Mohammed Haseebuddin

Robot-assisted partial nephrectomy: Evaluation of learning curve for an experienced renal surgeon

PURPOSE The learning curve for robot-assisted partial nephrectomy (RAPN) has not been extensively studied. We therefore evaluated the learning curve of RAPN for a fellowship-trained laparoscopic surgeon with extensive prior experience with laparoscopic partial nephrectomy (LPN). We also examined the potential effect of tumor size on the learning curve. PATIENTS AND METHODS We prospectively evaluated 38 consecutive patients undergoing RAPN by a single surgeon (S.B.B.). Sixteen patients had tumors <2 cm, and 22 patients had tumors >2 cm. Warm ischemia times and overall operative times were recorded as indices of learning progression. RESULTS Average operative time for tumors <2 cm was 131.9 minutes (115.3-148.5 minutes) and for tumors >2 cm was 145.8 minutes (131.1-160.5 minutes). The difference between the operative times for tumors <2 and >2 cm was not statistically significant (p = 0.23). Average warm ischemia time for tumors <2 cm was 21 minutes (16.9-25.1 minutes) and for tumors >2 cm was 24.7 minutes (21.3-28.1 minutes). This difference was also not statistically significant (p = 0.20). Defined by the overall operative time, the learning curve for RAPN was 16 cases, and by ischemic time, the learning curve was 26 cases. Tumor size did not have an effect on the learning curve. CONCLUSIONS The learning curve for RAPN is short for surgeons already experienced with LPN. The learning curve for portions performed under warm ischemia is slightly longer, implying that the critical portions of the procedure require more experience to become facile. Tumor size does not appear to have a significant impact on the learning curve for surgeons experienced with LPN.

11C-Acetate PET/CT Before Radical Prostatectomy: Nodal Staging and Treatment Failure Prediction

Despite early detection programs, many patients with prostate cancer present with intermediate- or high-risk disease. We prospectively investigated whether 11C-acetate PET/CT predicts lymph node (LN) metastasis and treatment failure in men for whom radical prostatectomy is planned. Methods: 107 men with intermediate- or high-risk localized prostate cancer and negative conventional imaging findings underwent PET/CT with 11C-acetate. Five underwent LN staging only, and 102 underwent LN staging and prostatectomy. PET/CT findings were correlated with pathologic nodal status. Treatment-failure–free survival was estimated by the Kaplan–Meier method. The ability of PET/CT to predict outcomes was evaluated by multivariate Cox proportional hazards analysis. Results: PET/CT was positive for pelvic LN or distant metastasis in 36 of 107 patients (33.6%). LN metastasis was present histopathologically in 25 (23.4%). The sensitivity, specificity, and positive and negative predictive values of PET/CT for detecting LN metastasis were 68.0%, 78.1%, 48.6%, and 88.9%, respectively. Treatment failed in 64 patients: 25 with metastasis, 17 with a persistent postprostatectomy prostate-specific antigen level greater than 0.20 ng/mL, and 22 with biochemical recurrence (prostate-specific antigen level > 0.20 ng/mL after nadir) during follow-up for a median of 44.0 mo. Treatment-failure–free survival was worse in PET-positive than in PET-negative patients (P < 0.0001) and in those with false-positive than in those with true-negative scan results (P < 0.01), suggesting that PET may have demonstrated nodal disease not removed surgically or identified pathologically. PET positivity independently predicted failure in preoperative (hazard ratio, 3.26; P < 0.0001) and postoperative (hazard ratio, 3.07; P = 0.0001) multivariate models. Conclusion: In patients planned for or completing prostatectomy, 11C-acetate PET/CT detects LN metastasis not identified by conventional imaging and independently predicts treatment-failure–free survival.

Long-Term Impact of Laparoscopic Cyst Decortication on Renal Function, Hypertension and Pain Control in Patients with Autosomal Dominant Polycystic Kidney Disease

PURPOSE Cyst proliferation in patients with autosomal dominant polycystic kidney disease is associated with renal failure, hypertension and pain. We examined the long-term impact of laparoscopic cyst decortication on renal function, hypertension and pain control in patients with adult dominant polycystic kidney disease presenting with refractory pain. MATERIALS AND METHODS Between 1994 and 2003, 37 patients with adult dominant polycystic kidney disease underwent laparoscopic cyst decortication at Barnes-Jewish Hospital. A total of 19 patients (4 male, 15 female) with at least 3-year followup were included in the study. Renal function was evaluated using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) estimated glomerular filtration rate formula. End stage renal disease was defined as progression to transplant, dialysis or stage 5 chronic kidney disease. Hypertension was evaluated using the antihypertensive therapeutic index. Pain assessment was based primarily on a telephone questionnaire. RESULTS At a mean followup of 10.9 years (range 6.4 to 16.9), 67% of evaluable patients reported more than 50% improvement in pain. Ten patients had progression to end stage renal disease--3 dialysis, 6 transplant, and 1 chronic kidney disease stage 5. Two patients had stage 5 chronic kidney disease at initial presentation. A comparison of preoperative estimated glomerular filtration rate between patients with and those without end stage renal disease revealed a lower preoperative estimated glomerular filtration rate in the former group (43.4 vs 75.4 ml/minute/1.73 m(2), p = 0.01). Of the patients 53% had an improved or stable antihypertensive therapeutic index at last followup, although no improvement in mean overall antihypertensive therapeutic index was noted (4.7 pre-laparoscopic cyst decortications vs 7.0 post-laparoscopic cyst decortications, p = 0.28). CONCLUSIONS Durable pain relief but not hypertension control was seen at 10-year followup. Preoperative estimated glomerular filtration rate is a strong predictor of post-laparoscopic cyst decortication progression to end stage renal disease. A cautious approach with laparoscopic cyst decortication should be taken in patients with poor preoperative renal function.

Robot-assisted pyeloplasty: outcomes for primary and secondary repairs, a single institution experience

INTRODUCTION Robotic Pyeloplasty (RAP) is a technique for management of ureteropelvic junction obstruction (UPJO). PURPOSE To report outcomes of RAP for primary and secondary (after failed primary treatment) UPJO. MATERIALS AND METHODS Single institution data of adult RAP performed from 2007 to 2009 was collected retrospectively following approval by our IRB. Database analysis included patient age, race, pre and post-operative imaging studies and perioperative variables including operative time, blood loss, pain and complications. RESULTS Fifty-five adult patients underwent RAP (26 left/29 right) for UPJO including 9 secondary procedures from 2007 to 2009. Average follow-up was 16 months (1-36). Mean age was 41 years (18-71) with an average BMI of 27 (17-42); 32 were female. Most patients were diagnosed with preoperative diuretic renal scintigraphy and the obstructed side demonstrated mean function of 41% and t1/2 of 70 minutes. Mean operative time was 194 minutes with average blood loss less than 100 mL. Mean hospital stay was 1.7 days with an average narcotic equivalent dose of 15 mg. RAP for secondary UPJO took longer with more blood loss and had a lower success rate. Failure was defined as the need of another procedure due to persistent pain and/or obstruction after diuretic renal imaging. One patient (2%) with primary UPJO failed and 2 patients (22%) with secondary UPJO failed. One major complication occurred. CONCLUSION RAP is a good option for the treatment of patients with UPJO. Reported series have established that endopyelotomy has inferior success rate for the treatment of primary UPJO which compromises the success of subsequent treatment as demonstrated in our higher failure rate with secondary UPJO repair.

Surgical Cyst Decortication in Autosomal Dominant Polycystic Kidney Disease

PURPOSE To provide a summary of the relevant literature regarding the impact of surgical cyst decortication on hypertension, renal function, and pain management in patients with autosomal dominant polycystic kidney disease (ADPKD). METHODS Data collection was conducted via a Medline search using the subject headings autosomal dominant polycystic kidney disease, surgery, decortication, and marsupialization. Additional reports were derived from references included within these articles. RESULTS Despite a trend for improved blood pressure control after cyst decortication in some studies, this cumulative review of the literature did not provide consistent evidence supporting the role of this procedure in blood pressure management in patients with ADPKD. Surgical cyst decortication was associated with renal deterioration in a subset of patients with compromised baseline renal function but did not otherwise appear to have a significant impact on renal function in the majority of studies reviewed. Improvement in chronic pain after this procedure was ubiquitously reported across all studies examined. CONCLUSIONS Despite a potential role in blood pressure management in the setting of ADPKD, surgical cyst decortication has not been definitively shown to alleviate hypertension in this clinical setting. Renal function does not appear to improve following this surgery. Patients with compromised baseline renal function appear to be at increased risk for further deterioration in renal function after cyst decortication, although the role of this procedure in altering the natural trajectory of renal failure in this patient subset needs further investigation. Cyst decortication is highly effective in the management of disease-related chronic pain for the majority of patients with ADPKD, providing durable pain relief in this patient population.

WBC Associates with Readmission Following Cystectomy

Background: Radical cystectomy is associated with perioperative complication rates exceeding 50% in some series. Readmission rates are increasingly used as a surgical quality metric. White blood cell count is a crude surrogate for physiologic processes which may reflect postoperative complications leading to readmission. Objective: We assessed the association between final white blood cell count at discharge and risk of readmission following radical cystectomy. Methods: Records on 477 patients undergoing radical cystectomy from 2006–2013 were reviewed. Final white blood cell count was defined as the last documented value during index admission. Univariate analysis was performed using Fisher’s exact, Wilcoxon rank sum test, and Spearman’s coefficient tests where appropriate. Multivariable logistic regression models were used to test the associations between final white blood cell count and readmission. Results: 34% of patients were readmitted within 90 days of surgery. Amongst this cohort, a cutoff final white blood cell count of 9000/mm3 was identified, with a significantly higher proportion of patients with values >9000/mm3 experiencing readmission than those with values≤9000/mm3 (42% vs 28%, p = 0.004). Other perioperative variables associated with an increased readmission rate included initial hospital length of stay≤10 days, and receipt of a continent diversion. Following adjustment, final white blood cell count >9000/mm3 was associated with increased risk of readmission (OR 2.09, 95% CI 1.23–3.53, p = 0.006). Conclusions: Final white blood cell count is associated with hospital readmission following radical cystectomy. This metric may provide important guidance in discharge algorithms.

MP92-01 PD-1 EXPRESSION ON CLASSICAL MONOCYTES (CM) IS AN INDEPENDENT PREDICTOR OF CANCER SPECIFIC SURVIVAL IN CLEAR CELL RENAL CARCINOMA (CCRCC)

genetic counseling, Klinefelter syndrome (3.6%) who underwent testicular sperm extraction (no men with Klinefelter syndrome had a positive YCM assay), and men with chromosomal abnormalities of the Y chromosome (1.9%) who chose donor sperm or adoption. Sequential testing for karyotype first and then YCM, results in 9.8% of men savings of

MP53-01 DEFINING DELIVERABLES OF MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING (MPMRI)/ULTRASOUND (US) FUSION-GUIDED TARGETED PROSTATE BIOPSY: ACTIONABLE INTELLIGENCE METRIC (AIM) AND REDUCTION METRIC (RM)

500. This reduces the average cost of testing to

PD-1 expression on classical monocytes (CM) as an independent predictor of cancer specific survival in clear cell renal carcinoma (ccRCC).

1,250.69 per patient, a savings of 3.8%. CONCLUSIONS: The probability of having both a karyotype abnormality and YCM in men with testicular failure is extremely rare. Sequential performance of karyotype, followed by YCM assay if there are no abnormal karyotype findings results in demonstrable financial savings.

Contemporary utilization trends of systemic chemotherapy for upper tract urothelial carcinoma (UTUC).

INTRODUCTION AND OBJECTIVES: Transrectal ultrasoundguided prostate biopsy (TRUS-B) is the gold standard for prostate cancer (CaP) diagnosis. mpMRI/US fusion targeted biopsy (TB) has emerged as a technique to optimize the procedure. The ideal prostate biopsy would: (1) identify all non-low risk CaP with greater sensitivity than TRUS-B; (2) eliminate the need for unnecessary sampling. Using our institutional dataset and the available literature, the objective of the present study was to define metrics that more accurately demonstrate the deliverables of TB and facilitate meaningful data comparisons. METHODS: Patients (pts) with indications for TRUS-B having identified prostate lesions (PIRADS 3-5) on mpMRI were included. The UroNav System (Invivo) was used to obtain 1-4 TBs of each targeted lesion. All men underwent concurrent 12-core TRUS-B. Actionable intelligence metric (AIM) was defined as all pts with higher Gleason score (GS) on TB (minimum GS 3+41⁄47) relative to TRUS-B O total pts with GS 3+41⁄47 CaP (i.e. % for whom TB offered actionable data over TRUS-B). Reduction metric (RM) was defined as 1 [all pts with higher GS on TRUS-B (minimum GS 3+41⁄47) relative to TB O total pts undergoing biopsy] (i.e. % who could have foregone TRUS-B). Cohort metrics were compared to previously published data. RESULTS: 149 pts (mean age 64 7.4y, PSA 9.1 8.6 ng/ml, and prostate volume 53.6 34.2 cc) were examined: 21 (14.1%) biopsy naive men (G1), 74 (49.7%) men with prior negative TRUS-B (G2), and 54 (36.2%) men with prior positive TRUS-B on an active surveillance (AS) protocol (G3). Overall cancer detection rate was 90/149 (60.4%): 12/21 (57%) for G1, 33/74 (44.6%) for G2, and 45/54 (83.3%) for G3. AIM and RM for the entire cohort was 22.6% and 78.5%; 25% and 81.0% for G1, 28.6% and 81.1% for G2, and 12.0% and 72.2% for G3. These findings are similar to previously published cohorts in which the AIM and RM are 13.6% and 95.5% and 23.6% and 93.6% for G1 and G2, respectively. AIM and RM for men on AS is not calculable from the currently published literature. CONCLUSIONS: TB harbors potential for improvement over TRUS-B; however, deliverables of this costly technology must be outlined. We define two metrics, AIM and RM, for use in future reports to help quantify, communicate, and compare the added value of TB technology. At present, 12-core TRUS-B remains a necessary adjunct to TB, particularly in the AS setting.