Jared S. Winoker

Predicting Complications Following Robot-Assisted Partial Nephrectomy with the ACS NSQIP® Universal Surgical Risk Calculator

Purpose: We evaluated the predictive value of the ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Program®) surgical risk calculator in a tertiary referral cohort of patients who underwent robot‐assisted partial nephrectomy. Materials and Methods: We queried our prospectively maintained, multi‐institutional database of patients treated with robot‐assisted partial nephrectomy and input the preoperative details of 300 randomly selected patients into the calculator. Accuracy of the calculator was assessed by the ROC AUC and the Brier score. Results: The observed rate of any complication in our cohort was 14% while the mean predicted rate of any complication using the calculator was 5.42%. The observed rate of serious complications (Clavien score 3 or greater) was 3.67% compared to the predicted rate of 4.89%. Low AUC and high Brier score were calculated for any complication (0.51 and 0.1272) and serious complications (0.55 and 0.0352, respectively). The calculated AUC was low for all outcomes, including venous thromboembolism (0.67), surgical site infection (0.51) and pneumonia (0.44). Conclusions: The ACS NSQIP risk calculator poorly predicted and discriminated which patients would experience complications after robot‐assisted partial nephrectomy. These findings suggest the need for a more tailored outcome prediction model to better assist urologists risk stratify patients undergoing robot‐assisted partial nephrectomy and counsel them on individual surgical risks.

Transgender patient care in urology: an evaluation of attitudes, knowledge, and practice patterns among urologists in the New York metropolitan area

Introduction: Transgender individuals suffer from significant health disparities, due in part to deficiencies in physician knowledge or comfort with addressing transgender health care needs. In this study we assessed the attitudes and clinical knowledge in caring for transgender patients of a representative sample of urologists in the New York metropolitan area. Methods: An anonymous, online based questionnaire was sent to members of the New York Section of the American Urological Association. Statements evaluating knowledge and attitudes toward transgender care were scored on a 5-point Likert scale. Results: A total of 92 providers (83.7% male) participated in the study, of whom 78.3% (72) have been in practice for at least 15 years. With respect to physician attitudes, there was a trend toward greater comfort with discussion of gender identity and counseling on gender confirmation surgery based on total number of transgender patients cared for during the course of their career. Regarding knowledge scores there were no significant associations with physician age, gender or years of practice. Despite the relatively weak self-reported fund of knowledge (2.64) and overall clinical competence (2.09), there was no overwhelming support to incorporate transgender care into urology training curricula (3.11). Conclusions: Despite growing education and awareness of transgender specific medical issues, many urologists self-report deficiencies in requisite knowledge and comfort in providing adequate, culturally competent care for transgender patients. Further work is needed to increase our collective comfort level with this new and evolving aspect of our field.

Effects of Feminizing Hormones on Sperm Production and Malignant Changes: Microscopic Examination of Post Orchiectomy Specimens in Transwomen

OBJECTIVE To examine post-orchiectomy specimens of transgender individuals to better understand the reproductive implications of hormonal therapy and to look for potential malignant or premalignant changes. MATERIALS AND METHODS A retrospective chart review was performed on the orchiectomy specimens from 135 TG individuals who underwent bilateral simple orchiectomy (54) or vaginoplasty with combined orchiectomy (81) at a single institution from 2014-2017. Factors examined included microscopic evidence of spermatogenesis, weight of specimens, evidence of malignant or premalignant changes, and patient demographic information. RESULTS Four percent (6/135) of all orchiectomy specimens had normal spermatogenesis in both testicles. Twenty-one percent (28/135) demonstrated some stage of spermatogenesis, of which 61% (17/28) were in maturational arrest. The median patient age at surgery was 30 years (range 18-76). Median overall testicle weight was 24 g (range 10.4-71.1), compared with 24 g (range 10-71g) in testicles without evidence of spermatogenesis and 26 g (range 17.9-40.9) in testicles with normal spermatogenesis. None of the specimens demonstrated premalignant or malignant changes. CONCLUSION Up to 21% of individuals undergoing a gender affirming surgery had microscopic evidence of spermatogenesis in varying stages. Furthermore, 4% of individuals had normal spermatogenesis. None of the specimens had malignant or premalignant changes. These findings may have implications for counseling transgender individuals on sexual and reproductive health and highlight the need for further research in this sector.

PD65-04 MR/US FUSION GUIDED ULTRA-FOCAL GOLD NANOPARTICLE DIRECTED LASER ABLATION OF PROSTATE TUMORS: RESULTS IN THE FIRST 11 PATIENTS (PHASE I/II TRIAL)

INTRODUCTION AND OBJECTIVES: Gold Nanoparticles (GNP) mediated laser ablation has been shown to be biocompatible and safe for the treatment of focal cancer. Herein, we report the first 11 cases in the world using GNP-directed focal laser ablation of prostate tumors using ultrasound (US) and MR/US fusion technology (NCT NCT02680535). METHODS: All patients were diagnosed with Gleason 7 or less prostate cancer with biopsy proven MR visible lesions and no disease other than appreciated on the MRI. Patients underwent ultra-focal laser ablation of the tumors using GNP with MR/US fusion guidance. Following infusion of intravenous GNP on Day 0, trans-perineal laser catheters were placed into the prostate lesions for GNP excitation/tumor ablation under MR/US fusion guidance using an electromagnetictracked MR/US fusion device (UroNav, Invivo Gainesville FL). At 48 hours post-ablation, the patient is imaged, followed by re-imaging and MR/US fusion guided biopsy (FBx) at 3 months. All patient demographics, clinical variables, and complications were recorded. RESULTS: To date, 11 patients (mean age: 69.6 yrs; range 5879 yrs) have been enrolled in the trial. All patients were diagnosed with Gleason < 7. All patients had a solitary lesion with mean tumor volume 0.73 mL (range 0.6-1.87 cc). A single patient did not tolerate the cold IV infusion of the gold nano particles and was not able to undergo ablation the following day. 8 of 10 patients have completed the 3 month followup targeted biopsy as primary endpoint. Mean pre-treatment PSA was 7.84 ng/mL (range 5.5-12.3 ng/mL). Mean post-treatment PSA was 3.9 ng/mL (range 1.5-6.1 ng/mL; 50% reduction). Five out of eight patients (62.5%) did not have any cancer detected on follow up biopsy. Only 1 out of 8 patients had clinically significant cancer as per Delphi consensus criteria (Gleason score >6 or cancer > 3mm at Gleason score 6). CONCLUSIONS: Recent trends toward less invasive image guided therapies have been seen as investigators pursue focal targeted therapies. This report is the first in-man demonstration of MR/US guided ultra-focal laser ablation of prostate tumors using GNP.

Targeted Ablative Therapies for Prostate Cancer

Men diagnosed with low- to intermediate-risk, clinically localized prostate cancer (PCa) often face a daunting and difficult decision with respect to treatment: active surveillance (AS) or radical therapy. This decision is further confounded by the fact that many of these men diagnosed, by an elevated PSA, will have indolent disease and never require intervention. Radical treatments, including radical prostatectomy and whole-gland radiation, offer greater certainty for cancer control, but at the risk of significant urinary and/or sexual morbidity. Conversely, AS preserves genitourinary function and quality of life in exchange for burdensome surveillance and the psychological impact of living with cancer.

Minimally invasive adrenal surgery: virtue or vice?

Adrenocortical carcinoma (ACC) is a rare malignancy associated with poor prognosis despite available treatments. In patients with localized or locally advanced disease, complete resection with negative margins offers the only potential for cure. Unfortunately, most patients develop local and distant recurrence following initial resection highlighting the importance of meticulous surgical technique in the hands of an experienced surgeon. While minimally invasive surgery (MIS) has supplanted open surgery for small to medium-sized benign adrenal tumors, controversy surrounds the use of MIS for resection of ACC. We sought to provide an overview of the key oncological principles in the surgical management of ACC and to critically review the literature comparing outcomes between the open and MIS approaches.

Imaging Protocols for Active Surveillance in Renal Cell Carcinoma

Purpose of ReviewTo review the growth kinetics of small renal masses and available imaging modalities for mass characterization and surveillance, highlight current organizational recommendations for the active surveillance of small renal masses, and discuss the most recently reported oncological outcomes of patients as they relate to various surveillance imaging protocols and progression to delayed intervention.Recent FindingsOverall, organizational guideline recommendations are broad and lack specifics regarding timing and modality for follow-up imaging of small renal masses. Additionally, despite general consensus in the literature about certain criteria to trigger delayed intervention, there exist no formal guidelines.SummaryActive surveillance of small renal masses is an acceptable management strategy for patients with prohibitive surgical risk; however, standardized imaging protocols for surveillance are lacking, as are randomized, prospective trials to evaluate the ideal follow-up protocol.

Factors influencing long-term urinary symptoms after prostate brachytherapy

To determine which patient and treatment‐related factors are associated with increased American Urological Association symptom score (AUASS) in men who presented with minimal symptoms before treatment for prostate cancer by permanent seed implantation.

PD59-09 MANAGEMENT OF SMALL RENAL MASSES IN RENAL TRANSPLANT RECIPIENT CANDIDATES: A MULTI-INSTITUTIONAL SURVEY ANALYSIS

validate a criterion for AS eligibility based on tumour clinical size and age on a cohort of patients treated with surgery. METHODS: 1922 patients diagnosed with a cT1cN0cM0 renal mass elected for surgical treatment and collected into a prospective database were assessed. Under the assumption that older patients with smaller tumours are optimal candidates for AS relative to younger patients with larger tumours, we relied on the ratio [R] between tumour clinical size and age in order to differentiate patients suitable for AS (R<5) from patients unsuitable for AS (R 5). X2 test was used to compare the rate of malignant histology, stage pT3-pT4 and grade G3G4 at final pathology in patients suitable vs. unsuitable for AS. Smoothed Poisson’s incidence plots were used to examine the rate of cancer specific [CSM] and other cause mortality [OCM] in patients suitable vs. unsuitable for AS. RESULTS: According to the proposed definition, the rate of patients suitable for AS was 34%. Patient suitable for AS had a lower rate of malignant histology (78 vs. 87%; p<0.001), pT3-pT4 (4 vs. 10% p1⁄40.001) and grade G3-G4 (7 vs. 17% p<0.001) relative to patients unsuitable for AS. In patients suitable for AS, the 10-year rates of CSM and OCM were 1.7 and 19%, respectively (Fig. 1A). In patients unsuitable for AS, the 10-year rates of CSM and OCM were 6.7 and 11% (Fig. 1B), respectively. CONCLUSIONS: When validated in a cohort of surgically treated patients, the ratio between tumour clinical size and age is a useful parameter to differentiate patients with adverse pathologic outcomes from patients with more favourable pathologic outcomes. These differences translate into critically different relative rates of CSM and OCM. These findings suggest that the proposed strategy criterion deserve further examination as a potential criterion for AS.

MP69-04 IDENTIFICATION OF MODIFIABLE RISK FACTORS ASSOCIATED WITH PATIENT-REPORTED ERECTILE DYSFUNCTION TO ENHANCE PATIENT HEALTH COUNSELING AND SEXUAL QUALITY OF LIFE

INTRODUCTION AND OBJECTIVES: Clinical trials have suggested that pelvic floor rehab (PFR) can improve early urinary control following radical prostatectomy. However, the details surrounding its use in clinical practice and its contribution to cost and value are not well understood. In this context, we examined the use of PFR in a diverse statewide quality improvement collaborative, including patient characteristics, implementation patterns, and costs. METHODS: Using registry data from the Michigan Urological Surgery Improvement Collaborative and claims data from Michigan Value Collaborative, we identified all men who underwent a laparoscopic radical prostatectomy from 04/2014 through 11/2015 with insurance from Medicare or a large commercial payer. All men reported pre-operative urinary function using the STAR questionnaire with scores ranging from 0 (worst) to 21 (best). We compared patient demographics, cancer characteristics, pre-operative urinary function, and 90-day total episode costs of patients who did and did not receive PFR. RESULTS: 142 menmet our inclusion criteria, of whom 53 (37%) received pelvic floor rehab. There were no differences in patient or cancer characteristics among patients who did and did not receive PFR. Patients initiated PFR an average of 34 days after discharge (range 15-83 days). Mean baseline urinary function scores were worse for PFR patients (17.8 vs 19.3, p1⁄40.01). Ninety-day episode costs were similar in the two cohorts, with PFR contributing an average of