localized Prostate Cancer.

In the era before the widespread adoption of PSA screening for prostate cancer, most incident cases were already advanced stage. Because treatment options, such as surgery or radiation, are thought mainly to benefit patients with localised disease, prostate cancer imaging was necessary before treatment of almost all patients. However, in the PSA era >90% of incident cases are localised, making the need for routine imaging with CT, MRI, or bone scan obsolete [1]. Numerous studies show a relatively low rate of positive staging imaging in low- and intermediate-risk patients. Recognising these trends, several professional societies issued prostate cancer imaging guidelines in the mid-1990s in an effort to curb the overuse of imaging. However, despite these longstanding guidelines, a great number of patients undergo improper imaging [2]. Given how stubborn this problem has been to eradicate, there has been a renewed interest in finding ways to decrease unnecessary imaging, including a Physician Quality Reporting System (PQRS) quality measure and a highlighting of the problem in the ‘Choosing Wisely’ campaign [3–5]. In addition to the guidelines regarding the staging of incident prostate cancer, some groups have also presented guidelines on the use of imaging to follow men with advanced disease [6]. The purpose of the present article is to summarise the main points from multiple professional society guidelines on imaging in prostate cancer to help clarify when patients with prostate cancer should be imaged and with which modalities.

Salvage Percutaneous Nephrolithotomy: Analysis of Outcomes following Initial Treatment Failure

PURPOSE Percutaneous nephrolithotomy has high potential for morbidity or failure. There are limited data regarding risk factors for failure and to our knowledge no published reports of surgical outcomes in patients with prior failed attempts at percutaneous stone removal. MATERIALS AND METHODS We identified patients referred to 3 medical centers after prior failed attempts at percutaneous nephrolithotomy. A retrospective chart review was performed to analyze reasons for initial failure and outcomes of salvage percutaneous nephrolithotomy. Outcomes were compared to those in a prospectively maintained database of more than 1,200 patients treated with a primary procedure. RESULTS Salvage percutaneous nephrolithotomy was performed in 31 patients. Unsuitable access to the stone was the reason for failure in 80% of cases. Other reasons included infection, bleeding and inadequate instrument availability in 6.5% of cases each. Compared to patients who underwent primary percutaneous nephrolithotomy those treated with salvage were more likely to have staghorn calculi (61.3% vs 31.4%, p <0.01) and a larger maximum stone diameter (3.7 vs 2.5 cm, p <0.01), and require a secondary procedure (65.5% vs 42.1%, p <0.01). There was no significant difference between the cohorts in the remaining demographics or perioperative outcomes. All patients were deemed completely stone free except one who elected observation for a 3 mm nonobstructing fragment. CONCLUSIONS Despite the more challenging nature and prior unsuccessful attempts at treatment, the outcomes of salvage percutaneous nephrolithotomy were no different from those of primary percutaneous nephrolithotomy when performed by experienced surgeons.

Defining the Rate of Primary Ureteroscopic Failure in Unstented Patients: A Multi-Institutional Study

PURPOSE Primary ureteroscopic intervention for kidney or ureteral stones occasionally encounters difficulty with passage of the ureteroscope in the initial procedure. These patients require a second procedure after stenting. We aim to define the contemporary failure rate of primary ureteroscopy (URS) and identify predictive factors that necessitate prestenting. This will assist in preoperative patient counseling, informed consent, and clinical decision-making. MATERIALS AND METHODS We conducted a multi-institutional retrospective review of 535 unstented patients undergoing primary URS from August 2011 to August 2013. The primary outcome was gaining access to the unstented ureter. RESULTS The failure rate for accessing the unstented ureter was 7.7% (41/535). The median age of females with primary ureteroscopic failure was significantly lower than in females who had successful ureteroscopic access (34 vs 52 years; p = 0.0041). There was no difference in the median age of males with access vs failure (58 vs 57 years; p = 0.3683). Proximal ureteral stones had the highest failure rate for ureteral access at 18.28% (p = 0.006). On multivariable logistic regression, proximal ureteral stone location remained a significant predictor of failure when compared to renal stones (odds ratio [OR] 3.14, p = 0.006). When including only ureteral stones in the multivariable analysis, stone location in the proximal ureter compared to the distal ureter remained the only significant predictor of access failure (OR 0.24, p = 0.015). CONCLUSIONS A low overall rate of ureteral access failure in unstented patients is shown. Young female patients and proximal ureteral stones were less likely to be accessed primarily. This study provides information that will help urologists counsel their patients preoperatively regarding their likelihood of failing primary URS necessitating a second procedure. This will also help the patient to make an informed decision during the consent process and may guide urologists on selective prestenting in higher risk patients.

Dramatic Enlargement of the Prostate due to Xanthogranulomatous Inflammation.

Xanthogranulomatous inflammation of the prostate is a rare condition that can cause lower urinary tract symptoms and may be mistaken for adenocarcinoma. It is often seen on prostate biopsy, but can usually be treated conservatively with temporary catheterization, alpha blockade, and allowing time for improvement. We present a case of a 78‐year‐old man found to have a 318 g prostate secondary to xanthogranulomatous inflammation.

MP18-19 IMPACT OF MALNUTRITION ON RADICAL NEPHROURETERECTOMY MORBIDITY AND MORTALITY: OPPORTUNITY FOR PRE-OPERATIVE OPTIMIZATION

Introduction/background: Nutritional status is increasingly recognized as an important predictor of prognosis and surgical outcomes in cancer patients. We evaluated the impact of preoperative malnutrition on the development of surgical complications and mortality following radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Materials and Methods: Using data from The American College of Surgeons National Surgical Quality Improvement Program, we evaluated the association of poor nutritional status with 30 day postoperative complications and overall mortality following RNU over years 2005-2015. Preoperative variables suggestive of poor nutritional status included hypoalbuminemia (<3.5 g/dL), weight loss 6 months before surgery (>10%), and low body mass index (BMI). Results: A total of 1,200 patients were identified who underwent RNU for UTUC. The overall complication rate was 20.5% (n=246) and mortality rate was 1.75% (n=21). On univariate analysis, patients who had a postoperative complication were more likely to have hypoalbuminemia (25.0% vs. 11.4% p<0.001) and weight loss (3.7% vs. 1.0% p=0.003). After controlling for baseline characteristics and comorbidities, hypoalbuminemia was found to be a significant independent predictor of postoperative complications (OR 2.09 95% CI 1.29-3.38 p=0.003). Hypoalbuminemia was also found to be significant independent predictor of mortality (OR 4.31 95% CI 1.45-12.79 p=0.008) on multivariable regression analysis. Conclusions: Hypoalbuminemia is a significant predictor of surgical complications and mortality following RNU for UTUC. This finding supports the importance of preoperative nutritional status in this population and suggests that effective nutritional interventions in the preoperative setting could improve patient outcomes. M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 5

PD35-09 COMPARISON OF A NOVEL SINGLE-USE FLEXIBLE URETEROSCOPE TO CURRENTLY EXISTING REUSABLE AND SINGLE-USE FLEXIBLE URETEROSCOPES

with maximum pressure set at 150 mm Hg; in the other cohort, hand irrigation was performed using 60 ml syringe and IV extension tubing. Statistics were performed in Prism (Graph Pad) and included means, standard deviations, chi squared tests, and student0s t-tests. RESULTS: Group (A) consisted of 206 patients in which pressurized irrigation was used. Group (B) consisted of 25 patients in which hand irrigation was used during their URS. In group (A), 52.9% were male vs in group (B), 36%. Group (B) were younger on average, with a mean age of 43 18.5, compared with group (A) whose mean age was 53 19.2 (p<0.05). In Group (A), 110/206 patients were stented preoperatively compared with 15/25 in Group (B) (p1⁄40.67). Procedure times were 59 44 minutes in Group (A) and 67 35 minutes in Group (B) (p1⁄40.38) Complication rates were 13.1% vs 24% in groups (A) and (B), respectively (P1⁄40.14). Emergency Department (ED) return rate was 27 (13.1%) vs 6 (24%) in groups (A) and (B), respectively (P1⁄40.14). Most complications in both cohorts were Urinary tract infection (UTI) and pain-associated complications. UTI was encountered in 5 vs 3 patients in groups (A) and (B), respectively (p<0.05). No occurrences of sepsis in either group. Therewas no calyceal rupture or intraoperative extravasation in either cohort. CONCLUSIONS: Pressurized irrigation in the absence of UAS during URS appears to be safe. There was no significant difference in procedure times and, although there were more complications and ED visits in the hand irrigation group, many of these were experienced by a single patient who experienced a significant number of complications.

Juxta-adrenal Ancient Schwannoma: A Rare Retroperitoneal Tumor.

Retroperitoneal schwannoma is a rare tumor that is often misdiagnosed as malignancy due to a concerning appearance on cross-sectional imaging. Pathology and immunohistochemistry form the gold standard for diagnosis; as such, local excision is the treatment of choice for this disease. We present two cases of juxta-adrenal ancient schwannoma that were treated with adrenalectomy and discuss the current literature regarding this entity.