Khurram Siddiqui

A Randomized Clinical Trial of Lidocaine Jelly for Prevention of Inadvertent Retrograde Stone Migration During Pneumatic Lithotripsy of Ureteral Stone

PURPOSE We studied the efficacy of lidocaine jelly instillation proximal to the ureteral stone during intracorporeal lithotripsy using a semirigid ureteroscope for the prevention of retrograde migration and improvement in stone-free rate. MATERIALS AND METHODS From November 2006 to September 2007, 50 patients with 5 to 18 mm ureteral stones undergoing ureteroscopic removal using pneumatic lithotripsy were randomized into 2 groups. Group 1 (25 patients) had lidocaine jelly instilled proximal to the stone before and after fragmentation, and group 2 was the control group (25 patients). Ureteroscopy was performed using an 8 or 6.4Fr semirigid ureteroscope. A 5Fr ureteral stent was advanced beyond the stone. Lidocaine jelly (2 ml) was instilled and lithotripsy was performed with a Swiss LithoClast . A 5Fr ureteral catheter was left in place for 24 hours. Patients were followed at 24 hours with plain x-ray of the kidneys, ureters and bladder, and at 2 weeks with noncontrast enhanced computerized tomography of the kidneys, ureters and bladder. RESULTS The 2 groups were comparable with regard to age and stone size. Stone or stone fragment migration occurred in 4% and 28% of patients in groups 1 and 2, respectively, and this difference was statistically significant (p = 0.002). At 2 weeks followup with imaging the stone-free rate was 96% and 72% in groups 1 and 2, respectively, and this difference was also statistically significant (p = 0.045). Although the mean operative time was slightly longer in the treatment group (33.56 +/- 13 vs 35.84 +/- 12.5 minutes) the difference was not significant (p = 0.450). CONCLUSIONS Lidocaine jelly instillation proximal to ureteral calculi during lithotripsy is an effective method of preventing retrograde stone displacement as well as significantly improving the stone-free rate.

Dovitinib: rationale, preclinical and early clinical data in urothelial carcinoma of the bladder.

Introduction: Bladder cancer (BC) is the third and fifth cancer in men in terms of incidence and mortality in the US. Overexpression and mutations of fibroblast growth factor receptor 3 (FGFR3) are frequently found in BC and can represent a very interesting therapeutic target. Different FGFR3-targeted strategies have been investigated through in vitro and in vivo settings, including FGFR3 tyrosine kinase inhibitors such as dovitinib. Areas covered: The authors review the data that provide a scientific rationale for FGFR3-targeted therapy in BC. They also provide an evaluation of the currently available in vitro and in vivo data on the use of dovitinib in BC patients. Expert opinion: The development and progression of BC rely on a very complex signaling network that involves many different receptors aside from FGFR3 and VEGFR2. The involved signaling network can also be very different from one BC to the other, and can also evolve through time in the same patient. Inhibiting only one single target may thus not be sufficient to achieve a complete downstream oncogenic signaling blockage. Additionally, in vitro data on the use of neutralizing monoclonal antibodies targeting FGFR3 show that it can be a more efficient strategy to reach the same goal, with the potential advantage of less toxicity.

Epidemiology of Stone Disease in Pakistan

Urinary tract stones are a common affliction across river, desert, and mountainous regions of Pakistan. A third of the stones have a single component. The commonest stone is composed of oxalate, with phosphate and uric acid as additional components. Calcium oxalate monohydrate is more abundantly present than the dihydrate. Phosphate stones comprise only about 7 % of all stones, and struvite is uncommon. Populations in the north have a greater proportion of pure and predominantly oxalate stones. Rural areas in the south have phosphate stones. The government of British India documented the frequent occurrence of stone in this region from the nineteenth century. The commonest stone was vesical. Noted stone transitions include (1) the marked increase in the discovery of renal stones, (2) the disappearance (except in pockets) of the idiopathic adult vesical stone, and (3) the decrease in children in the proportions of stones that are vesical. Late presentation for treatment and consequent renal destruction are still frequent.

MP70-07 A MULTIVARIABLE MODEL AND RISK SCORE FOR BIOCHEMICAL FAILURE AFTER WHOLE-GLAND SALVAGE CRYOSURGERY AT 10 YEARS FOLLOW-UP.

INTRODUCTION AND OBJECTIVES: Whole-gland salvage cryosurgery (SCS) is a potential curative treatment for organ-confined radiorecurrent prostate cancer (PCa). To enhance patient selection and optimize follow-up, a prediction model was created for biochemical failure (BF). METHODS: Data on patients (pts) treated (1995-2004) with salvage SCS at one centre was prospectively collected. Recurrences were biopsy proven and metastatic disease was excluded with pelvic/abdominal CT and radionuclide bone scan. Cox regression was adopted to assess the influence of clinical characteristics on BF. Missing data was imputed 20 times. Factors with a p-valueÿ0.25 were left in the model. The model was internally validated using bootstrap resampling (500 times) after which the C-statistic and hazard ratios could be adjusted for optimism. Calibration at different time points was performed and a risk score were created to assess different prognostic groups. RESULTS: 152 pts had follow-up data. A total of 89 pts experienced BF according to the Phoenix-definition (PSA-nadir+2 ng/ml). Median follow-up was 117 months (interquartile range 56154). Five and ten year biochemical disease free survival (BDFS) was 45% (95%-CI 37-54%) and 35% (95%-CI 27-45%). Age at SCS, pre-salvage PSA, Gleason score and PSA-nadir after treatment were associated with BF after multivariable regression (table 1), adjusted C-statistic 0.76. The model was well calibrated up to 10 years. Four risk groups were created (score <22, 22-25, 25-30 and >30, see table 1). BDFS estimates at ten years were 68%, 41%, 27% and 12%, respectively (log-rank p<0.0001)(fig.1). CONCLUSIONS: Selection of salvage pts is challenging, since guidance in the literature is scarce as to prognostic value of clinical characteristics. The presented model can guide patient selection and individualize follow-up. The model is not externally validation. Applicability might therefore be limited for other centres performing SCS. Source of Funding: None

PD56-01 LONG-TERM OUTCOMES OF SALVAGE CRYOABLATION FOR RECURRENT PROSTATE CANCER FOLLOWING RADIATION THERAPY: A COMBINED ANALYSIS OF TWO CENTERS

INTRODUCTION AND OBJECTIVES: There is a paucity of longterm data following local recurrences from radiation refractory prostate cancer (RRPCa). We analyzed the long-term survival outcomes of salvage cryoablation (Cryo) for RRPCa cancer across two centers. METHODS: Patients undergoing salvage Cryo for biopsy proven, localized RRPCa from 1990 to 2004were prospectively accrued. Preoperative characteristics, perioperative morbidity and postoperative data were reviewed from a prospectively maintained database. The primary outcome was overall survival (OS). Secondary outcomes were metastasis-free survival (MFS) and disease specific survival (DSS). RESULTS: 268 patients were identified with a median follow up of 115 months (55.25-151 IQR). Median age is 70 yrs. (65.8-73 IQR). Median PSA nadir was 2 (1-4.25 IQR) and median pre-salvage PSA was 6 (3.5-10.4 IQR). 20% (54/268) had Gleason score <7 at time of recurrence, 10% (28/268) had a Gleason score of 7, and 69% (184/268) had Gleason score>7. Out of 268 patients, 15 (5.6%) underwent repeat cryotherapy and neoadjuvant hormones were used in 29% of patients (77/268). Of the 268 patients, 123 (45%) experienced some form of morbidity. 101 (38%) had mild-moderate incontinence (0-1 pad/day), 43 (16%) had severe incontinence ( 2 pad/day), 43 (16%) experienced pelvic/perineal pain, 4 (1.5%) had rectourethral fistula, 68 (25%) had urinary retention, 38 (14%) had gross hematuria, and 28 (10.4%) had a bladder neck contracture, 12 (4.4) had urethral stricture disease. There were 176 Clavien 1-2, and 48 Clavien 3 events in the cohort. 4 (1.4%) patients were SP tube dependent and 3 (1.1%) patients went on to cystoprostatectomy.48% (130/268) of patients died by study follow up, 22% (59/268) died of RRPCa, and 31% (84/268) developed metastasis. Median OS was 163 mo., DSS 210 mo. and MFS was 199 mo. There was a significantly worse OS (p1⁄40.027) and MFS (p1⁄40.0114) for patients with a pre-cryotherapy PSA > 10 than those with a PSA <5, and those with PSA 5-10 e Figure 1. CONCLUSIONS: Cryo for RRPCa provides long term MFS, DSS and OS with an acceptable degree of morbidity and is a viable treatment option of localized RRPCa following radiation therapy. PreCryo PSA appears to serve as a prognostic tool for patient selection, and further prospective trials are required for validation.

Development and evaluation of the TrueNTH-Prostate Cancer Canada electronic Library for Improved (urinary and bowel) Function post Treatment (TrueNTH-PCC-eLIFT).

161 Background: The TrueNTH program is a Movember-funded, pan Canadian effort to develop a comprehensive patient-centered online portal in English and French that will cover a full spectrum of prostate cancer survivor needs. Through the support of Prostate Cancer Canada, the TrueNTH-PCC-eLIFT resource, as part of the TrueNTH program, is being developed by a multi-disciplinary team of urologists, radiation oncologists, gastroenterologists, researchers, nurses and survivors at pilot sites in Victoria, BC and London, ON. eLIFT will address urinary and bowel side effects that may be experienced after curative intent treatment by External Beam Radiation Therapy (EBRT), Brachytherapy (BT), combined EBRT + BT or Radical Prostatectomy (RP). METHODS eLIFT includes a didactic electronic library, symptom assessment tool and content tailored to treatment or symptoms experienced. A sequential prospective cohort study is underway to evaluate the impact of the resource. A baseline cohort of eighty patients per site receiving standard of care is currently open. A second cohort of eighty patients per site will be accrued to receive the eLIFT intervention. The study measurespatient self-efficacy, knowledge, Health Related Quality of Life (HRQoL), urinary and bowel function, health resource usage and satisfaction. RESULTS eLIFT content, with a total of 22 video modules is complete and in production. Preliminary results from the first cohort of patients, receiving standard care, confirm a need for a reliable, online resource in Canada. Patients note that the oral information provided by their oncologist at their preliminary consultation, while informative, is not easily retained. Information that was provided as print varied and was often outdated. Further, patients deem websites outside of Canada as the most reliable and helpful, which may not reflect Canadian recommendations. CONCLUSIONS eLIFT will provide a unique and scalable centralized resource that will allow for expansion to a National level and increase access to a scientifically-sound library of information with the goal of improving the quality of care for prostate cancer patients across Canada.

Ureteric Stenting: Tips and Tricks

Ureteric stents are indispensable tools in urology, especially endourology. Technical difficulties can arise during their placement and removal. It is therefore important that stent procedures should not be regarded as “minor.” This chapter describes the basic protocol for stent placement and describes some “tricks of the trade” to combat the technical difficulties. The tips, approaches, and instruments that are needed to deal with these problems are also described.

The Operating Room Technicians’ and Nurses’ Roles in Urologic Surgery

Successful completion of an operative procedure requires careful planning and coordination on the part of operating room staff. This chapter outlines the behind-the-scene preparations that support safe and successful surgery.