Paul Gellhaus

Utility of the RENAL nephrometry scoring system in the real world: predicting surgeon operative preference and complication risk

Study Type – Prognosis (individual cohort)

Incidence and Risk Factors of Parastomal Hernia in Patients Undergoing Radical Cystectomy and Ileal Conduit Diversion

PURPOSE We evaluate the incidence and risk factors of parastomal hernia formation in patients undergoing radical cystectomy and ileal conduit urinary diversion. MATERIALS AND METHODS We retrospectively reviewed the Indiana University cystectomy database between 2001 and 2011, and identified 516 patients who underwent radical cystectomy and ileal conduit diversion. Overall 199 patients had a clinical followup of at least 12 months and all underwent postoperative staging computerized tomography to confirm the presence of parastomal hernia. The incidence of parastomal hernia is reported with correlations made to demographic, patient level and perioperative risk factors. RESULTS A parastomal hernia developed in 58 patients (29%) at a median followup of 27 months (range 12 to 125). Of these patients 26 (45%) underwent surgical repair due to abdominal discomfort (58%), acute strangulation or obstruction of the small bowel (15%), partial small bowel obstructions (15%) and elective repair for other intra-abdominal procedures (12%). Prior exploratory laparotomy (adjusted HR 1.98, 95% CI 1.97-3.36, p = 0.011) and severe obesity (adjusted HR 4.26, 95% CI 1.52-11.93, p = 0.006) were predictive of parastomal herniation. The cumulative risk of parastomal hernia formation at 1 and 2 years after cystectomy was 12.2% and 22.5%, respectively. CONCLUSIONS We demonstrated that parastomal hernia will develop in nearly a third of patients after radical cystectomy with ileal conduit diversion. Prior laparotomy and severe obesity are independent risk factors. Preoperative counseling and preventative measures regarding parastomal hernia formation should be emphasized, particularly in these at risk patients.

Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes.

To evaluate the utility of robotic repair of injuries to the ureter or bladder from obstetrical and gynaecological (OBGYN) surgery

Robot-Assisted Radical Prostatectomy in Patients with a History of Holmium Laser Enucleation of the Prostate: Feasibility and Evaluation of Initial Outcomes

PURPOSE To evaluate outcomes of post-holmium laser enucleation of the prostate (HoLEP) robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS Using an institutional database, we identified 11 HoLEP patients who subsequently underwent RARP. These were matched 1:2 to RARP patients without a previous transurethral surgical procedure. Variables matched were age, pre-RARP prostate-specific antigen level, and biopsy Gleason score. Urinary continence and sexual function were evaluated by physician questioning, American Urological Association symptom score, and Sexual Health in Men (SHIM) scores. Descriptive statistics were used to compare cohorts. RESULTS RARP pathologic outcomes were similar between cases and controls. Twenty-seven percent of previous HoLEP patients reached strict urinary continence (leak free, pad free) at last follow-up compared with 64% of matched controls (P=0.071). The average (range) SHIM score at last follow-up was 2.6 (1-5) for previous HoLEP patients compared with 13.9 (5-20) (P<0.001). The posterior bladder neck and apical dissections were significantly more challenging in the setting of previous HoLEP and necessitated a low threshold for wider resection to minimize positive surgical margins. CONCLUSIONS Post-HoLEP RARP is challenging but preliminarily appears safe and feasible when performed by an experienced robotic surgeon. Patients should be counseled regarding expectations of urinary continence and sexual function in this setting.

MP64-07 LYMPH NODE YIELD AND POSITIVITY RATE BY LOCATION IN 1000 ROBOTIC PROSTATECTOMY PATIENTS THAT UNDERWENT EXTENDED PELVIC LYMPH NODE DISSECTIONS AT A SINGLE INSTITUTION

INTRODUCTION AND OBJECTIVES: The current evidence for lymphadenectomy (LND) at the time of radical prostatectomy (RP) for Gleason 7 intermediate-risk prostate cancer (PCa) is not as robust as for high-risk prostate cancer. Current guidelines defer to various nomograms regarding the risk of lymph node involvement to dictate the need for LND. The objective of this study was to examine utilization trends and survival data for patients who underwent LND for Gleason 7 PCa. METHODS: The SEER database was queried for all patients with either Gleason 3+4 (G34) or 4+3 (G43) PCa from 2004-2013, limited to patients with no evidence of metastatic disease or prior radiotherapy. Distributions and trends of LND, cancer-specific survival (CSS) and overall-survival (OS) were calculated. Memorial-Sloan Kettering Cancer Center (MSKCC) nomogram was applied to stratify patients based on risk of nodal disease at time of RP (<5% risk or >5% risk). Finally, multivariate logistic regression analyses (MVA) were performed to determine covariates associated with the likelihood of receiving LND. RESULTS: A total of 78641 patients with either G34 or G43 PCa underwent RP (59194 and 19447, respectively) with mean followup of 57.9 months. Of these patients, 61.2% of G34 and 73.5% of G43 patients underwent LND. During this time, the proportion of G43 patients undergoing LND remained relatively stable. The proportion of G34 patients undergoing LND varied between 55.9% in 2008 and 67.9% in 2013 despite decreasing RP rates in that same time frame. On MVA, the primary contributor to the variability in LND completion was socioeconomic status (SES): patients with higher SES were less likely to receive LND when indicated (OR 0.82, p < 0.05) and more likely to receive LND when not indicated (OR 1.15, p < 0.05). Age, race and insurance status were not significant predictors of LND. The incidence of pN+ disease was 1.5% and 5.2% in the <5% and >5% risk groups, respectively. Completion of LND at time of RP did not significantly change CSS in patients with G34 PCa (99.50% with LND and 99.59% without LND, p 1⁄4 0.14.) In G43 patients, however, CSS was better in patients who did not undergo LND (98.81% with LND and 99.33% without LND, p 1⁄4 0.002), the difference primarily driven by pN1 patients. CONCLUSIONS: The role of LND for Gleason 7 prostate adenocarcinoma is not yet standardized, as indicated by the variability of LND dissection rates over an 11-year period in the United States. SES was the primary predictor of LND completion at time of RP. As CSS was not affected by completion of LND for G34 PCa, further evaluation of oncologic benefit in this patient population is warranted.

MP03-16 UTILITY OF MULTI-PARAMETRIC MRI/ULTRASOUND FUSION: COGNITIVE NOT INFERIOR TO TARGETED SOFTWARE-BASED PROSTATE BIOPSIES

INTRODUCTION AND OBJECTIVES: Prostate cancer (PCa) remains the only solid organ tumor that is diagnosed by a non-targeted sampling method. Recently, multi-parametric MRI (MP-MRI) in conjunction with an MRIultrasound (US) fusion guided biopsy (bx) has demonstrated improved PCa detection. Unfortunately, this technology has been limited to tertiary care centers. Therefore, we sought to compare cognitive versus targeted software to assess the ability of cognitive registration to disseminate more readily into the community. METHODS: Consecutive patients underwent an MRI-US fusion prostate bx for elevated PSA, abnormal DRE, active surveillance or prior negative bx with a persistently elevated PSA. All subjects underwent pre-bx MP-MRI and lesions visible on MRI were graded using the PI-RADS version 2 classification system. The UroNav bx tracking system was used to fuse the stored MR images with real-time US generating a 3D model, which was then used to sequentially perform cognitive, targeted, and standard 12 core systematic biopsies in an office setting under local anesthesia. Descriptive statistics included patient characteristics and univariate analysis was done using logistic regression analysis to detect the associations between presence of cancer, clinically significant cancer, demographic variables, and bx method. Signed rank test was used for paired comparisons amongst bx method. RESULTS: 44 patients (median age 66 yrs, median PSA 6.4) underwent an MRI-US fusion bx between July 2014 and October 2015 with an overall CDR of 59%. Cognitive CDR was 40.9% with 25% being clinical significant disease. The targeted CDR was 27.3% with 22.7% being clinically significant disease. Overall, the cognitive approach had a sensitivity of 69.2% (95% CI: 50%, 88%) whereas the targeted approach had sensitivity of 46.2% (95% CI: 26%, 67%). Furthermore, the targeted approach missed 8 cancers when compared to the cognitive approach, whereas, the cognitive approach missed 2 cancer when compared to the targeted approach. The difference in sensitivity is most pronounced when comparing standard and targeted methods (p1⁄40.02) and approaches significance when comparing cognitive and targeted methods (p1⁄40.11). CONCLUSIONS: MRI-US fusion targeted software when compared to the cognitive platform, was not found to have higher cancer detection rate nor sensitivity. We believe this highlights the importance of the MRI itself, rather than the platform used.

Neoadjuvant chemotherapy in urothelial bladder cancer: impact of regimen and variant histology

AIM We compared the efficacy of methotrexate/vinblastine/doxorubicin/cisplatin (MVAC) versus gemcitabine/cisplatin in urothelial cancer and neoadjuvant chemotherapy (NACT) efficacy in variant histology (VH). MATERIALS & METHODS Radical cystectomy patients were retrospectively compared with those who received NACT. Factors associated with survival, pathologic complete response (pCR) and downstaging (pDS) were evaluated in multivariable models. RESULTS 9% of radical cystectomy patients (84/919) received NACT, with improved survival, pCR and pDS on both regimens. MVAC lead to higher pDS without an increase in pCR. On multivariable analysis, there was a nonsignificant increase in pDS with MVAC. NACT conferred similar responses in squamous and glandular differentiation VH. CONCLUSION NACT was associated with improved survival, pCR and pDS. Furthermore, responses to NACT were not dependent on presence of VH.