Mark Ferretti

Diagnosis and Management of Upper Urinary Tract Recurrences After Radical Cystectomy

Upper Urinary Tract Urothelial Carcinoma (UUT-UC) can be a deadly disease in patients who present with an otherwise normal genitourinary system. For patients who have undergone radical cystectomy for bladder cancer, however, the diagnosis and management of UUT-UC may be complex and elusive. Advances in non-contrast-based magnetic resonance imaging (MRI), cytology and FISH analysis, and molecular studies such as the identification of mismatch repair (MMR) mutations may help predict the risk of UUT-UC in cystectomy patients. We review the epidemiology of UUT-UC occurring de novo and in patients with a prior history of bladder UC, advances in imaging sciences that are relevant to the diagnosis of UUT-UC, and novel biomarkers that are in use and under consideration in the detection and prognosis of UUT-UC. We will review endoscopic techniques unique to those patients who have undergone urinary diversion. Surgical options for UUT-UC will be discussed which may include conservative approaches for elderly bladder cancer patients after urinary diversion and renal insufficiency who may tolerate neoadjuvant chemotherapy or radical nephroureterectomy.

Genetics Factors and Tumor Markers in Upper Urinary Tract-Urothelial Carcinoma

The diagnosis of urothelial carcinoma of the upper urinary tract (UUT) may be more elusive than for UC of the bladder especially for low-stage, low-volume disease. Genetic markers may allow the diagnosis and possible prognosis of UUT-UC based on the very small tissue samples obtained through endoscopic biopsy. Families with UUT-UC are rare but point to distinct genetic features that may underlie sporadic cases such as mutations in the DNA mismatch repair (MMR) genes. MMR mutations are thought to lead to inability to repair DNA copy errors during replication causing microsatellite instability (MSI) and mutations in p53 or FGFR3. Cytology has low sensitivity in the diagnosis of low-stage UUT-UC, especially after post-cystectomy urinary diversion to bowel. Diagnostic yield may be improved by chromosomal enumeration tests (e.g., FISH), DNA assays (e.g., p53 status, methylation status, FXYD3 gene), and/or protein markers (e.g., ImmunoCyt, BTA Stat, Nuclear Matrix Protein 22 (NMP22), survivin, telomerase). Markers may also be used to identify patients who may be at risk of bladder recurrence after nephroureterectomy (e.g., expression of TP53 and E-cadherin). No single tumor marker appears to have enough specificity and sensitivity to obviate the need for careful endoscopic and imaging evaluation of the patient who may have UUT-UC. However, genetic markers continue to improve the ability to lateralize, diagnose, and predict failure after conservative or definitive management of a commonly aggressive neoplasm subtype.

Percutaneous and Endoscopic Management of Nephrolithiasis in a Patient with Five Native Ureters (Trifid Right and Bifid Left Collecting System)

Abstract Triplication of the ureter is a rare urologic finding that has been well described in the literature. Patients can present with urinary tract infections, incontinence, and calculi. We present the case of a patient with extensive stone burden with right trifid and left bifid collecting systems. Stone management was performed with a multimodal approach using a combination of endoscopic and percutaneous approaches. Our systematic and staged approach highlights a method for efficacious stone treatment in a complex endourologic case.

MP73-15 PROTECTIVE EFFECT OF ETHYL PYRUVATE ON OXIDATIVE RENAL CELL INJURY: IMPLICATION IN PREVENTION OF RENAL ISCHEMIA/REPERFUSION INJURY

RESULTS: The mean magnitude and phase angle of the impedances were proved to have a statistically significant variation (p <0.05) in accordance with the distance from the tumor at the frequency from 10.08 kHz to 1MHz and at 39.89 kHz, respectively. At these frequencies, the mean magnitude and phase angle of section V was significantly different (p <0.05) to that of at least one other section of the specimen. However, the mean impedance differences between each respective sections other than section V did not show any statistical significance. CONCLUSIONS: The present thesis has proved the capability of EoN in detecting the tumor when EoN was inserted from the normal renal parenchyma. The depth of tumor margin beneath the renal surface is assumed to be measurable by estimating the inserted length of EoN which has reached an area showing significant change of impedance values at specific frequencies.

PD40-05 DETERMINANTS OF DEFAULT FROM FOLLOW-UP CARE IN A PROSTATE CANCER SCREENING PROGRAM

RESULTS: Among 1,290 patients with available data, 585 (45%) and 284 (22%) men had any PCa and significant PCa, respectively. PSA density was significantly more predictive than PSA for detecting any and significant PCa in the PSA ranges of 4-10 and >10 ng/mL. AUC for significant prostate cancer was 0.72 (0.68, 0.77), p<0.0001 for PSA 4-10 ng/mL and 0.82 (0.75, 0.89), p<0.0001 for PSA >10 ng/mL. PSA density was significantly more predictive than PSA in detecting any and significant PCa in men with and without a prior negative biopsy. However, the incremental AUC value was larger for significant PCA than any PCA in men who had a prior negative prostate biopsy (AUC 0.81 vs 0.70, p 1⁄4 0.0042), and those who did not (AUC 0.77 vs 0.73, p 1⁄4 0.0026). CONCLUSIONS: In contrast to previous studies, we found that PSA density outperformed PSA most within the PSA range >10 ng/mL, suggesting that PSA density will save large volume prostate patients from the costs associated with the over-diagnosis of PCa. Additionally, PSA density performed best among men with a prior negative biopsy, saving these men from the burden of repeated biopsies that are likely to be negative in this population. With the current need for better markers to indicate prostate biopsy, PSA density may have significant value as a more sensitive and specific test than PSA to detect PCa when used with an extended template biopsy scheme.

MP24-01 A MULTI-INSTITUTIONAL EXPERIENCE WITH ROBOTIC URETEROPLASTY WITH BUCCAL MUCOSA GRAFT

INTRODUCTION AND OBJECTIVES: Buccal mucosa is wellsuited for grafting in the urinary tract as it is compatible with a wet environment, has a thick epithelium that facilitates tissue handling, and has a highly vascular lamina propria that promotes imbibition and inosculation. Despite this, the use of buccal mucosa grafts in ureteral reconstruction has been limited. We report our multi-institutional experience with robotic ureteroplasty with buccal mucosa graft. METHODS: We retrospectively reviewed 25 patients who underwent robotic ureteroplasty with buccal mucosa graft by three primary surgeons at three institutions between October 2013 and October 2016. Indication for the procedure was a proximal or mid ureteral stricture not amenable to primary anastomosis secondary to length of stricture or extensive fibrosis. On follow-up, patients were assessed for: clinical success, the absence of symptoms from ureteral pathology; and radiological success, the absence of ureteral obstruction on imaging, which included renal scan, CT urogram, and/or ultrasound. RESULTS: In 21/25 (84.0%) cases, the diseased ureter was incised and a buccal mucosa graft was onlayed over the defect. In 4/25 (16.0%) cases, the diseased ureter was transected, a plate of healthy ureter was brought together, and buccal mucosa graft was used to perform an augmented ureteroplasty. Eighteen of 25 (72.0%) patients had proximal and 9/27 (28.0%) patients had mid ureteral strictures. Ten of 25 (40.0%) patients had previously undergone a failed ureteral reconstruction. The median length of stricture was 4.0 cm (range 2.0-8.0 cm), and length of buccal mucosa graft harvested was 4.0 cm (range 2.5-8.0 cm). The buccal mucosa graft was onlayed ventrally in 21/25 (84.0%) and dorsally in 4/25 (16.0%) patients. The anastomosis was reinforced with peri-renal fat in 1/25 (4.0%), omentum and appendix in 1/25 (4.0%), and only omentum in 23/25 (92.0%) cases. The median operative time was 203 min (range 136-397 min), estimated blood loss was 100 ml (range 25-420 ml), and length of stay was 2 days (range 115 days). There were no intraoperative complications. At a median follow-up of 8 months (range 0-32 months), 23/25 (92.0%) cases were clinically and radiologically successful. CONCLUSIONS: Robotic ureteroplasty with buccal mucosa graft is an effective technique for managing complex proximal and mid ureteral strictures with excellent short-medium term outcomes.

V12-10 ROBOT-ASSISTED LAPAROSCOPIC RADICAL CYSTECTOMY AND INTRACORPOREAL NEOBLADDER UTILIZING A VAGINAL-SPARING AND STAPLE-FREE APPROACH

INTRODUCTION AND OBJECTIVES: At our institution robot assisted laparoscopy with intracorporeal neobladder has become standard of care for our treatment of patients with muscle invasive bladder cancer. When indicated and feasible we perform a vaginal sparing and staple-free approach for our female patients in order to optimize continence and sexual function. METHODS: Using a high definition recording system and iMovie software with narrative and annotative editing we created a video illustrating our vaginal-sparing and staple-free approach to the robot assisted laparoscopic radical cystectomy and neobladder. Our Patient is a 66 year old female with high grade bulky urothelial carcinoma of the bladder. RESULTS: We have performed vaginal-sparing and staple-free robot-assisted laparoscopic radical cystectomy and intracorporeal neobladder in 12 patients. Patients age range of 41-72 years old. 70% of these patients underwent neoadjuvant chemotherapy. Total operative times range from 4.25 e 5.85 hours. The majority of patients have selfreported good satisfaction with neobladder after surgery. CONCLUSIONS: In our experience, the robotic staple-free, vaginal-sparing intracorporeal neobladder is a safe and effective method of treatment for muscle invasive bladder cancer. Long term cancer control not yet proven with the robotic approach; however short term control is comparable to other methods. Further study will be needed to demonstrate the long term safely and cancer control with this technique.

V9-09 ROBOT-ASSISTED LAPAROSCOPIC MANAGEMENT OF INFLATABLE PENILE PROSTHESIS RESERVOIR MIGRATION INTO BLADDER WITH UTILIZATION OF CRYOPRESERVED AMNIOTIC MEMBRANE AND UMBILICAL TISSUE

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.

V10-01 RECONSTRUCTION OF TWO CONCURRENT IPSILATERAL URETERAL STRICTURES WITH APPENDICEAL ONLAY AND NON-TRANSECTING URETERAL REIMPLANT

(RC) for muscle-invasive urothelial carcinoma of the bladder (UCB) failed to meet its accrual target. We sought to examine the comparative effectiveness of TMT vs. RC for muscle-invasive UCB in an observational cohort study. METHODS: Within the National Cancer Data Base (20042011), we identified 12,843 individuals who received TMT or RC for definitive treatment of cN0M0 muscle-invasive UCB. Inverse probability of treatment weighting (IPTW) adjusted Kaplan-Meier and Cox regression analyses with time-varying covariate were used to compare overall survival (OS) of patients who received TMT vs. RC. Exploratory analyses according to patient characteristics were also performed. RESULTS: Overall, 1,257 (9.8%) and 11,586 (90.2%) patients received TMT and RC, respectively. IPTW-adjusted Kaplan-Meier curves showed that median OS was similar between TMT and RC groups (39.6 [95% CI, 33.7-45.5] vs. 43.0 [95% CI, 40.9-45.1] months; P1⁄40.290; Figure 1). In IPTW-adjusted Cox regression analysis with time-varying covariate, TMT was associated with a significant adverse effect on OS after 25 months of follow-up (HR1⁄41.37;95%CI1⁄4[1.16-1.59];p<0.001). In exploratory analyses (Figure 2), there was no significant difference between TMT and RC with regard to long-term OS in individuals aged >1⁄470 (HR1⁄41.21;95% CI1⁄4[0.83-1.60];P1⁄40.225), of female gender (HR1⁄41.28;95%CI1⁄4[0.831.74];P1⁄40.170), with Charlson comorbidity index >1⁄41 (HR1⁄41.10;95% CI1⁄4[0.83-1.38];P1⁄40.439) and/or >1⁄4cT3 disease (HR1⁄41.16; 95% CI1⁄4[0.80-1.52];P1⁄40.338. CONCLUSIONS: We generally observed that TMT was associated with worse long-term OS compared to RC for muscle-invasive UCB. However, selected subgroups of patients may choose TMT over RC to avoid surgical toxicities with minimal impact on OS.

Hyper IgE Syndrome and Renal Cell Carcinoma

Hyper IgE Syndrome (HIES) is an immunodeficiency disorder characterized by increased serum levels of IgE, eczema, and recurrent cutaneous and pulmonary infections. In this report, we present, to our knowledge, the first documented case of renal cell carcinoma (RCC) found in a patient with HIES. The patient received infectious disease clearance prior to obtaining a partial nephrectomy which revealed clear cell histology. Both HIES and RCC have an immunological basis for their pathophysiology and may involve common pathways. Further studies may provide insight into any possible link and clinicians should be mindful of immunocompromised patients who present with risk factors for genitourinary malignancy.