Lambros Stamatakis

Comparison of laparoendoscopic single site (LESS) and conventional laparoscopic donor nephrectomy at a single institution

Most transplant centres harvest living donor kidneys via a conventional laparoscopic surgical approach. Laparoendoscopic single‐site donor nephrectomy (LESS‐DN) is a relatively novel minimally invasive approach that allows the surgery to be performed via a single incision. This technique may be advantageous in decreasing surgical morbidity and improving cosmetic outcomes, thus plausibly reducing the barriers to kidney donation. The study demonstrates the safety and feasibility of LESS‐DN in a large consecutive series of kidney donors. Comparative analysis between LDN and LESS‐DN showed that there was a significant decrease in intra‐operative blood loss and allograft warm ischaemia time in the LESS‐DN group, but also a significant increase in operating time. Other peri‐operative outcomes were similar between the two approaches. Evaluation of the LESS‐DN cases alone revealed that, the operating times did not significantly change through the course of the series. Using this outcome as a surrogate for technical difficulty suggests a relatively shallow learning curve for LESS‐DN.

Innovations in Radical Cystectomy and Pelvic Lymph Node Dissection

Radical cystectomy with bilateral pelvic lymphadenectomy remains the gold standard in the surgical management of muscle-invasive urothelial carcinoma of the bladder and provides optimal locoregional cancer control in conjunction with perioperative cisplatin-based chemotherapy. Improvements in preoperative staging can aid in the identification of patients who may optimally benefit from neoadjuvant chemotherapy and determine candidacy for orthotopic neobladder reconstruction. Innovations in surgical technique and perioperative care have helped to minimize patient morbidity and preserve long-term urinary and sexual function while maintaining oncologic control. The use of minimally invasive surgical approaches has grown dramatically in urologic surgery over the past decade and the preliminary results of robot-assisted laparoscopic radical cystectomy have been reported recently. Anatomic pelvic and iliac lymphadenectomy is crucial for precise pathologic staging and may improve patient survival by removing micrometastatic disease.

A 60-year-old Woman With an Incidentally Discovered Right Renal Mass

CASE REPORT 60-year-old woman presented to our clinic for evaluation of a right renal mass, incidentally Adiscovered on a computed tomography (CT) scan obtained during a workup for shortness of breath. Her medical history was significant for hypertension, hyperlipidemia, hypothyroidism, and asthma. She had undergone several abdominal surgeries, including laparoscopic gastric banding, splenectomy, hysterectomy, and bilateral salpingo-oophorectomy. She denied a history of tobacco, heavy alcohol, or illicit drug use. She had no family history of kidney disease or genitourinary malignancy. On a review of systems, she reported intermittent nausea, vomiting, and dyspepsia but denied fevers, night sweats, weight loss, gross hematuria, dysuria, or a change in bowel habits. Her vitals signs were within normal limits, and her body mass index was 32.4 kg/m. Her abdomen was soft, not distended, and without palpable masses, although several surgical scars were present. Routine laboratory tests, including complete blood count, electrolytes, creatinine, coagulation studies, and urinalysis, were performed. The complete blood count with differential demonstrated mild thrombocytosis (473 K/ mL) and leukocytosis (13 K/mL) but was otherwise normal. The results from the remainder of the laboratory studies were also within normal limits. A CT scan with intravenous contrast of the abdomen and pelvis obtained 1 month before her clinic evaluation revealed a 3.4 3.0-cm, enhancing mass located in the posterior mid-pole cortex of the right kidney (Fig. 1). No additional masses were seen in the remainder of the right kidney. The left kidney and both ureters appeared normal. No retroperitoneal lymphadenopathy or other intra-abdominal abnormalities were identified.

MP20-04 DECIPHER PROSTATE CANCER CLASSIFIER DOES NOT CORRELATE WITH CLINICOPATHOLOGIC PROSTATE CANCER CLASSIFIERS IN AFRICAN AMERICAN MEN

prostatectomy (RP), brachytherapy (BT), external beam radiation (EBRT) or no local treatment (NLT). METHODS: Using the Surveillance Epidemiology and End results (SEER)-database, we identified 242 531 patients diagnosed with nonmetastatic PCa between 2004 and 2009. Patients were grouped according to local treatment type (RP, BT, EBRT) or NLT. Biopsy and/or pathological Gleason score was categorized either in 6, 7 and 8-10 or according to the newgrading system intoGGG I ( 6), II (3+4), III (4+3), IV (8) and V (9-10). Primary endpoint was prostate cancer specific mortality (PCSM). Univariable Kaplan-Meier plots graphically depict PCSM-free survival (PCSM-FS) according to the different GGG. Multivariable Cox regression analyses adjusted for age, clinical/pathological tumor stage and lymph node status were used to compare the different GGG in each treatment cohort. The discriminant ability was assessed using the area under the Receiver Operating Characteristics (ROC) curve. RESULTS: Median follow-up was 76 months (IQR: 59 94). For all local treatment types and NLT, PCSM-FS rates differed significantly between the five strata of the 2014 ISUP GGG. All five GGG strata independently predicted PCSM. Relative to GGG II, GGG III exhibited a 1.5to 2-fold higher PCSM rate. Similarly, across all local treatment types and NLT, GGG V patients exhibited a 2-fold higher PCSM rate than GGG IV patients. The multivariable discriminant ability of the 2014 ISUP GGG was between 0.4% to 1.1% better than the old Gleason stratification. CONCLUSIONS: This large population-based cohort validates the ability of the new GGG to predict PCSM. The new GGG offers a modesty more accurate ability to predict PCSM-FS across all different local treatment types and NLT.

PD65-03 DECIPHER GENE EXPRESSION LEVELS DO NOT CORRELATE WITH PATHOLOGIC FEATURES OF AGGRESSIVE PROSTATE CANCER IN AFRICAN AMERICANS

Laurent Briollais, Hilmi Ozcelik, Jingxiong Xu, Toronto, Canada; Maciej Kwiatkowski, Aarau, Switzerland; Emilie Lalonde, Dorota H Sendorek, Neil E Fleshner, Toronto, Canada; Franz Recker, Aarau, Switzerland; Cynthia Kuk, Ekaterina Olkhov-Mitsel, Toronto, Canada; Sevtap Savas, St. John’s, Canada; Sally Hanna, Tristan Juvet, Geoffrey A Hunter, Matt Friedlander, Hong Li, Karen Chadwick, Ioannis Prassas, Antoninus Soosaipillai, Toronto, Canada; Marco Randazzo, Aarau, Switzerland; John Trachtenberg, Ants Toi, Yu-Jia Shiah, Michael Fraser, Theodorus van der Kwast, Robert G Bristow, Bharati Bapat, Eleftherios P. Diamandis, Paul C Boutros, Alexandre R Zlotta*, Toronto, Canada

MP67-15 TARGETED MAGNETIC RESONANCE IMAGING/ULTRASOUND FUSION BIOPSY IS A SIGNIFICANTLY BETTER PREDICTOR OF TOTAL PROSTATE CANCER TUMOR VOLUME THAN RANDOM 12-CORE BIOPSY

INTRODUCTION AND OBJECTIVES: Tumor quantification with percent core and/or core length involvement is used to infer burden of disease for patients with prostate cancer (PCa). However, controversy exists regarding tumor quantification in random 12 core biopsies due to discrepancies in lesion targeting and overall needle core lengths obtained. Targeted magnetic resonance imaging/ultrasound (MRI/US) fusion biopsy allows for more optimal lesion targeting and interpretation of this parameter. We aim to correlate highest percentage core involvement and corresponding tumor length for both targeted fusion and random 12 core biopsies with total tumor volume. METHODS: Patients who underwent multiparametric MRI (MP MRI) with targeted MRI/US fusion biopsy at our institution between 2007 and 2013 were reviewed. MRI tumor volumes were calculated in fusion biopsy positive lesions and correlated with the highest percentage core involvement and corresponding tumor length in centimeters, for both targeted fusion biopsy and 12 core biopsy. Bivariate analysis was used to determine the empirical relationship between these variables and the correlative R2 value. RESULTS: 823 patients had MP MRI with MRI/US fusion biopsy, of which 100 patients had MRI tumor volumes quantified. Mean age was 62 years and mean PSA was 5.5ng/ml. For highest percentage core involvement, targeted biopsy showed a positive correlation (R1⁄40.54) whereas 12 core biopsy showed a poor correlation (R1⁄40.004) with total tumor volume (p<0.0001, p1⁄40.97 respectively). Similarly, for tumor length of the highest percentage core, targeted biopsy showed a positive correlation (R1⁄40.56) whereas 12 core biopsy showed a poor correlation (R1⁄40.06) with the total tumor volume (p<0.0001 and p1⁄40.59 respectively). (Figure 1) CONCLUSIONS: Highest percentage core involvement and tumor length on targeted MRI/US fusion biopsy positively correlate with total tumor volume. Targeted biopsy better predicts overall burden of disease and can aid in risk stratification of PCa patients.

MP7-17 DIFFERENTIAL DETECTION OF LESIONS ON MULTI-PARAMETRIC PROSTATE MRI WITH OR WITHOUT USE OF AN ENDORECTAL COIL BASED ON QUANTITATIVE MEASURES OF OBESITY

INTRODUCTION AND OBJECTIVES: Multiparametric 3T MRI (MP-MRI) with the use of an endorectal coil (ERC) provides improved signal to noise ratio for evaluation of prostatic lesions suspicious for prostate cancer. Herein, we aim to determine the degree of lesion identification lost by eliminating the use of an ERC based upon measures of obesity. METHODS: Prospectively collected data on 20 patients on an active surveillance protocol at the National Cancer Institute who have undergone non-ERC MP-MRI in 2013 following a prior ERC MP-MRI were analyzed. MP-MRI prostatic lesions suspicious for prostate cancer were identified and recorded on both ERC and non-ERC studies for each patient. Patient demographics including age, PSA, BMI, abdominal girth, waist circumference, and the drop distance from the anterior abdominal wall to the anterior aspect of the prostate were recorded. Quantitative measures of obesity were measured on T2-weighted MRI sequences. These parameters were analyzed using univariate and multivariable linear regression models individually with age and PSA to assess for significance in the decrease in number of lesions identified on followup studies without ERC use. RESULTS: The average number of lesions identified on ERC MP-MRI and followup non-ERC MP-MRI was 1.4 0.9 and 0.5 0.7, respectively. On univariate analysis, age and PSA were not significantly associated with a decrease in the number of lesions identified when the ERC was not used on followup MP-MRI. Of the quantitative parameters of obesity, on univariate analysis, greater BMI (p1⁄40.01) and abdominal girth (p1⁄40.0097) were significantly associated with a larger differential in the number of lesions identified. On multivariable linear regression models incorporating each of the measures of obesity with age and PSA, BMI (p1⁄40.026) and abdominal girth (p1⁄40.019) remained significant independent predictors of the difference in numbers of lesions identified between ERC and non-ERC studies. CONCLUSIONS: Typically more intraprostatic lesions are identified by MP-MRI performed with ERC due to the optimized signal to noise ratio. This difference is more dramatic in obese patients where the distance between body and surface coils and the prostate gland are increased. BMI and abdominal girth are predictors of significantly lower lesion identification when ERC is eliminated from the MP-MRI study. Since obesity has a negative impact on the detection of prostate cancer with non-ERC MRI, ERC use may be most important in this patient population.

OP3-04 DETECTION AND UPGRADING OF PROSTATE CANCER BY MRI/ULTRASOUND FUSION GUIDED BIOPSY ACROSS PSA-BASED CUTOFFS

INTRODUCTION AND OBJECTIVES: Active surveillance (AS) is a treatment strategy for prostate cancer (CaP) involving close monitoring of men diagnosed with low-risk CaP to reduce overtreatment. We report here factors associated with disease progression while on AS in a large, single institution cohort. METHODS: We retrospectively reviewed the data of men enrolled in the University of California at San Francisco (UCSF) AS cohort between 1990 and 2012. Strict eligibility criteria were prostatespecific antigen (PSA) 33% cores. Factors associated with progression while on active surveillance were determined through multivariate Cox proportional hazards regression. RESULTS: Of 1,106 men enrolled in AS at UCSF, 764 men have consented to participate in research to date and have been followed on AS for a median of 57 months. Of these, 520 (68%) met strict criteria for AS while 244 (32%) did not. The median number of repeat biopsies was 3 (IQR 2-4). At 5 years after diagnosis, 53 % were progression-free and 40% of patients received local therapy. Overall survival was 94% among those not AS eligible and 99% among those AS eligible at 5 years. There were no CaP-related deaths. In multivariate analysis, PSA density (PSAD), total number of biopsies, and later year of diagnosis were positively associated with the risk of both biopsy progression (HR (95% CI): 1.58 (1.33-1.88); 0.82 (0.72-0.94); 1.17 (1.11-1.25) , respectively) and receiving treatment (HR (95%CI): 1.39 (1.20-1.61); 0.71 (0.64-0.78); 1.20 (1.15-1.25), respectively), all p<0.01. CONCLUSIONS: The majority of men who enrolled in this active surveillance cohort remained on AS after a median follow up of 57 months. While higher PSAD was associated with biopsy progression, additional predictive tools would improve selection and counseling of men for AS.