Jason R. Bylund

Association of Tumor Size, Location, R.E.N.A.L., PADUA and Centrality Index Score with Perioperative Outcomes and Postoperative Renal Function

PURPOSE Multiple scoring systems have been proposed to standardize the description of anatomical features of renal tumors. However, it remains unclear which of these systems, if any, is most useful, or whether any performs better than simply reporting tumor size or location in patients undergoing partial nephrectomy. To clarify these issues we evaluated the association of tumor size, location, R.E.N.A.L. (Radius/Exophytic/Nearness to collecting system/Anterior/Location), PADUA (Preoperative Aspects and Dimensions Used for an Anatomical classification) and centrality index scores with perioperative outcomes. MATERIALS AND METHODS Patients undergoing partial nephrectomy with available preoperative imaging were identified from 2005 to 2011. R.E.N.A.L., PADUA and centrality index scores were assigned according to the described protocols for those systems. Associations between each variable and ischemia time, estimated blood loss, total operative time and change in estimated glomerular filtration rate were examined. RESULTS A total of 162 patients were identified with a median tumor size of 3.1 cm (IQR 2.2 to 4.6). Median estimated blood loss, ischemia time and total operative time were 200 ml (IQR 100 to 300), 24 minutes (IQR 20 to 30) and 211 minutes (IQR 179 to 249), respectively. Each scoring system was found to have a statistically significant (p <0.001) correlation with ischemia time, with the centrality index system showing the strongest correlation. Furthermore, each of the scoring systems showed a stronger correlation with ischemia time than tumor size or tumor location. CONCLUSIONS Each scoring system outperformed tumor size and location, and may be useful when describing the surgical complexity of renal tumors treated with partial nephrectomy.

Association of Clinical and Radiographic Features with Perinephric “Sticky” Fat

BACKGROUND AND PURPOSE The discovery of thick, adherent, perinephric sticky fat (PSF) is relatively common during open or laparoscopic retroperitoneal surgery. To our knowledge, however, there has been no previous analysis of clinical or radiographic features associated with the development of PSF or of perioperative outcomes for those patients in whom it is found. Our objective is to analyze potential predictive features and determine whether there is any effect on clinical or pathologic outcomes for patients with perinephric sticky fat. PATIENTS AND METHODS Patients undergoing partial nephrectomy or laparoscopic cryoablation with available preoperative imaging were identified from 2005 to 2011. Operative records were reviewed to identify patients with and without PSF. Preoperative images and medical records were examined to obtain patient data regarding potential predictors as well as clinical and pathologic outcomes. RESULTS A total of 29 patients were identified-16 with PSF and 13 controls. Statistically significant factors associated with PSF included sex, tumor size, presence of perinephric stranding, tumor >50% exophytic, and thickness of perinephric fat (P<0.05). Median total operative time for patients with sticky fat was nearly 40 minutes longer than the control group (228 min vs 190 min, P<0.05). All four (17%) patients with Fuhrman grade 3 or 4 renal-cell carcinoma were from the sticky fat group (P=0.09). CONCLUSIONS Despite the small sample size, multiple possible factors associated with perinephric sticky fat were identified and may provide guidance for future investigation of this phenomenon.

Trends in the Management of Male Urethral Stricture Disease in the Veteran Population

OBJECTIVE To evaluate the relative use of urethral dilation, urethrotomy, and urethroplasty for male stricture disease in the Veterans Affairs (VA) population and examine trends over time in this cohort. METHODS A retrospective chart review was performed using the VA Informatics and Computing Infrastructure database to access the Corporate Data Warehouse. The current procedural terminology codes were used to define a cohort of all men who underwent procedures for urethral stricture disease between October 1999 and August 2013. RESULTS A total of 92,448 procedures were performed: 50,875 urethral dilations (55.03%), 39,785 urethrotomies (43.03%), and 1788 urethroplasties (0.19%). Over the course of the study, there was a shift in the management of male stricture disease. The relative percentage of urethral dilations performed decreased in each quintile (71.27, 58.03, 45.61, 44.39, and 38.67). The relative percentage of urethrotomies increased in each quintile (27.89, 40.80, 52.18, 53.04, and 56.95) as did the relative percentage of urethroplasties performed (0.85, 1.17, 2.21, 2.57, and 4.38). A total of 80.4% of these urethroplasties were performed in locations with a residency program. CONCLUSION Although urethroplasty is still underused, there is a trend toward increased use of urethroplasty for male urethral stricture disease in the VA population. The majority of urethroplasties were performed at VA medical centers in locations with a residency program. We predict continued increases in utilization of urethroplasty for male urethral stricture disease as the number of fellowship-trained reconstructive urologists increases.

A case of acute renal failure caused by bilateral, multifocal malacoplakia lesions of the bladder and ureters

Background A 51-year-old woman with a history of hypertension and a 5-year history of recurrent perimenopausal Escherichia coli urinary tract infections presented with fatigue. She had a history of occasional urinary frequency, but denied gross hematuria, flank pain, abdominal pain, immunodeficiency or immunosuppression.Investigations Basic metabolic profile, ultrasonography, cystoscopy, retrograde pyelography, pathologic evaluation of resected lesions from the bladder, ureteroscopy, pathologic evaluation of resected lesions from the ureters, and MRI.Diagnosis Acute renal failure caused by bilateral, multifocal malacoplakia lesions of the bladder and ureters.Management Endoscopic resection and laser ablation, ureteral stent placement, and medical treatment with fluoroquinolones, vitamin C and bethanechol.

Hand-Assisted Laparoscopic Partial Nephrectomy Without Formal Collecting System Closure: Perioperative Outcomes in 104 Consecutive Patients

BACKGROUND AND PURPOSE Laparoscopic partial nephrectomy (LPN) paralleling open techniques, particularly closure of the collecting system, can be technically challenging for the novice laparoscopist. We describe operative results and complications of a single surgeon, retrospectively reviewed series using a simplified method of hand assistance and a fibrin glue patch for hemostasis without formal collecting system closure. PATIENTS AND METHODS We identified 104 consecutive patients between September 2003 and January 2009 who underwent hand-assisted laparoscopic partial nephrectomy (HALPN). Our technique involves routine hilar clamping after isolation of the tumor and mobilization of the kidney. After resection of the mass, a fibrin glue patch is placed within the surgical defect and secured with bolstering sutures. No attempt is made to suture the collecting system, nor are ureteral catheters placed when the collecting system is entered during resection of the tumor. RESULTS Mean tumor size was 2.8 cm (median 2.5 cm, range 0.7-7.0 cm). With hilar clamping, warm ischemia time averaged 24.5 minutes (range 11-39 min). Estimated blood loss averaged 220 mL (range 50-1500 mL), and five (4.8%) patients received transfusions either intraoperatively or postoperatively. Urine leak occurred in 1.9% (n=2) of patients overall and 4.3% (2/47) of patients with documented collecting system entry. Both urine leaks resolved with conservative management only. CONCLUSIONS HALPN without formal collecting system closure is a safe and effective technique with similar urine leak and transfusion rates compared with other series. This technique may allow more urologists to perform minimally invasive partial nephrectomy or to do so with potentially shorter ischemia times.

PD20-12 RISK OF URINE LEAK IN HIGH-RISK PATIENTS AFTER MINIMALLY INVASIVE PARTIAL NEPHRECTOMY WITHOUT COLLECTING SYSTEM CLOSURE

INTRODUCTION AND OBJECTIVES: Minimally invasive partial nephrectomy (MIPN) has become the gold standard for surgical treatment of small renal masses, and techniques have proliferated to decrease ischemia time, prevent complications, and improve outcomes. Dogma mandates that collecting system be closed after tumor excision to prevent postoperative urine leak, but our experience suggests that this step is not necessary, and may actually increase the risk of compromising underlying structures. We report our experience with MIPN without collecting system closure for patients at high risk of urine leak, as determined by parameters described in the urologic literature. METHODS: We reviewed the data for patients over a 10 year period that underwent MIPN, including clinical and radiographic features. We also performed a literature review to identify predictors of postoperative urine leak-defined as persistent drain output or elevated fluid creatinine requiring any intervention. Our surgical technique has been described previously and involves a fibrin glue bolster secured with parenchymal sutures. RESULTS: We identified 210 patients who underwent MIPN betweenMay 2006 andOctober 2016 andmet all inclusion criteria. Urine leak occurred in 3/210 (1.4%) patients overall. No patients deemed high risk by RENAL nephrometry score developed urine leak after surgery (0/13). Patients deemed high risk by Renal Pelvis Score had a urine leak rate of 2.0% (3/150), compared to published rate of 23.6%. Additionally, patients at low risk by RENAL score (<7) had leak rate of 1.3% (1/76), while moderate risk patients (7-8) had leak rate of 1.9% (2/103), compared to the published rates of 7.4 and 13.6%, respectively. Only one patient with a tumor size greater than 7cm (n1⁄49) and one with tumor size less than 4cm (n1⁄4121) experienced a postoperative urine leak. CONCLUSIONS: Our technique for MIPN shows superior outcomes with respect to urine leak in high-risk patients compared to traditional techniques that include formal collecting system closure. We have successfully applied our approach to pure lap, hand-assisted, and robotassisted laparoscopic procedures. These results challenge accepted dogma that formal collecting system closure is necessary for the prevention of urine leak formation. Omitting this step decreases the complexity of the closure, shortenswarm ischemia time, andmay actually reduce the risk of urine leak.

Concomitant Renal Cell Carcinoma and Hematologic Malignancy in Immunosuppressed Patients

Objectives: Treatment of a renal mass in patients with hematologic malignancy or on immunosuppression can be complex and is not well defined. Surgical excision or thermal ablation of renal mass is generally recommended in view of concern for tumor progression in immunosuppressed patients. We report our management decision experience in patients and literature review on concomitant renal and hematologic malignancy. Materials and Methods: A retrospective medical record review of patients with renal cell carcinoma (RCC) and a hematologic malignancy over 3 years at our University Hospital was performed. Data were collected including patients demographics, renal tumor and hematologic malignancy characteristics (stage, pathologic subtype, time of diagnosis, treatment type and prognosis). Surgical and medical management of each malignancy was reviewed and perioperative and overall outcomes are reported. Results: In total, 6 patients were identified with RCC and a hematologic malignancy of which 4 were on immunosuppressive therapy. A total of 5 patients had leukemia and 1 patient had multiple myeloma. Most kidney tumors were stage I, 83%; and 80% were Fuhrman grade II. There was equal distribution of clear cell and papillary‐type RCC. All but 1 patient had undergone nephron‐sparing surgery. Overall, 50% of our patients died within 1 year after renal surgery for pT1a tumors from causes that are unrelated to renal cancer. Conclusions: Our small cohort showed significant mortality in patients with hematologic malignancy on immunosuppression, who had their renal mass treated with surgical excision or thermal ablation. However, this mortality was not secondary to surgical procedure itself. The prognosis of the hematologic malignancy might dictate the management of RCC.

Impact of statin therapy on PSA kinetics during active surveillance of prostate cancer.

119 Background: Statin therapy has been associated with decreased serum PSA levels in men undergoing prostate cancer screening, lower rate of adverse pathologic features in radical prostatectomy specimens and decreased risk of biochemical recurrence following prostatectomy. Here we evaluate the impact of statin therapy on PSA kinetics during active surveillance of prostate cancer. METHODS A retrospective review of patients diagnosed with prostate cancer at our institution between the years 2000 and 2009 was performed. Patients undergoing at least 12 months of active surveillance were identified. PSA velocity and percentage change in PSA per year were compared between patients receiving and not receiving statin therapy during active surveillance. Subgroup analysis was performed on low risk patients (prebiopsy PSA <10, Gleason score <6, <cT2). RESULTS We identified 81 patients meeting our inclusion criteria, 43% (35/81) were on statin therapy during active surveillance. Prebiopsy PSA was significantly lower in patients receiving statin therapy (6.0 ng/ml) compared to controls (8.3 ng/ml), p = 0.005. There was no difference in duration of active surveillance, PSA velocity, and percentage change in PSA per year based on statin use in all patients. When evaluating the 41 low risk patients, 54% (22/41) were on statin therapy. Prebiopsy PSA was lower in low risk patients receiving statin therapy (4.9 ng/ml) compared to controls (6.4 ng/ml), p= 0.055. PSA velocity was significantly lower in low risk patients (0.02 ng/ml/year) compared to low risk controls (0.89 ng/ml/year), p=0.024. Percentage change in PSA per year was significantly lower in low risk patients receiving statin therapy (-1.7%/year) compared to low risk controls (11.6%/year), p=0.05. The percentage of low risk patients receiving definitive therapy following a period of active surveillance on statin therapy was 9% (2/22)compared to 26% (5/19) in controls, p = 0.14. CONCLUSIONS PSA kinetics during active surveillance appear to be significantly altered by statin therapy in low risk patients. Further evaluation of the impact of statin therapy on PSA kinetics and clinical outcomes of men undergoing active surveillance for prostate cancer are warranted.

Regional trends of renal mass management in the Southeast.

e16562 Background: Current management of renal masses emphasizes nephron sparing procedures due to similar oncologic outcomes while potentially decreasing renal and cardiovascular morbidity compared to radical nephrectomy. According to the AUA guidelines radical nephrectomy is overly utilized leading to increased morbidity from chronic renal insufficiency. Partial nephrectomy is now considered the treatment of choice in T1 renal masses. Here, we analyzed epidemiologic data from the southern states of Virginia, VA, and Kentucky, KY, to assess compliance with a changing standard of care. METHODS Using the Department of Health Patient Level Database System reported via the Thomson Reuters Polaris Suite, we identified all patients hospitalized for a primary International Classification of Disease (9th revision; ICD-9) code suggestive of malignant renal mass and compared the prevalence of nephrectomy, partial nephrectomy, and ablative procedures in VA and KY. Data analysis was performed using Microsoft Excel 2007 for both academic and community hospitals. RESULTS We identified patients treated in VA and KY from 2004-2009. The proportion of radical nephrectomies has been steadily decreasing from 2004 with peak prevalence in 2004 for both KY and VA. The proportion of nephron sparing procedures has been increasing from 2004 to 2007 with peak prevalence in 2007 in VA and 2009 in KY. By 2009 nephron sparing procedures accounted for 32% and 31% of all renal mass surgery in KY and VA, respectively. The proportion of all renal procedures performed that were radical nephrectomies has decreased in both academic and community hospitals. Academic institutions experienced an earlier and more rapid rise in nephron sparing procedures in both VA and KY. CONCLUSIONS VA and KY inpatient data indicate practice patterns for management of renal masses has been changing with increased use of nephron sparing therapies relative to radical nephrectomy. Furthermore, academic hospitals appear to have adopted nephron sparing therapies earlier than community hospitals. However, given that partial nephrectomies are the recommended standard of care for T1 renal masses by the AUA, the percentage of these procedures being performed are still surprisingly low.

Utilization of neoadjuvant chemotherapy in stages II and III urothelial carcinoma of the bladder.

292 Background: Level 1 evidence supports the use of neoadjuvant chemotherapy (NC) prior to cystectomy in patients with stage II and III urothelial carcinoma of the bladder. However, the utilization of NC in appropriate patients prior to cystectomy is unknown. Here we examine the use of and potential predictors for the use of NC prior to cystectomy. METHODS The Kentucky Cancer Registry was reviewed from the years 2000 to 2007 for patients undergoing cystectomy for stage II and III (T2-4aN0M0) bladder cancer. Histologic subtypes of bladder cancer other than urothelial carcinoma were excluded. Multiple logistic regression was utilized to examine factors associated with the use of neoadjuvant chemotherapy prior to cystectomy. RESULTS A total of 223 patients undergoing cystectomy during the study period were identified. Median age was 66 years and 74% of patients were male. The majority of patients, 66%, had AJCC stage II disease. 6.3% (14/223) of patients received NC prior to cystectomy. Bivariate analysis did not reveal significant differences in age, gender, stage, geographic location, or insurance status when comparing patients receiving and not receiving NC prior to cystectomy. Year of treatment was significantly associated with the use of NC with 2.8% and 9.6% of patients receiving NC between the years 2000-2003 and 2004-2007, respectively (p = 0.034). Year of diagnosis remained significantly associated with the use of NC on multiple logistic regression (OR 4.23, CI 1.12-15.9). CONCLUSIONS Although a significant increase in the number of patients receiving NC prior to cystectomy has been observed since 2003, the overall utilization of NC remains low despite the proven survival benefit noted in randomized trials. Further investigation of the low utilization of NC in this population is warranted. No significant financial relationships to disclose.