Igor Nunes-Silva

Effect of Prior Focal Therapy on Perioperative, Oncologic and Functional Outcomes of Salvage Robotic Assisted Radical Prostatectomy

Purpose: We assessed the impact of focal therapy on perioperative, oncologic and functional outcomes in men who underwent salvage robotic assisted radical prostatectomy compared to primary robotic assisted radical prostatectomy. Materials and Methods: Focal therapy was performed in patients presenting with Gleason score 3 + 3 or 3 + 4, clinical stage cT2a or less, serum prostate specific antigen 15 ng/ml or less, unilateral positive biopsy, maximum length of any positive core less than 10 mm and life expectancy greater than 10 years. Focal therapy was defined as target ablation of the index lesion plus a 1 cm safety margin in the normal ipsilateral prostatic parenchyma. The salvage group included 22 men who underwent salvage prostatectomy after focal therapy failure. The primary group was defined using matched pair 1:2 selection of 44 of 2,750 patients treated with primary prostatectomy. The primary and secondary end points were the between group differences in functional and oncologic outcomes, respectively. Results: Complication rates were comparable (p >0.05). Pad‐free probability was comparable between the groups at 1 and 2 years (p = 0.8). Recovery of erectile function was significantly lower after salvage robotic assisted radical prostatectomy (p = 0.008), which also showed a significantly lower probability of cumulative biochemical recurrence‐free survival compared to primary robotic assisted radical prostatectomy (56.3% vs 92.4% at 2 years, p = 0.001). Salvage prostatectomy demonstrated a significantly increased risk of biochemical recurrence (HR 4.8, 95% CI 1.67–13.76, p = 0.004). Study limitations included the retrospective nature, the lack of randomization and the short followup. Conclusions: Salvage robotic assisted radical prostatectomy after focal therapy failure is feasible with acceptable complication rates. However, patients assigned to primary focal therapy should be advised about a poorer prognosis in terms of oncologic control and lower erectile recovery rates in case of a future salvage surgery.

Comparative Analysis of Partial Gland Ablation and Radical Prostatectomy to Treat Low and Intermediate Risk Prostate Cancer: Oncologic and Functional Outcomes

Purpose We analyzed the oncologic and functional outcomes of partial gland ablation compared with robot‐assisted radical prostatectomy in patients with low and intermediate risk prostate cancer. Materials and Methods A total of 1,883 patients underwent robot‐assisted radical prostatectomy and 373 underwent partial gland ablation from July 2009 to September 2015. We selected 1,458 of these participants for analysis, including 1,222 and 236 treated with robot‐assisted radical prostatectomy and partial gland ablation, respectively. Patients had a Gleason score of 3 + 3 or 3 + 4, clinical stage T2b or less, prostate specific antigen 15 ng/dl or less, unilateral disease and life expectancy greater than 10 years. Propensity score matching analysis (1:2) was applied in the overall robot‐assisted radical prostatectomy sample, which selected 472 patients for comparison. For partial gland ablation 188 men underwent high intensity focused ultrasound and 48 underwent cryotherapy. Oncologic outcomes were analyzed in terms of the need for salvage treatment. Partial gland ablation failure was defined as any positive control biopsy after treatment. Functional outcomes were assessed by validated questionnaires. Results Matching was successful across the 2 groups, although men treated with partial gland ablation were older (p <0.001). Mean followup in the partial gland ablation group was 38.44 months. Partial gland ablation failure was observed in 68 men (28.8%), including 53 (28.1%) treated with high intensity focused ultrasound and 15 (31.2%) treated with cryotherapy. Partial gland ablation was associated with a higher risk of salvage treatment (HR 6.06, p <0.001). Complications were comparable between the groups (p = 0.06). Robot‐assisted radical prostatectomy was associated with less continence recovery and a lower potency rate 3, 6 and 12 months after surgery (p <0.001). Conclusions In select patients with organ confined prostate cancer partial gland ablation offered good oncologic control with fewer adverse effects that required additional treatments. Potency and continence appeared to be better preserved after partial gland ablation.

Laparoscopic - assisted transpyelic rigid nephroscopy - simple alternative when flexible ureteroscopy is not available

ABSTRACT Introduction: In special situations such as malrotated or ectopic kidneys and UPJ stenosis treatment of renal lithiasis can be challenging. In these rare cases laparoscopy can be indicated. Objective: Describe the Laparoscopic-assisted rigid nephroscopy performed via transpyelic approach and report the feasibility. Patients and methods: We present two cases of caliceal lithiasis. The first is a patient that ESWL and previous percutaneous lithotripsy have failed, with pelvic kidney where laparoscopic dissection of renal pelvis was carried out followed by nephroscopy utilizing the 30 Fr rigid nephroscope to remove the calculus. Ideal angle between the major axis of renal pelvis and the rigid nephroscope to allow success with this technique was 60-90 grades. In the second case, the kidney had a dilated infundibulum. Results: The operative time was 180 minutes for both procedures. No significant blood loss or perioperative complications occurred. The bladder catheter was removed in the postoperative day 1 and Penrose drain on day 2 when patients were discharged. The convalescence was completed after 3 weeks. Patients were stone free without symptons in one year of follow-up. Conclusions: Laparoscopic-assisted rigid nephroscopy performed via tranpyelic approach can be done safely with proper patient selection and adherence to standard laparoscopic surgical principles. This approach is an alternative in cases where flexible endoscope is not available and when standard procedure is unlikely to produce a stone-free status.

PD72-09 EARLY OUTCOMES OF FOCAL BRACHYTHERAPY FOR LOCALIZED PROSTATE CANCER: COMPARISON WITH WHOLE GLAND BRACHYTHERAPY.

radical prostatectomy (RP) but does not include multiparametric pelvic MRI (mpMRI). Here, we evaluate the utility of mpMRI in predicting sXRT failure after RP. METHODS: Men undergoing RP at Mayo Clinic from 20032015 who had biochemical recurrence and received sXRT were included in a retrospective chart review. Men who underwent prostate cancer treatment prior to RP, received adjuvant XRT, or who were hormone refractory at sXRT were excluded. Patients with mpMRI within 12 months of sXRT were retained. mpMRI lesions were grouped according to location: vesicourethral, seminal vesical (SV) bed / prostate fossa, pelvic nodes, pelvic bones. If no lesion was present, the mpMRI was categorized as negative. Standard descriptive statistics and multivariable cox regression analyses were performed to assess the impact of mpMRI on PSA recurrence after sXRT. Models were adjusted for the variables in the Stephenson Nomogram: PSA at RP, PSA prior to sXRT, PSA doubling time, hormone therapy with sXRT, sXRT dosage, extracapsular extension, SV invasion, pathologic Gleason score, margin status, and pN stage. RESULTS: Overall, 473 men had mpMRI prior to sXRT (median PSA at sXRT 0.45ng/ml). Of these, 56.9% (204) had an indeterminate or suspicious lesion on MRI: 25.6% (124) vesicourethral, 27.8% (135) SV bed / prostatic fossa, 7.0% (34) pelvic node, and 0.6% (3) pelvic bone. Median PSA with a visible lesion on mpMRI was 0.45ng/ml. At a median follow up of 42 months after sXRT, 29.3% (142) had PSA recurrence and 14.0% (68) had distant metastasis. Patients without a mpMRI lesion or with a suspicious nodal/bone lesion had higher rates of PSA recurrence at 4 years compared to those with vesicourethral/SV/prostate fossa lesions alone: 39.5% vs 21.9% (p<0.001), Figure 1. On multivariable analysis, patients without a mpMRI lesion or a suspicious nodal/bone lesion were significantly more likely to have PSA recurrence (HR 2.41, 95% CI 1.52-3.83, p<0.001) after adjusting for variables in the Stephenson Nomogram. CONCLUSIONS: Pre-sXRT mpMRI is a valuable tool in risk stratifying men undergoing sXRT. The median PSA with a visible lesion on mpMRI was 0.45ng/ml, supporting the use of mpMRI in the early sXRT setting.

PD73-06 COMPARATIVE TRIFECTA OUTCOMES AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY (LPN): CLAMPING VERSUS OFF-CLAMPING FOR HIGH COMPLEXITY RENAL SCORE TUMORS

INTRODUCTION AND OBJECTIVES: The duration of renal ischemia is the largest modifiable risk factor during partial nephrectomy. The shorter the warm ischemia time during LPN the lower the effect on long-term renal function. Real advantages of offclamping LPN compared with clamping surgery are not yet sufficiently studied. Few studies reported results of off-clamping LPN for high RENAL score cases. We compared Trifecta outcomes of the LPN with and without clamping stratifying cases through nephrometric RENAL score. METHODS: A total of 109 cases classified as low-complexity (54), intermediate-complexity (33) and high-complexity (22) underwent clamping (55) or off-clamping (54) laparoscopic partial nephrectomy and were compared in each group (clamping x off-clamping LPN). Clamping technique was performed with cold scissors intended to obtain 0.5cm of free surgical margins. Off-clamp technique was performed with harmonic scalpel close to the plane of enucleating to achieve minimal surgical margins. Renal function was measured at 1, 6 and 12 months postoperatively. All enrolled patients had normal contralateral kidney. Trifecta (Trifecta criteria: Clavien 2, negative-margins, and warm ischemia time 20 min) outcomes were analyzed and compared between the groups stratified by the nephrometric RENAL score. RESULTS: Trifecta achievement was similar in both groups for low complexity tumors (p < 0.31). The off-clamping group achieved higher trifecta rates for the intermediate (87.5% x 23.5%, p < 0.001) and high (83% x 0%, p < 0.005) complexity tumors. Patients with off-clamp technique had higher mean blood loss (150 X 400 ml) with no difference in blood transfusions. In the clamping group, significant higher proportion did not achieve trifecta (45.5% x 7.4%, p < 0.001). After 1 year, the difference of remnant renal function was 10% more for patients with off clamp surgery with high complexity RENAL score CONCLUSIONS: Off-clamping pure LPN was associated to accomplish higher trifecta rates for intermediate and high complexity RENAL score tumors. Long-term renal function was slightly better for off clamp group. It is unclear if off-clamp technique or differences in the amount resected of renal parenchyma were responsible for observed differences.

PD56-06 NEW FRONTIERS AHEAD FOCAL THERAPY POSTOPERATIVE FOLLOW-UP: WHAT IS THE REAL ROLE OF MRI IN THIS SETTING?

INTRODUCTION AND OBJECTIVES: Several studies have demonstrated the risk of upgrade from prostate biopsy (PBx) to radical prostatectomy (RP) pathology to be as high as 40%. The objective of the current study is twofold: to evaluate the prostate cancer upgrading on RP in a cohort of patients who underwent MRI-TRUS fusion biopsy (FBx) prior to RP and to determine if saturation of index tumor (IT) during PBx decreases this risk of upgrading. METHODS: Clinical and pathologic data from a prospectively maintained single institution database was analyzed for patients who underwent both FBx and standard 12-core biopsy (Sbx) followed by RP (2010-16). Index tumor was defined as the tumor with the largest diameter on T2W MRI. Patients were considered to have a saturated index tumor (SIT) if they had a fusion target (consisting of one axial and one sagittal biopsy) taken for every 6mm of IT diameter, and were considered to have a nonsaturated index tumor (NSIT) if they had only one target assigned regardless of the size of IT. Gleason 6, Gleason 7 and Gleason 8 or above were defined as low, intermediate and high risk respectively. Gleason Upgrade was defined as a higher Gleason score on RP specimen compared to PBx. Risk category upgrade was defined as higher risk category on RP specimen. Chi square and McNemar0s test were used to compare rates of upgrade. RESULTS: 206 patients (91 with SIT and 115 with NSIT) were included in the study with median age and PSA of 61.5 (IQR 9.3) yrs and 7.38 (IQR 8) ng/ml respectively. Median number of biopsy cores per index tumor was 4 in the SIT group and 2 in the NSIT group (p<0.001) . For the entire cohort, highest Gleason score from combined Fbx/Sbx was upgraded on final pathology in 36 (17.5%) patients vs 95 (46.1%) patients when compared to Sbx only (p1⁄40.001). Risk category upgrade from combined Fbx/Sbx vs Sbx only was found in 26 (12.6%) vs 83 (40.3%), p<0.0001. Patients with SIT had lower Gleason upgrade (12.1% vs 21.7% , p 1⁄40.07) and significantly lower risk category upgrade (6 (6.6%) and 20 (17.4%), p1⁄40.02) compared to patients with NSIT. CONCLUSIONS: Ensuring that high risk cancer is not missed on biopsy is crucial to treatment planning in patients with prostate cancer. Our results demonstrate that the addition of mpMRI-TRUS Fbx significantly decreases the risk of upgrade on RP pathology, proving the efficacy of Fbx in accurately characterizing PCa preoperatively. Saturation of the index tumor further decreases the risk of upgrade on final pathology by extensive sampling and minimizing the impact of tumor heterogeneity.

PD56-07 CAN FOCAL THERAPY IMPACT ON PERIOPERATIVE, ONCOLOGICAL AND FUNCTION OUTCOMES IN MEN UNDERWENT FOCAL THERAPY SALVAGE ROBOTIC-ASSISTED RADICAL PROSTATECTOMY? A RETROSPECTIVE MATCHED-PAIR COMPARATIVE STUDY

INTRODUCTION AND OBJECTIVES: Salvage surgery is an option for recurrent prostate cancer(PCa) after focal therapy(FT). This is the first study to assess the impact of FT on surgical outcomes comparing salvage robotic-assisted radical prostatectomy(S-RARP) versus primary-RARP(P-RARP). We aimed to compare the impact of FT on perioperative, oncological and functional outcomes in men underwent S-RARP versus P-RARP. METHODS: Prospective data of 2775 men underwent RARP for localized PCa from 2000 to 2016 were reviewed. Twenty-five men underwent S-RARP after FT failure(S-RARP group). Total 2750 underwent RARP as primary treatment. Matched-pair 1:2 selection of 44 out of 2750 patients by age, IPSS and IIEF5 defined P-RARP group. Primary endpoint was between-groups differences on functional outcomes. Secondary endpoint was oncological data. p<0.05 was significant. RESULTS: Surgical time, transfusion and complication rates were comparable(p 0.05). Rates of continence probability[49.5%(SE 0.13) versus 62.4%(SE 0.08), p1⁄40.8 and 73%(SE 0.14) versus 76.5%(SE 0.07), p1⁄40.8, at 1 and 2 years, respectively] and the chance for achieving continence[HR 1.062, 95%CI 0.54-2.08, p1⁄40.861] were comparable between-groups. Potency recovery was significant lower on S-RARP at 1 year follow-up[3 2 versus 9.22 6.55, p1⁄40.008]. S-RARP showed significant lower rates of cumulative BCR-free survival probability[67.6%(SE 0.12) versus 95.1%(SE 0.03), p1⁄40.001 and 56,3%(SE 0.15) versus 92,4%(SE 0.04), p1⁄40.001, at 1 and 2 years, respectively]. S-RARP presented significant increased risk of BCR[HR 4.8, 95%CI 1.67-13.76, p1⁄40.004]. Upstaging was an independent predictor factor for BCR on S-RARP[HR 14.65, 95%CI 1.46-146.37, p1⁄40.022]. CONCLUSIONS: Salvage-RARP following FT failure is feasible and safe with acceptable complications rates. Patients assigned to FT should be previously advised about lower erectile recovery rates in case of a salvage surgery. Urologists may be warned about the risk of undertreatment in patients presenting failure along FT follow-up. Source of Funding: None

PD51-09 CONDITIONAL PROBABILITY OF BIOCHEMICAL RECURRENCE-FREE SURVIVAL AND CANCER-SPECIFIC MORTALITY AFTER RADICAL PROSTATECTOMY AT LONG TERM FOLLOW-UP

INTRODUCTION AND OBJECTIVES: Data on the oncologic outcomes of high-risk prostate cancer (HRPCa) patients at 20 years after radical prostatectomy (RP) are lacking. The aim of our investigation was to evaluate the long-term patterns of biochemical (BCR), clinical recurrence (CR), cancer specific mortality (CSM) and othercause mortality (OCM) in a multi-institutional database of surgicallytreated HRPCa patients. METHODS: We evaluated 2280 patients with HRPCa treated with RP and pelvic lymph node dissection at 3 tertiary care centers between 1986 and 2015. High-risk prostate cancer was defined according to D’Amico criteria. We estimated BCR and CR rates using the Kaplan-Meier method. The CSM and OCM rates were obtained using competing risk analyses. BCR, CR, and CSM were assessed after 20 years from surgery. Cox regression analyses assessed predictors of long-term oncological outcomes. RESULTS: Median follow-up was 210 months. Median age was 66 years. The 20-year overall BCR-free survival and CR-free survival rates were 36.7% and 76.3%. Overall, 1050 experienced BCR. The latest BCR was registered at 237 months after RP. Out of 1230 patients who experienced BCR, 394 (37.5%) developed CF, while 656 (62.5%) were CF-free at last follow-up. The latest CF was registered at 244 months from RP. Overall, 394 and 172 patients experienced OCM and CSM. The competing risk 20 years CSM and OCM rates were 12.4 and 30.8%. Overall, 74 patients (3.5%) had a follow up 20 years. Of those, 7 (9.2%) and 1 (1.3%) experienced CSM and OCM. The 25-year competing-risks OCM and CSM-free survival rates were 77.9 and 98.5%. Age at RP (HR1⁄40.97), pathological Gleason score 6 (HR1⁄43.73), time to BCR (HR1⁄41.01) and number of nodes removed (HR1⁄41.06) were predictors of being free from overall mortality at 20year follow up (all p 0.04). Among patients with a follow-up 20 years (n1⁄474), 39 (51.3%) experienced BCR at a median follow-up of 214 months. No patient developed BCR after 20 years from RP. Moreover, 12 (33.3%) developed CF within 20 years (median follow-up 231 months), while only 1 (1.5%) developed CF after 20 years from RP. CONCLUSIONS: Among HRPCa patients, CSM may still occur even after 20 years from RP. Therefore, long monitoring and follow-up should be prolonged even after this time point. Moreover, time to BCR was a strong predictor of reaching a long follow-up after surgery and should be considered as a main criterion to further stratify patients according to their risk of CF and mortality over time.

Un mayor número de cilindros de biopsia transrectal de próstata guiada por ultrasonido se asocia con una mayor pérdida de sangre y complicaciones perioperatorias en la prostatectomía radical asistida por robot

INTRODUCTION The local inflammatory process after prostate biopsies can have a negative impact on functional outcomes of radical prostatectomy. There is no evidence in literature demonstrating its impact on radical prostatectomy. OBJECTIVES To evaluate the impact of the number of TRUS core biopsies in the surgical morbidity and rate of positive margin on robot assisted radical prostatectomy (RARP). MATERIAL AND METHODS A prospectively maintained database of 2,054 RARPs in a single institution. Patients were further grouped into 2 groups based on the number of TRUS biopsy cores (G1≤12 cores; G2>12 cores). Multivariable logistic regression model was applied to analyze the impact of number of cores on complications. RESULTS A total number of 1,042 patients in the group 1 (≤12 cores) and 1,012 patients in the group 2 (>12 cores) were included. The rate of perioperative complications increased with higher number of biopsies (G1 6.4 vs. G2 8.5%; P=.03), but high grade complication (Clavien 3-4) were similar (G1 1.4 vs. G2 2.2%; P=.16). Positive surgical margin rates were similar in both groups (G1 11.8 vs. 9.98%; P=.2). At the multivariable logistic regression analysis shown that G2 had a 39% (OR 0.645) higher rate to experience perioperative complications during RARP. CONCLUSION Higher number of TRUS biopsy cores (>12) is associated to higher blood loss and perioperative complications during RARP. Careful preoperative evaluation for those patients underwent multiple biopsies or saturation protocols is mandatory. Application of longer intervals (>6 weeks) between biopsy and surgery may be advisable to minimize potential risks of surgical complications in patients may benefit from RARP. Further studies are still necessary to confirm these results.

PD3-04 LESS POSTERIOR RETROPERITONEOSCOPIC ADRENALECTOMY: STEP-BY-STEP TECHNIQUE DESCRIPTION AND COMPARISON WITH 3-PORTS LATERAL RETROPERITONEAL APPROACH

INTRODUCTION AND OBJECTIVES: When a biochemically active adrenal mass is found surgery is usually recommended. While partial adrenalectomy is gaining popularity for small adrenal masses, it is not clear which patients will benefit from adrenal sparing to preserve adrenal function in case of contralateral adrenal pathology. We reviewed the available literature to evaluate the frequency of bilaterality of adrenal involvement with most common primary adrenal tumors and frequency of other pathologies potentially threatening the health of the adrenal gland. METHODS: We reviewed the PUBMED literature to evaluate the reported bilaterality of primary adrenal tumors including hereditary and nonhereditary pheochromocytomas (PHEOs), aldosterone producing adenomas (APAs), and cortisol producing adenomas and identified 25 articles describing the frequency of bilaterality of adrenalmasses.Wealso reviewed the literature to assess the etiologies of adrenal damage due to other pathological processes that may affect the adrenal gland in the lifespan of a patient and calculated the combined probability for adrenal damage. RESULTS: Table 1 reports the bilaterality of adrenal tumors in hereditary and non-hereditary diseases and demonstrates that adrenal tumors range in bilaterality between 4.25 e 80%. Hereditary PHEOs were bilateral in up to 80% of cases, while nonhereditary PHEOs were bilateral in up to 25%. APAs were bilateral in about 4% of cases, while only case reports reported bilaterality in cortisol producing tumors. Additionally, review of other processes such as infections, infiltrative etiologies, metastasis to adrenal, and others accounted for about 1% chance for the adrenal damage from all possible causes. CONCLUSIONS: Partial adrenalectomy is a valid option for patients with hereditary syndromes as there is an increased likelihood of disease in the contralateral gland. PHEOs followed by APAs appear to have the highest rate of bilateral involvement. Coupled with a possibility that an additional 1% of the population may have adrenals affected by various pathologic processes, partial adrenalectomy in patients with PHEO and APAs should be strongly considered. Percentage of bilaterality of adrenal tumors in hereditary syndromes and non-hereditary disease