David Kakiashvili

Pathological stage review is indicated in primary pT1 bladder cancer

Study Type – Diagnosis (case series)u2028Level of Evidenceu20034

Long-term follow-up of T1 high-grade bladder cancer after intravesical bacille Calmette-Guérin treatment

Study Type – Therapy (cohort) Level of Evidenceu20032b

Chemoprevention of bladder cancer

Epidemiologic and experimental evidence has implicated environmental carcinogens in the etiology of bladder cancer. However, many cases arise with no apparent exposure to known carcinogens, and many individuals with obvious exposure never develop bladder cancer. As with other malignancies, it is likely that bladder carcinogenesis involves aberrations in cell diVerentiation and proliferation, often with derangements in the genetic composition of malignant cells. In the majority of human malignancies, particularly those arising in middle age or in later life such as bladder cancer, these acquired alterations in DNA often lead to either the induction of oncogenes or the negation of tumor suppressor genes, resulting in a malignantly transformed cell. The eVects of the inducing agents, be they viruses, chemical carcinogens, or other chemical/ physical stimuli (such as ultraviolet light or radiation), often result from the direct exposure of host cells to these agents. However, inherited, acquired, and anatomic factors, including those that regulate processes such as the metabolism of chemicals, and the excretion and delivery of those metabolites to potential target cells, help determine which individuals with similar exposures develop malignancies and in which sites. Additionally, because mechanisms usually exist in all cells to repair mutated or miscopied DNA or to aVect the death of those cells that contain such altered DNA, escape from such safeguards must occur in most, if not all, malignancies. Surely, all these inXuences play important roles in determining who develops bladder cancer. Urothelial cancer often behaves as a Weld change disease in which the entire urothelium from the renal pelvis to the urethra is susceptible to malignant transformation. The multiple occurrences and recurrences of urothelial tumors that are treated by local resection are highly characteristic of this disease. However, urothelial carcinoma cells can also implant and probably migrate to other sites of the urothelium, thus making it diYcult to determine whether a recurrent tumor represents an inadequately treated initial tumor, tumor implantation/migration, or the eVects of multifocal carcinogenesis. On the basis of clinical and experimental data, it is likely that all these factors are important. D. J. Golijanin (&) · R. R. Madeb · E. M. Messing Urology Department, University of Rochester Medical Center, 601 Elmwood Avenue, P.O. Box 656, Rochester, NY 14642, USA e-mail: Dragan_Golijanin@URMC.Rochester.edu

MP75-10 TAILORING ANTIBIOTIC PROPHYLAXIS FOR URETEROSCOPIC PROCEDURES BASED ON LOCAL RESISTANCE PROFILES MAY LEAD TO REDUCED RATES OF INFECTIONS AND UROSEPSIS

INTRODUCTION AND OBJECTIVES: The insertion of double J ureteral catheters is a common practice in modern urology. Unfortunately, different symptoms may occur with indwelling stents, such as dysuria, hematuria, flank and suprapubic pain. The objective of the present study was to evaluate the safety and efficacy of levobupivacaine as an intravesical instillation in the control of pain and urinary symptoms generated by the ureteral stent. METHODS: 77 patients with double J catheter (Percuflex 26/6 TM, Boston Scientific) after endoscopic treatment of an ureteral stone were randomized into 2 groups. Both groups received standard therapy for catheter discomfort management (paracetamol, ketorolac and tamsulosine). At the end of the procedure group 1 received instillation of 30 cc of saline and group 2 received a dose of 150 mg (30 cc) of intravesical levobupivacaine. Surgeon and patient were blinded for type of instillation received. Symptomatology was evaluate at 4 and 24 hours after the procedure and at the moment of catheter removal. The USSQ survey, in its Spanish-validated version, was used for this purpose. Plasma levels of levobupivacaine were measured at 5, 10, 15 and 20 minutes after instillation in both groups. RESULTS: Both groups were comparable in terms of age, location and size of stone treated , duration of procedure, stone free rate and days of catheter permanence. Statistical analysis showed significant reduction in group 2 regarding the intensity of pain at 4 hours postoperatively (p 1⁄4 0.02). In addition, during the catheter carrying period, those patients in whom the levobupivacaine solution was applied had less alteration in work activities (p 1⁄4 0.03), and less discomfort in the sexual sphere (p 1⁄4 0.01) Plasma levels of levobupivacaine in the 40 patients exposed to the drug were undetectable (<0.1 mg / dL). There were no side effects attributable to intravesical levobupivacaine. CONCLUSIONS: To our knowledge this is the first clinical trial using levobupivacaine in bladder instillation, which demonstrate better pain control in the immediate postoperative period. There is a significant effect on daily life parameters that could allow better tolerance to the catheter during the time it should remain installed. Also, the use of this substance does not imply a higher cost and its safe, without side effects.

PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION FOR CLINICAL LOW STAGE NONSEMINOMATOUS GERM CELL TESTICULAR TUMORS

498 PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION FOR CLINICAL LOW STAGE NONSEMINOMATOUS GERM CELL TESTICULAR TUMORS David Kakiashvili*, Lynn Anson-Cartwright, Malcolm Moore, Jeremy F G Sturgeon, Alvaro Zuniga, Padraig R Warde, Peter Chung, Justin Liu, Clement Ma, Michael A S Jewett. Toronto, ON, Canada. INTRODUCTION AND OBJECTIVE: Non-risk adapted surveillance is the recommended standard of care for clinical stage I non-seminomatous germ cell testis tumors (NSGCTT) at the Princess Margaret Hospital Testis Tumor Clinic. Primary bilateral retroperitoneal lymph node dissection with sympathetic nerve sparing when feasible (NS-RPLND) is offered as an alternative at patient request and when surveillance is contraindicated. Small volume stage II patients with low marker levels are offered surgery as they usually do not need subsequent chemotherapy. We have evaluated our experience with primary RPLND. METHODS: The charts of the 120 consecutive patients from the Princess Margaret Hospital Testis Tumor Clinic with clinical low stage NSGCTT who underwent primary NS-RPLND between November 1984, when NS was introduced, and October 2007 were reviewed. Adjuvant chemotherapy was offered if resected disease was extensive or pathological characteristics were adverse. Perioperative tumor characteristics, histology, need for additional treatment and functional outcomes, including loss of antegrade ejaculation were assessed. Survival outcomes were generated using the Kaplan-Meier method. RESULTS: The median age at diagnosis was 28.6 years. The median time of follow-up was 4.9 years (0.02 20.89 ). 51 patients (42.5%) were clinical stage I and 69(57.5%) were stage II (61-IIA and 8 IIB). Of those with initial stage I, 20 underwent immediate RPLND and 31 at progression to clinical stage II ( 25 IIA and 6-II B).Outcomes were similar for these groups. Laparotomy revealed grossly enlarged lymph