Dennis J. Robins

Predictors of biochemical recurrence after primary focal cryosurgery (hemiablation) for localized prostate cancer: A multi-institutional analytic comparison of Phoenix and Stuttgart criteria

BACKGROUND The Phoenix definition (PD) and Stuttgart definition (SD) designed to determine biochemical recurrence (BCR) in patients with postradiotherapy and high-intensity focused ultrasound organ-confined prostate cancer are being applied to follow patients after cryosurgery. We sought to identify predictors of BCR using the PD and SD criteria in patients who underwent primary focal cryosurgery (PFC). MATERIALS AND METHODS We performed a retrospective review of patients who underwent PFC (hemiablation) at 2 referral centers from 2000 to 2014. Patients were followed up with serial prostate-specific antigen (PSA). PSA levels, pre- and post-PFC biopsy, Gleason scores, number of positive cores, and BCR (PD = [PSA nadir+2ng/ml]; SD = [PSA nadir+1.2ng/ml]) were recorded. Patients who experienced BCR were biopsied, monitored carefully or treated at the discretion of the treating urologist. Cox regression and survival analyses were performed to assess time to BCR using PD and SD. RESULTS A total of 163 patients were included with a median follow-up of 36.6 (interquartile range: 18.9-56.4) months. In all, 64 (39.5%) and 98 (60.5%) experienced BCR based on PD and SD, respectively. On multivariable Cox regression, the number of positive pre-PFC biopsy cores was an independent predictor of both PD (hazard ratio [HR] = 1.4, P = 0.001) and SD (HR = 1.3, P = 0.006) BCRs. Post-PFC PSA nadir was an independent predictor of BCR using the PD (HR = 2.2, P = 0.024) but not SD (HR = 1.4, P = 0.181). Survival analysis demonstrated a 3-year BCR-free survival rate of 56% and 36% for PD and SD, respectively. Of those biopsied after BCR, 14/26 (53.8%) using the PD and 18/35 (51.4%) using the SD were found to have residual/recurrent cancer. Of those with prostate cancer on post-PFC biopsy, 57.1% of those with BCR by the PD and 66.7% of those with BCR by the SD were found to have a Gleason score ≥7. CONCLUSION Both the PD and the SD may be used to determine BCR in post-PFC patients. However, the ideal definition of BCR after PFC remains to be elucidated.

Timing and Predictors of Early Urologic and Infectious Complications After Renal Transplant: An Analysis of a New York Statewide Database

OBJECTIVES The most common complications after renal transplant are urologic and are a cause of significant morbidity in a vulnerable population. We sought to characterize the timing and predictors of urologic complications after renal transplant using a statewide database. MATERIALS AND METHODS We queried the New York Statewide Planning and Research Cooperative System database to identify patients who underwent renal transplant from 2005 to 2013. Postoperative complications included hydronephrosis, ureteral stricture, vesicoureteral reflux, nephrolithiasis, and urinary tract infections. Cox proportional hazards model was used to assess independent predictors of urologic complications. RESULTS In total, 9038 patients were included in the analyses. Urologic complications occurred in 11.3% of patients and included hydronephrosis (12.0%), nephrolithiasis (2.8%), ureteral stricture (2.4%), and vesicoureteral reflux (1.5%). We found that 23% experienced at least one urinary tract infection. On multivariate analysis, predictors of urologic complications included medicare insurance, hypertension, and prior urinary tract infection. Graft recipients from living donors were less likely to experience urologic complications than deceased-donor kidney recipients (P < .001). CONCLUSIONS Urologic complications occur in a significant proportion of renal transplants. Further study is needed to identify risk factors for complications after renal transplantation to decrease morbidity in this vulnerable population.

MP86-17 THE 2017 AMERICAN JOINT COMMITTEE ON CANCER EIGHTH EDITION CANCER STAGING MANUAL: CHANGES IN STAGING GUIDELINES FOR CANCERS OF THE KIDNEY, RENAL PELVIS AND URETER, BLADDER, AND URETHRA

improve risk stratification for patients who are perceived as higher risk. To date, no published studies describe treatment patterns for Veterans following use of genomic tests. This study compares treatment patterns before and after introduction of the GPS assay within 6 VAMCs. METHODS: Men with newly diagnosed, NCCN very low, low, or intermediate risk PCa were eligible. We established treatment patterns in an untested patient cohort by reviewing charts from 2013-2014. From 2015-2016, we introduced the GPS assay within these same VAMCs in a prospective study. Six months after biopsy results, we reviewed charts to establish treatments patterns for both untested and tested Veterans. RESULTS: There were 200 men in the untested cohort and 190 men in the tested cohort. Patient characteristics were similar across groups. AS increased by 12% overall. The largest increase was among patients under age 60 (33% increase). AS increased in all NCCN risk groups with the largest increases in NCCN low risk (16%) and across racial subgroups (11% Caucasian, 16% Black, 20% Other). Veterans exposed to AO showed a small decrease in AS, while Veterans without exposure showed a 19% increase in AS. Median GPS was similar across racial groups and between Veterans exposed and not exposed to AO. CONCLUSIONS: In clinically similar cohorts of untested and tested Veterans, implementation of the GPS assay increased use of AS across all age, risk, and racial groups. The assay showed similar biological risk between Caucasians and Blacks and Veterans exposed and not exposed to AO. GPS may be a useful tool to refine risk assessment of PCa and to increase the already high rates of AS among clinically and biologically low risk patients, regardless of their race and AO exposure. Future studies of Black and AO exposed Veterans, including persistence on AS, are needed confirm these findings.

Systematic Review and Meta-Analysis on the Efficacy of Chemotherapy with Transurethral Resection of Bladder Tumors as Definitive Therapy for Muscle Invasive Bladder Cancer

Background: Bladder-sparing treatment of muscle invasive bladder cancer (MIBC) with systemic chemotherapy plus transurethral resection of bladder tumors (TURBT) is increasingly seen in the literature –both in case series and subanalyses of patients who opt out of or are unfit for radical cystectomy (RC). Survival outcomes among these patients are often impressive, but these are typically small retrospective studies from single institutions and therefore of limited clinical value. Objectives: Our aim is to summarize the literature regarding definitive treatment of MIBC with systemic chemotherapy plus TURBT and provide a meta-analysis of survival outcomes for patients who received this treatment. Methods: A systematic literature search was performed consistent with the Prisma statement to identify publications reporting the outcomes of patients treated with TURBT and systemic chemotherapy as definitive treatment for locally confined MIBC. Identified studies were screened in a two-stage process: first by title and abstract; then by full-text reading. 18 publications (518 patients) were included in the qualitative systematic review and 10 publications (266 patients) were included in the meta-analysis. The primary objective was overall survival (OS). Results: Overall survival ranged from 20% to 87.5% across studies at median follow-up ranging 4 to 120 months. 5-year survival rate for all patients included in the meta-analysis was estimated to be 72% [95% CI: 64%, 82%]. Conclusions: Definitive treatment with systemic chemotherapy plus TURBT can lead to favorable survival outcomes in select patients. Further study to improve patient selection for this method of treatment is needed.

Collecting duct carcinoma of the kidney: Disease characteristics and treatment outcomes from the National Cancer Database

OBJECTIVE To use a large population-level database to assess survival outcomes for collecting duct renal cell carcinoma (CDRCC). MATERIALS AND METHODS The National Cancer Database was queried for all cases of CDRCC and clear cell renal cell carcinoma (CCRCC) from 2004 to 2013. After removing patients with other cancer diagnoses, the analytic cohort was composed of 201,686 CCRCC and 577 CDRCC cases. Kaplan-Meier and cox proportional hazards analysis were employed to model survival. RESULTS Compared to CCRCC, patients with CDRCC presented with higher grade and stage, node positive, and metastatic disease (70.7% vs. 30.0% with metastasis; P<0.001). Overall median survival for CDRCC was 13.2 months (95% CI: 11.0-15.5) compared to the 122.5 months (95% CI: 121.0-123.9) for CCRCC. On multivariate analysis of the CDRCC cohort, increasing T stage, high-grade disease, and metastasis were predictors of mortality. Of 184 patients with metastatic CDRCC, 113 underwent cytoreductive nephrectomy (CNx) whereas the rest were treated with chemo/radiation or observed. Survival outcomes were improved in patients who received both CNx with chemo/radiation compared to CNx alone (hazard ratio = 0.51, 95% CI: 0.32-0.79) or chemo/radiation alone (hazard ratio = 0.57, 95% CI: 0.37-0.89) on multivariate analysis. CONCLUSION CDRCC is an aggressive subtype of renal cell carcinoma. Median survival is 13 months after diagnosis, drastically lower than for CCRCC. More than 70% of patients have metastatic disease at diagnosis. Chemo/radiation in addition to CNx is associated with a survival benefit over single mode therapy.

Conservative Management Following Complete Clinical Response to Neoadjuvant Chemotherapy of Muscle Invasive Bladder Cancer: Contemporary Outcomes of a Multi-Institutional Cohort Study

Purpose We report the outcomes in patients with muscle invasive bladder cancer from 2 institutions who experienced a clinically complete response to neoadjuvant platinum based chemotherapy and elected active surveillance. It was unknown whether conservative treatment could be safely implemented in these patients. Materials and Methods We retrospectively reviewed the records of patients with muscle invasive bladder cancer at our institutions who elected surveillance following a clinically complete response to transurethral resection of bladder tumors and neoadjuvant chemotherapy from 2001 to 2017. A clinically complete response was defined as absent tumor on post‐chemotherapy transurethral resection of bladder tumor, negative cytology and normal cross‐sectional imaging. Results In the 148 patients followed a median of 55 months (range 5 to 145) the 5‐year disease specific, overall, cystectomy‐free and recurrence‐free survival rates were 90%, 86%, 76% and 64%, respectively. Of the patients 71 (48%) experienced recurrence in the bladder, including 16 (11%) with muscle invasive disease and 55 (37%) with noninvasive disease. Salvage radical cystectomy prevented cancer specific death in 9 of 12 patients (75%) who underwent cystectomy after muscle invasive relapse and in 13 of 14 (93%) after noninvasive relapse. Conclusions We observed high rates of overall and disease specific survival with bladder preservation in patients who achieved a clinically complete response to neoadjuvant chemotherapy. These outcomes support the safety of active surveillance in carefully selected, closely monitored patients with muscle invasive bladder cancer. Future studies should aim to improve patient selection by identifying biomarkers predicting invasive relapse and developing novel imaging methods of early detection.

MP36-13 CHANGES IN NOCTURNAL BLADDER DIARY PARAMETERS IN MEN AFTER URETHROPLASTY FOR ANTERIOR URETHRAL STRICTURES

underwent placement of an artificial urinary sphincter, of which 2 required explantation/revision. At the time of updated followup (mean 45.6 27.1 months), 15 patients were contacted. Two had died of unrelated causes. 53% of patients reported perineal pain (mean 2.1 1.3; 10-point scale). 43% reported residual problems related to the gracilis flap (one each with numbness, weakness, limited groin mobility, difficulty walking/climbing stairs, occasional leg cramping, and leg swelling). 80% of patients reported urinary incontinence, the majority with occasional mild leakage. Two patients reported fecal incontinence.21% of patients were unable to do the things they wanted in their daily lives due to the surgery. 80% reported the surgery led to a positive change in their lives (mean satisfaction 3.5 0.7, 4-point scale). 87% of patients would undergo surgery again, and 80% would recommend it to others. Nine patients reported they would have done things differently: 4 sought different treatment/provider for RUFinciting medical condition, 3 RUF repair sooner, 2 see a reconstructive specialist in lieu of local repair, 1 request bilateral over unilateral gracilis flap. None would have opted for complete urinary diversion. CONCLUSIONS: RUF repair leads to patient satisfaction and improvement in QOL, despite possible residual issues such as perineal pain and urinary incontinence. Definitive RUF repair should be offered to radiated and non-radiated patients who are suitable operative candidates.

MP70-20 PREDICTORS AND UTILIZATION OF ABLATIVE THERAPIES IN NEW YORK STATE

INTRODUCTION AND OBJECTIVES: With the increased incidence of low-risk prostate and renal cancer, minimally invasive treatment options have become more desirable. In selected patients, focal ablative therapies offer less morbidity while achieving comparable outcomes to extirpative surgery. We describe patterns of usage of such therapies within a statewide database. METHODS: We queried the New York Statewide Planning and Research Cooperative System database to identify patients who underwent any focal ablative treatment for prostate or renal malignancy from 2001-2014 using CPT codes (55873, 53852, 53850, 50593, 50250, 50592, 50542), ICD-9-CM procedure codes (55325535, 6096, 6097), and ICD-9-CM diagnosis codes (185, 189.0, 189.1, 198.0). Medical comorbidities are also available. Hospital specific characteristics were obtained using available information from the New York Department of Health and the American Hospital Association. High volume centers were defined as the five highest volume hospitals according to number of ablative procedures. Logistic regression was performed to determine independent predictors of utilization. RESULTS: The final cohort included 1872 prostate ablations and 989 renal ablations. The five highest volume prostate and renal ablation centers performed 1173 (62.7%) and 376 (38.0%) cases, respectively. Demographic information is displayed in Table 1. On multivariate analysis, treatment with prostate ablation was associated with black race (OR 0.27, 95%CI 0.19-0.39, p<0.001), increasing age (OR 0.98, 95%CI 0.967-0.998, p1⁄40.03), teaching hospital status (OR 3.32, 95%CI 2.34-4.71, p<0.001), and number of beds (OR 1.002, 95%CI 1.001-1.002, p<0.001). For renal ablation, significant predictors on multivariate analysis were black race (OR 0.46, 95%CI 0.25-0.84, p1⁄40.012), other non-white race (OR 0.48, 95%CI 0.29-0.79, p1⁄40.004), number of beds (OR 1.001, 95%CI 1.000-1.001, p<0.001), and higher Elixhauser comorbidity index (OR 1.017, 95%CI 1.002-1.033, p1⁄40.025). CONCLUSIONS: In New York State, the use of ablative therapies is largely limited to academic institutions in urban areas, yet minority populations are significantly less likely to undergo such procedures. Future study should focus on identifying the barriers to treatment and what impact this might have on disease outcomes among different populations.

MP79-14 PENILE FRACTURE INCIDENCE AND PHYSICIAN COMPLIANCE WITH UROTRAUMA GUIDELINES IN NEW YORK STATE

INTRODUCTION AND OBJECTIVES: The importance of psychosocial and sexual outcomes for patients after glansectomy or partial penectomy cannot be overstated. Penile lenght preservation and a good cosmetic apearence are essential for good functional outcomes. Despite the popular use of different skin flaps to cover the distal penile shaft, the use of grafts have been increasing during the last years. The objective of this study is to evaluate the experience with skin graft glanuloplasty. METHODS: The charts of 17 patients submitted to a total glansectomy or a partial penectomy and to a glanuloplasty with a skin graft were analysed. The age of the patients ranged from 58 to 76 years (mean of 67 years). The mean follow-up time was 16 months (minimal follow-up of 6 months). The group included 15 patients with diagnosis of penile cancer (stages I or II) and 02 patients with complications after malleable penile implants. In all patients with penile cancer the disassembly technique principle (proposed to treat distal penile deformities) was used to achieve themaximumpenile lenght preservation (organ sparing surgery). After the mobilization of the complex urethra, glans, tumor, skin and dorsal plexus, a partial penectomy was performed in 4/15 patients (26,7%) and a total glansectomy in 11/15 (73,3%). After the oncological ressection, the glanuloplasty was performed. First, a corporoplasty to modify the shape of the distal penile shat ( to become more cylindrical) . After, the fixation of the spatulated urethra on the top penile shaft, the dorsal plexus and the penile skin creating an area for neoglans . A splitticknessskin grafts harvest from the thighwasused to the glanuloplasty in 14/17 patients ( 82,3%) and a full tickness skin graft in 3/17 cases (17,7%) Additional cosmetic procedures was used in 5 patients (29,4%) suspensory ligament release, ventral phaloplasty, and suprapubic lipectomy. RESULTS: None patients had local recurrences during the follow-up period. None urethral complications (meatal stenosis) were observed. All patients are able to urinate in a standing position. Erection was preserved in 12/17 patients (70,6%) and 8/12 (66,7%) refered sexual intercourse. The patients satisfaction was excellent and all patients were satisfied with the cosmetic results and considered that they expected a penile lenght lower and a worse cosmetic result than was observed in the postoperative period. CONCLUSIONS: The use skin graft glanuplasty in the scenario of the organ sparing glasectomy or partial penectomy seems to be a safe option for the treatment of penile cancer with involvement of the distal portion of the penile shaft, offering the high functional and cosmetic outcomes.

MP77-11 ASSESSMENT OF DISCOMFORT AND PAIN IN PATIENTS UNDERGOING FUSION-MRI-GUIDED VERSUS TRUS-GUIDED PROSTATE BIOPSY

INTRODUCTION AND OBJECTIVES: The diagnostic work-up of prostate cancer has experienced a rapid shift worldwide in recent years. This study aims to provide a current appraisal of the practice of prostate biopsy in Australia and New Zealand in the emerging era of transperineal template biopsy (TPB) and multiparametric MRI (mpMRI). METHODS: A 36-question online survey was distributed to 545 members of the Urological Society of Australia & New Zealand (USANZ), including consultant urologists and trainees. This was an updated survey, based on a similar questionnaire distributed to USANZ members in 2012, addressing patterns of prostate biopsy practice in 4 domains: transrectal ultrasound-guided (TRUS) biopsy; TPB; mpMRI and peri-operative antibiotic and analgesia use. Survey results were collated and statistical analysis was performed using descriptive statistics and chi-squared test. RESULTS: 155 participants completed the survey, with a response rate of 21.1%. 81.9% of respondents were consultant urologists and 66.5% worked in a metropolitan setting. 92.3% perform TRUS biopsy and 91.3% sample between 10-16 cores. 66.9% of respondents perform TPB, increased from 38.4% in 2012 (p<0.001). 59.4% perform mpMRI prior to initial biopsy, increased from 19.6% (p<0.001). 90.1% perform MRI prior to repeat biopsy after an initial negative biopsy. 97.2% use prophylactic oral antibiotics prior to TRUS biopsy, most commonly quinolones. 55.7% use parenteral antibiotics, compared to 69.4% previously (p1⁄40.013). 27.7% routinely use carbapenem prophylaxis in settings of recent overseas travel or quinolone exposure, compared to 27.9% in 2012 (p1⁄40.965). General anaesthetic/IV sedation is used for 60.6% of TRUS biopsies and 97.9% of TPB. CONCLUSIONS: Our survey demonstrates a shift in practice of biopsy for the diagnosis of prostate cancer among urologists in Australia & New Zealand, when compared with results of our initial study in 2012. More urologists are performing TPB now, and there has been a corresponding increase in the use of pre-initial biopsy mpMRI despite no current guidelines recommending this practice yet. There has been a reduction in the use of parenteral antibiotics overall, prior to TRUS biopsy, however, rates of carbapenem use have remained stable, suggesting ongoing concerns regarding the risk of sepsis due to antibiotic resistance.