Frederiek D'Hondt

Agreement of Gleason Score on Prostate Biopsy and Radical Prostatectomy Specimen: Is There Improvement With Increased Number of Biopsy Cylinders and the 2005 Revised Gleason Scoring?

INTRODUCTION The objectives of this study were to assess the agreement of GS on biopsy compared with RP specimens and to assess whether an increased number of biopsy cylinders and the 2005 International Society of Urological Pathology (ISUP) GS modification improved this agreement. MATERIALS AND METHODS Pathological data of biopsy and RP specimens were analyzed in 328 consecutive patients, before (group 1; n = 135) and after (group 2; n = 193) implementation of the 2005 ISUP modification. Additionally, patients had more biopsy cylinders taken in group 2 (mean 10 vs. 6.9). The agreement of GS between biopsy and RP specimens was evaluated using the kappa coefficient. GS was pooled into 3 grades: low- (GS ≤ 6), intermediate- (GS = 7), and high-grade (GS ≥ 8) prostate cancer. RESULTS Kappa coefficient for GS in group 1 and 2 was 0.261 and 0.341, respectively. For tumor grade, this was 0.308 and 0.359 for group 1 and 2, respectively. For RP specimens, there was more agreement between biopsy and RP GS in group 2 compared with group 1 (53.9% vs. 37.8%). Upgrading was almost exclusively (89.5%) seen in patients with biopsy GS ≤ 6 and was lower in group 2 (25.4% vs. 48.1%) because of classification of more intermediate- and high-grade tumors using the 2005 ISUP modification. Taking > 6 biopsy cylinders was associated with better GS and tumor grade agreement. CONCLUSION Extended biopsy template and the 2005 ISUP modification resulted in an improved agreement between biopsy GS and RP GS and a shift toward more aggressive tumors.

Low Pressure Robot-assisted Radical Prostatectomy With the AirSeal System at OLV Hospital: Results From a Prospective Study

Micro‐Abstract Limited studies examined the effects of pneumoperitoneum during robot‐assisted radical prostatectomy (RARP) and with AirSeal. The aim of this study was to assess the effect on hemodynamics of lower pressure pneumoperitoneum (8 mmHg) with AirSeal, during RARP in steep Trendelenburg 45°, proving how the combination of steep Trendelenburg, lower pressure pneumoperitoneum and the extreme surgeons experience allows to safely perform RARP using a low‐impact surgery. Background: Limited studies examined effects of pneumoperiotneum during robot‐assisted radical prostatectomy (RARP) and with AirSeal. The aim of this study was to assess the effect on hemodynamics of a lower pressure pneumoperitoneum (8 mmHg) with AirSeal, during RARP in steep Trendelenburg 45° (ST). Materials and Methods: This is an institutional review board‐approved, prospective, interventional, single‐center study including patients treated with RARP at OLV Hospital by one extremely experienced surgeon (July 2015‐February 2016). Intraoperative monitoring included: arterial pressure, central venous pressure, cardiac output, heart rate, stroke volume, systemic vascular resistance, intrathoracic pressure, airways pressures, left ventricular end‐diastolic and end‐systolic areas/volumes and ejection fraction, by transesophageal echocardiography, an esophageal catheter, and FloTrac/Vigileo system. Measurements were performed after induction of anesthesia with patient in horizontal (T0), 5 minutes after 8 mmHg pneumoperitoneum (TP), 5 minutes after ST (TT1) and every 30 minutes thereafter until the end of surgery (TH). Parameters modification at the prespecified times was assessed by Wilcoxon and Friedman tests, as appropriate. All analyses were performed by SPSS v. 23.0. Results: A total of 53 consecutive patients were enrolled. The mean patients age was 62.6 ± 6.9 years. Comorbidity was relatively limited (51% with Charlson Comorbidity Index as low as 0). Despite the ST, working always at 8 mmHg with AirSeal, only central venous pressure and mean airways pressure showed a statistically significant variation during the operative time. Although other significant hemodynamic/respiratory changes were observed adding pneumoperitoneum and then ST, all variables remained always within limits safely manageable by anesthesiologists. Conclusion: The combination of ST, lower pressure pneumoperitoneum and extreme surgeons experience enables to safely perform RARP.

MP24-03 ROBOTIC-ASSISTED URETERAL REIMPLANTATION WITH PSOAS HITCH: EXPERIENCE IN 21 PATIENTS

INTRODUCTION AND OBJECTIVES: Robot-assisted surgery represents a feasible and less challenging minimally-invasive option for complex urological reconstructive procedures, including ureteral reimplantation with psoas hitch. Published experience in this field is still limited. We report our 10-year experience of this technique from a tertiary care center. METHODS: All patients that underwent ureteral reimplantation with psoas hitch technique between 2006 and 2016 at our institution were included in this study. The robotic system was used in 4-arm configuration with the addition of 2 assistant ports. The transperitoneal approach and tunneled nonrefluxing ureteral anastomosis was performed in all patients. The psoas hitch was performed using a 1-0 suture. The perioperative complications were described according to Clavien-Dindo classification. RESULTS: 21 patients (11 men and 10 women) underwent robot-assisted ureteral reimplantation with psoas hitch technique. The median age was 66 years (IQR 41,73), body mass index 24 kg/m (IQR 23,28) and Charlson Comorbidity Index 1 (IQR 0,2). In 2 (9,5%) patients the procedure was performed for bilateral pathology. 11 (52,4%) patients were symptomatic; of these 7 (33,3%) had pain, 2 (9,5%) hematuria and 2 (9,5%) pyelonephritis. 17 (81,0%) patients had hydronephrosis at the diagnosis. Indication for surgery was distal ureteral tumor in 7 (33,3%) patients, iatrogenic ureteral injury in 7 (33,3%), external ureteral compression in 4 (19,1%), vesicoureteral reflux in 2 (9,5%) and 1 (4,8%) patient had distal ureteral fibrosis of unknown origin. 13 (61,9%) patients had previous surgery near the distal ureter. Median operative time was 150 minutes (IQR 120,180). Mean blood loss was 30 mL (IQR 30,50). The all grade complication rate was 28,6%; five grade 1 (two prolonged pain, two transient paresthesia of the thigh and one urinary tract infection) and one grade 3 complication (bleeding required surgical revision) occurred. Median hospital stay was 5 days (IQR 4,7) and catheter time 7 days (IQR 6,10). Ureteral stent was placed in 13 patients and left in place for a median time of 30 days (IQR 20,42). After a median follow-up of 15 months (IQR 15,23) all patients were asymptomatic with no signs of hydronephrosis. Most of the patients improved renal function and none of them had a significant postoperative worsening of it. CONCLUSIONS: This series represents the largest singleinstitution experience with robot-assisted ureteral reimplantation with psoas hitch technique and long follow-up. It represents a safe and effective technique with excellent outcomes and limited morbidity.