Luís Felipe Sávio

Using microscope for onco-testicular sperm extraction for bilateral testis tumors

OBJECTIVE To demonstrate a step-by-step approach to the use of the operating microscope for onco-testicular sperm extraction. DESIGN Video presentation. SETTING University hospital. PATIENT(S) A 34-year-old man (status post right orchiectomy at another institution for pT3 pure seminoma with negative preoperative tumor markers) was referred for contralateral orchiectomy for multifocal left testis mass and fertility preservation. A postoperative semen analysis for attempted cryopreservation of ejaculated semen identified azoospermia. INTERVENTION(S) Left radical orchiectomy, left microsurgical onco-testicular sperm extraction (TESE). MAIN OUTCOME MEASURE(S) Intraoperative technique with commentary highlighting tips for successful fertility preservation via microsurgical onco-TESE. Discussion of alternatives. RESULT(S) This video provides a step-by-step guide to microsurgical onco-TESE coordinated with radical orchiectomy for testis cancer as a means of fertility preservation in an azoospermic patient. Preoperative imaging with scrotal ultrasound can serve as a useful guide for targeting microdissection to areas of normal testicular parenchyma for extraction of seminiferous tubules likely to host normal spermatogenesis. This patient had successful recovery and cryopreservation of abundant testicular sperm following targeted ex-vivo testicular microdissection. CONCLUSION(S) Microsurgical onco-TESE may be offered to azoospermic patients when undergoing orchiectomy for testis cancer. Use of preoperative imaging and the surgical microscope guide surgical dissection and optimize sperm recovery.

Trends in Utilization of Robotic and Open Partial Nephrectomy for Management of cT1 Renal Masses

BACKGROUND Partial nephrectomy is widely used for surgical management of small renal masses. Use of robotic (RPN) versus open partial nephrectomy (OPN) among various populations is not well characterized. OBJECTIVE To analyze trends in utilization of RPN and disparities that may be associated with this procedure for management of cT1 renal masses in the USA. DESIGN, SETTING, AND PARTICIPANTS Patients who underwent RPN or OPN for clinical stage T1N0M0 renal masses in the USA from 2010 to 2013 were identified in the National Cancer Data Base. A total of 23 154 patients fulfilled the inclusion criteria. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Univariable and multivariable logistic regression analyses were performed to evaluate differences in receiving RPN or OPN across various patient groups. RESULTS AND LIMITATIONS Utilization of RPN increased from 41% in 2010 to 63% in 2013. Black patients (adjusted odds ratio [aOR] 0.91, 95% confidence interval [CI] 0.84-0.98) and Hispanic patients (aOR 0.85, 95% CI 0.77-0.95) were less likely to undergo RPN. RPN was less likely to be performed in rural counties (aOR 0.80, 95% CI 0.66-0.98) and in patients with no insurance (aOR 0.52, 95% CI 0.44-0.61) or patients covered by Medicaid (aOR 0.81, 95% CI 0.73-0.90). There was no significant difference in RPN utilization between academic and non-academic facilities. Patients with higher clinical stage (aOR 0.58, 95% CI 0.55-0.62) and comorbidities (aOR 0.79, 95% CI 0.71-0.88) were also less likely to undergo RPN. CONCLUSIONS Utilization of RPN has continued to increase over time; however, there are significant disparities in its utilization according to race and socioeconomic status. Black and Hispanic patients and patients in rural communities and with limited insurance were more likely to be treated with OPN instead of RPN. PATIENT SUMMARY The use of robotic surgery in partial nephrectomy for management of small renal masses has increased over time. We found a significant disparity across different racial and socioeconomic groups in use of robotic partial nephrectomy compared to open surgery. Patients living in rural areas, with limited insurance, and multiple medical comorbidities were more likely to undergo open than robotic partial nephrectomy.

Microsurgical identification and excision of an intratesticular mass

OBJECTIVE To demonstrate a step-by-step approach to microsurgical partial orchiectomy (PO) in a man with a small intratesticular mass. DESIGN Video presentation. SETTING University hospital. PATIENT(S) A 22-year-old man with right testicular pain and swelling found to have a small, nonpalpable 8-mm hypoechoic testicular mass on ultrasound. Tumor markers were negative. INTERVENTION(S) Partial orchiectomy. MAIN OUTCOME MEASURE(S) Intraoperative technique with commentary highlighting tips for a successful resection. RESULT(S) This video provides a brief introduction to and indications for PO as an alternative to radical orchiectomy. We describe the microsurgical approach to PO through an inguinal incision for the resection of a small intratesticular mass. CONCLUSION(S) Microsurgical PO should be considered for select patients as an alternative to radical orchiectomy. The microscopic approach provides a more precise resection with limited collateral damage to surrounding parenchyma.

Lymph node yield as a predictor of overall survival following inguinal lymphadenectomy for penile cancer

OBJECTIVE To determine whether a specific lymph node yield (LNY) affects overall survival (OS) in patients with penile cancer. MATERIALS AND METHODS Using the National Cancer Database, we identified 364 men diagnosed with pSCC who underwent ILND between 2004 and 2013. Men diagnosed on autopsy or at the time of death, patients with preoperative chemotherapy or radiotherapy, M+ and N3 disease, or with less than 3-month of follow-up were excluded. Kaplan-Meier analysis was used to compare Overall Survival (OS). A multivariable Cox regression model was developed to assess predictors of OS. RESULTS The median number of LN retrieved was 16 (IQR: 9-23). There was no significant difference in race, stage, grade for men with LNY ≤15 vs. >15. However, men with LNY ≤15 were significantly older than those with LNY >15 (65 vs. 59 years, p<0.001). On multivariable analysis, radical surgery, age, N+ disease, and LNY ≤15 were independent predictors of worse OS. Patients with LNY ≤15 showed significantly worse 5-year OS versus those with LNY >15 (49% vs. 67%, p=0.008). Nodal density (ND) ≥12.5% was also associated with decreased 5-year OS versus ND <12.5% (31% vs. 70%, p<0.0001). CONCLUSIONS LNY following ILND for pSCC appears to be an independent predictor of OS. A total LNY of >15 following ILND may have a beneficial impact on OS and serve as the threshold for defining an adequate ILND.

V11-02 A RANDOMIZED CLINICAL TRIAL ON SAFETY AND EFFICACY OF LOW INTENSITY SHOCKWAVES FOR THE TREATMENT OF ERECTILE DYSFUNCTION – COMPARISON OF TWO TREATMENT SCHEDULES

INTRODUCTION AND OBJECTIVES: We aim to evaluate the safety and efficacy of low intensity shockwave treatment (LISWT) for erectile dysfunction (ED). Further, we sought to report 1 month and 3 months post-treatment follow-up data from an ongoing phase II randomized clinical trial. METHODS: Men with ED (n?1⁄4?30) between the ages of 30 and 80 years who had a baseline International Index of Erectile Function questionnaire (IIEF-EF) score between 11-26, total testosterone between 300 and 1000 ng/dL in AM, phosphodiesterase inhibitor washout period of at least 4 weeks and had 1 month follow-up data were included in this analysis. We excluded patients with previous radical prostatectomy, extensive pelvic or back surgery, HbA1c > 7.5%, or in use of antidepressants. Patients were randomized in a 1:1 ratio into two treatment schedules for a total number of 3600 shocks using the Direx Renova LISWT device. Group A received 720 shocks on a five-day consecutive treatment schedule for one week and group B received 600 shocks every other day on a 6 days schedule for two weeks. Subjects reported the IIEF and Erection Hardness Score (EHS) questionnaires at baseline, 1 month and 3 months follow up. RESULTS: Mean þ/IIEF-EF score at base line was 17.5 þ/0.8 for group A, and 17.7 þ/1.1 for group B. 1 month follow-up group A revealed an increasing in the IIEF-EF score from 17.5 þ/0.8 to 20.1þ/1.5 (p 1⁄4 0.10). However, group B had a lower increase in the IIEF-EF score at 1 month follow up 17.7 þ/1.1 to 19 þ/1.1 (p1⁄40.15). Mean þ/IIEF-EF score after three-month follow-up was 20.8þ/2.5 and 22.1þ/1.3 for group A and B respectively. Group A and B had a significant increase in the EHS-EF score at 1 month follow-up (p<0.001 and p<0.02 respectively). However, no significant difference was found on the mean þ/EHS-EF score at 3 months follow-up despite an increase in the EHS-EF score in both groups (3.1þ/0.2 and 3.1þ/0.16). CONCLUSIONS: Ongoing Phase II clinical trial of the effect of LISWT on ED revealed a promising effect on recovery of the erectile function at 3 months follow-up. In this interim analysis, a clinically and statistically relevant effect of LISWT was observed. Long-term follow-up is needed to determine efficacy of shockwave therapy for erectile dysfunction.

Adverse Effects of Common Sports and Recreational Activities on Male Reproduction

CONTEXT Male factor infertility plays a significant role in infertility. Many factors have been associated with male infertility; however, the link between many sports and recreational factors and male reproduction remains poorly characterized. OBJECTIVE To evaluate the current literature regarding the impact of many common sports and recreational factors on male reproduction. EVIDENCE ACQUISITION A comprehensive PubMed and Embase search for relevant articles published between 1970 and 2017 was performed by combining the following search terms: male, sports (including individual sports), traumatic brain injury, sauna, hot tub, fertility, erectile dysfunction, varicocele, environment, cell phone, and laptop computer. EVIDENCE SYNTHESIS Hypogonadism and erectile dysfunction can be associated with sports with high rates of head injuries, such as American football. Although early reports linked other sports, such as bicycling, to erectile dysfunction, subsequent studies isolated these associations to sports cycling rather than recreational cycling. Certain sports (football, basketball, handball, and volleyball) were linked to increasing prevalence and severity of varicocele, offering a potential link to male infertility. In addition, recreational activities such as sauna, hot tubs, Jacuzzis, heated car seats, and laptop use were associated with high testicular temperature, which can impair spermatogenesis. Radio frequency electromagnetic waves from cell phones and laptops have also been shown to have deleterious effects on sperm viability and motility. CONCLUSIONS Many common sports and daily activities represent potential sources of male infertility. Clinicians should be aware of these associations in explaining idiopathic infertility in males. PATIENT SUMMARY Male infertility is an often overlooked component of a couples inability to conceive. We outline many common and often overlooked sports and recreational exposures that have been associated with male infertility.

PD66-09 UTILIZATION OF ROBOTIC VERSUS OPEN PARTIAL NEPHRECTOMY FOR MANAGEMENT OF CT1 AND CT2 RENAL MASSES

INTRODUCTION AND OBJECTIVES: Partial nephrectomy is widely utilized for surgical management of small renal masses. Robotic partial nephrectomy (RPN) has demonstrated improved postoperative morbidity and comparable oncologic outcomes compared to open partial nephrectomy (OPN). However, there is limited data regarding the utilization of RPN across different socio-economic strata and racial groups in the United States. We investigated trends and disparities in utilization of RPN for management of cT1 and cT2 renal masses. METHODS: Patients who underwent RPN and OPN for clinical stage T1 and T2, N0, M0 renal masses from 2010 to 2013 were identified in the National Cancer Data Base (NCDB). Univariate and multivariable logistic regression analyses were performed to evaluate differences in receiving RPN across various patient groups. RESULTS: A total of 23,681 patients fulfilled inclusion criteria. Utilization of RPN for management of cT1/cT2 renal masses significantly increased from 2010 to 2013 compared to OPN (Figure.1). Black (aOR1⁄40.91, 95%CI: 0.84-0.99) and Hispanic (aOR1⁄40.85, 95% CI: 0.76-0.94) patients were less likely to undergo RPN in favor of OPN. RPN was less likely to be performed in rural counties (aOR1⁄4 0.81, 95% CI: 0.66-0.98) and in patients with no insurance (aOR1⁄40.52, 95% CI: 0.45-0.61) or patients covered by Medicaid (aOR1⁄40.81, CI: 0.73-0.89). No significant difference was seen with respect to utilization of RPN between academic and non-academic facilities. Patients with higher clinical stage and co-morbidities were also less likely to undergo RPN (aOR1⁄40.23, 95% CI: 0.150.36 and 0.79, 95% CI: 0.71-0.87 respectively). CONCLUSIONS: Utilization of RPN continues to increase over time; however, there is significant disparity in utilization of RPN based on socio-economic status and race. Black or Hispanic patients and patients in rural communities and with limited insurance were more likely to be treated with OPN instead of RPN.

MP04-18 SMOKING INTENSITY AS A PREDICTOR OF SURVIVAL IN BLADDER CANCER PATIENTS: RESULTS FROM A POPULATION-BASED FLORIDA CANCER REGISTRY (1981-2009)

INTRODUCTION AND OBJECTIVES: Our group has previously demonstrated that blood-based tumor markers can be useful clinical outcome predictors for non-muscle invasive urothelial carcinoma of the bladder (UCB) Our aim in this study is to further evaluate the predictive value of CEA, CA 19-9 and CA 125 on disease recurrence and progression. METHODS: We prospectively included 328 consecutive patients between February 2008 and August 2014 to measure preoperative serum levels of CEA, CA 19-9 and CA 125 before first transurethral resection of the bladder (TUR). Institutional Ethical Committee approval was obtained prior to this study. Patients diagnosed with pT2 UBC were excluded (42), leaving 286 patients for analysis of recurrence or progression. After first TUR, patients were followed with routine cystoscopy, cytology and ultrasound every 6 months. All patients with non-muscle invasive (NMI) bladder cancer with high-grade disease, previous recurrence, carcinoma in situ (CIS) or T1 received induction and maintenance intravesical BCG. RESULTS: We found that CEA and CA 19-9 levels were significantly higher in patients who had either tumor recurrence and/or progression compared to those who had no UBC recurrence during follow-up (p1⁄40.02; p1⁄40.03). As we had found previously, however, CA 125 levels did not differ between the two groups (p1⁄40.42). Overall, mean CEA level was 2.1 (0.2-12.8), CA 19-9 was 17.1 (0.4-189.9) and CA 125 was 12.5 (1.2-103.9). In patients who presented tumor recurrence and/or progression, mean CEA was 5.5, mean CA 19-9 was 21.0 and CA 125 was 13.8, while in the non-recurring group, mean CEA was 3.1, mean CA 19-9 was 11.1 and CA 125 was 11.3. Mean follow-up was 4.9 years. Patients were 70.3% males (201); 63.3% (181) of patients had pTa at first TUR. Concomitant carcinoma in situ was present in 25 cases (8.7%). CONCLUSIONS: Biomarkers utilized in routine follow-up of other malignancies, such as CEA and CA 19-9, can also be included in UCB management, since it proved able to distinguish a higher risk group of patients that could be managed accordingly. Future studies may add these blood-based tumor markers to a predictive model and validated in a larger cohort. Although CA 125 was not significantly associated with oncologic outcome, further studies are required before excluding this potential biomarker in UBC.

V9-10 TRANSURETHRAL RESECTION OF EJACULATORY DUCTS: A STEP-BY-STEP GUIDE

18 items, each on a 5-point Likert scale. Trainee scores were assessed and compared for improvement over the course of the training course. RESULTS: The most common mistakes made by our trainees revolved around sitting position, hand tremor, instrument handling, needle control, suture placement, and knot tying. The errors were most prevalent early on and there were statistically significant improvements across all domains by the end of the MIM training course (Table). CONCLUSIONS: A MIM training program is an effective tool for teaching MIM skills. By incorporating intense supervision and continuous evaluation into an MIM training program, MIM trainees can avoid the development of bad habits that may be difficult to overcome and potentially have a negative impact on surgical outcomes.

Transurethral resection of ejaculatory ducts: a step-by-step guide

OBJECTIVE To demonstrate the key components for completing a successful transurethral resection of ejaculatory ducts (TURED) for completely obstructed ejaculatory ducts (EDs). DESIGN Video presentation. SETTING University Hospital. PATIENT(S) A 40-year-old man presenting with primary infertility and abnormal semen analysis (pH 6.4, volume of 0.7 cc, concentration 16 million/cc, and 7% motility) in whom a transrectal ultrasonography revealed dilated seminal vesicles measuring more than 1.5 cm and seminal vesicle aspiration detected no sperm in the aspirate. INTERVENTION(S) Transurethral resection of ejaculatory ducts. MAIN OUTCOME MEASURE(S) Intraoperative technique with commentary highlighting tips for a successful TURED. RESULT(S) This video provides a step-by-step guide for TURED, including transrectal ultrasonography-guided seminal vesicle puncture for instillation of methylene blue to allow more precise identification of EDs. Vesiculography was performed near the end of the procedure to assess for patency of EDs and confirm both sides had been opened. (Institutional review board approval was obtained for this presentation.) CONCLUSION(S): The key portions for performing a successful TURED includes seminal vesicle instillation of methylene blue for easier identification of EDs. Vesiculography is performed near the end of the procedure to ensure both EDs have been opened as well as to assess for passive drainage of the seminal vesicles through the newly open EDs.