Peter Haddock

Experienced Open vs Early Robotic-assisted Laparoscopic Radical Prostatectomy: A 10-year Prospective and Retrospective Comparison

OBJECTIVE To undertake a prospective/retrospective comparison of longer-term oncologic and quality of life outcomes in open radical prostatectomy (ORP) or robotic-assisted laparoscopic radical prostatectomy (RALP) patients. MATERIALS AND METHODS The clinical progression of ORP and RALP patients who underwent surgery during 2004 was followed over an extended (10 year) period. Pre- and perioperative parameters, oncologic outcomes, recurrence, mortality, and quality of life were compared between surgical modalities. Follow-up time was calculated from the time of surgery to the latest contact. Postoperative quality of life data were obtained from Expanded Prostate Cancer Index Composite survey questionnaires. Recurrence rates, times to recurrence, surgical time, length of stay, hematocrit, follow-up time, and sexual and urinary bother scores were compared between surgical groups. Multivariate analyses were used to predict positive surgical margins and biochemical recurrence. RESULTS 63 ORP and 116 RALP patients were included (mean age of 60.4 ± 6.4 and 58.6 ± 5.8 years; P = .067), with follow-up times of 10.3 and 10.1 years (P = .191). RALP patients had longer operative times (P < .001), shorter hospital stays (P < .001), and higher discharge hematocrits (P < .001). With prostate-specific antigen, Gleason score, and T-stage as covariates, time to recurrence (P = .365) and positive margin rate (P = .230) were not statistically different between groups. Ninety-five percent of RALP patients were continent and 48.0% were potent vs 92.6% and 41.5% of ORP patients (P = .720; .497). Urinary and sexual bother were not significantly different between groups (P = .392; .985). CONCLUSION Our longer-term follow-up data suggest that ORP and RALP patients have comparable oncologic and quality of life outcomes.

Active surveillance of renal masses: an analysis of growth kinetics and clinical outcomes stratified by radiological characteristics at diagnosis

AIMS To determine the growth rate of renal masses (RMs) under active surveillance (AS), and to describe the clinical outcome of AS patients. MATERIALS AND METHODS We conducted a retrospective review of an AS database to obtain demographics, radiological and pathologic characteristics and RM size of patients. RMs were followed at 6-12 month intervals for ≥1 year with computed tomography (CT), magnetic resonance imaging (MRI), or renal ultrasound. Kaplan-Meier analysis determined the annual likelihood of intervention. RMs were divided into 3 radiographic subcategories (solid, cystic, and angiomyolipoma). A linear regression model determined RM growth rates. RESULTS 131 RMs in 114 patients were included. Median age, Charlson Comorbidity Index score and mean follow-up were 69.1 years, 4.0 and 4.2±2.6 years, respectively. Maximal tumor diameter (MTD) at diagnosis was 2.1 ± 1.3 cm. 49 RMs exhibited negative or zero net growth. Mean MTD growth rate for all RMs was 0.72±3.2 (95% CI: 0.16-1.28) mm/year. When stratified by MTD at diagnosis, mean RM growth rates were 0.84, 0.84, 0.44, 0.74 and 0.71 mm/year for RMs ≤1 cm, 1-≤2cm, 2-≤ 3cm, 3-≤ 4cm and ≥4cm, respectively (p≤0.01). The 5 and 10-year freedom from intervention rates were 93.1% and 88.5%, respectively. There was a single case of suspected metastases, but no deaths related to kidney cancer. CONCLUSIONS RMs under AS grew slowly, and had a low incidence of requiring surgical intervention and progression. Solid enhancing masses grew slowly, and were more likely to trigger intervention. AS should be considered for selected patients with small RMs.

Seminal vesicle cyst with ipsilateral renal agenesis and ectopic ureter (Zinner syndrome).

The symptomatic presentation of seminal vesicle cysts with ipsilateral renal agenesis and ectopic ureter (Zinner syndrome) is rare. Patients are typically diagnosed at the third or the fourth decade of life and often present with infertility. Although the diagnosis can generally be made with magnetic resonance imaging, cystography can also be useful in indeterminate cases. We report on the unusual case of an 18-year-old man who presented with pelvic pain that was intensified by ejaculation. Computed tomography and magnetic resonance imaging revealed a cystic structure in the area of the right seminal vesicle that was successfully excised robotically without complications.

A comparison of preliminary oncologic outcome and postoperative complications between patients undergoing either open or robotic radical cystectomy

ABSTRACT Purpose: To compare complications and outcomes in patients undergoing either open radical cystectomy (ORC) or robotic-assisted radical cystectomy (RRC). Materials and Methods: We retrospectively identified patients that underwent ORC or RRC between 2003- 2013. We statistically compared preliminary oncologic outcomes of patients for each surgical modality. Results: 92 (43.2%) and 121 (56.8%) patients underwent ORC and RRC, respectively. While operative time was shorter for ORC patients (403 vs. 508 min; p<0.001), surgical blood loss and transfusion rates were significantly lower in RRC patients (p<0.001 and 0.006). Length of stay was not different between groups (p=0.221). There was no difference in the proportion of lymph node-positive patients between groups. However, RRC patients had a greater number of lymph nodes removed during surgery (18 vs. 11.5; p<0.001). There was no significant difference in the incidence of pre-existing comorbidities or in the Clavien distribution of complications between groups. ORC and RRC patients were followed for a median of 1.38 (0.55-2.7) and 1.40 (0.582.59) years, respectively (p=0.850). During this period, a lower proportion (22.3%) of RRC patients experienced disease recurrence vs. ORC patients (34.8%). However, there was no significant difference in time to recurrence between groups. While ORC was associated with a higher all-cause mortality rate (p=0.049), there was no significant difference in disease-free survival time between groups. Conclusions: ORC and RRC patients experience postoperative complications of similar rates and severity. However, RRC may offer indirect benefits via reduced surgical blood loss and need for transfusion.

Gross haematuria associated with penetration of an inferior vena cava filter into the right renal collecting system

Inferior vena cava (IVC) filters are a viable alternative for patients with venous thromboembolic disease for whom standard anticoagulation therapy is contraindicated. Rare complications associated with their use, however, include misplacement and IVC penetration. We report a case of a 63-year-old woman who developed gross haematuria following IVC filter penetration into both the right renal collecting system and renal pelvis, for which open caval removal and reconstruction was required. This is an unusual case of IVC filter penetration causing symptomatic haematuria and requiring surgical intervention.

MP77-19 TIMING OF CONFIRMATORY BIOPSIES INFLUENCES ELIGIBILITY FOR ACTIVE SURVEILLANCE

INTRODUCTION AND OBJECTIVES: While serial biopsies are a key component of most active surveillance (AS) programs, surveillance protocols differ as to when the first surveillance biopsy should be performed. Some protocols mandate a confirmatory biopsy while in others, the first surveillance biopsy is performed at 1 year. In the present study we sought to determine differential impact of obtaining the first surveillance biopsy either within 6 months or at 9-15 months after diagnosis. METHODS: We retrospectively identified patients who enrolled in a prostate cancer active surveillance (AS) program during 2004-2015 and underwent a biopsy either 6 months or between 9-15 months after their initial diagnostic biopsy. Eligibility for enrollment in AS was defined according to MSK criteria (biopsy Gleason: 6; biopsy T stage: cT1c or cT2a, diagnostic PSA <10, % positive for each core 50%, 3 positive cores, or if number of total cores >12, then number of positive cores 25% of the total cores). We compared MSK-defined eligibility for AS in patients who received a second biopsy at either 6 or 9-15 months after their initial diagnostic biopsy. RESULTS: A total of 115 patients on AS were identified within the study period. 62 (53.9) and 53 (46.1%) of patients underwent a second biopsy at 6 or 9-15 months after their initial diagnostic biopsy, respectively (table). Age, number of biopsy cores and positive cores, serum PSA, and eligibility for AS by MSK criteria were similar between groups. 56(90.3%) and 42 (79.2%) of patients initially met MSK AS criteria. Of these, those rebiopsied at 9-15 months appear more apt to be reclassified as ineligible than patients rebiopsied at 6 months (42.9 v. 25.0%, p1⁄40.082). Patients biopsied at 6 months had more cores taken at the second biopsy (15(IQR 12-16) vs. 12 (12-12), p<.001) CONCLUSIONS: Surveillance protocols differ as to when the first surveillance biopsy is performed. In patients initially meeting AS inclusion criteria, a delay in confirmatory biopsy may be associated with a higher rate (42.9% v 25.0%) of AS ineligibility. Just as important, 25% of patients immediately learn they do not meet AS criteria. These findings may be due to disease progression rather than under sampling, as patients who were biopsied at 6 months had more biopsies performed. These data may be helpful in patient counseling prior to AS enrollment. Source of Funding: none

Process Improvements Positively Impact the Use of Intravesical Mitomycin C after Transurethral Resection of Nonmuscle Invasive Bladder Cancer in a Large, Urban Urology Practice

Introduction: We assessed the rate of intravesical mitomycin C therapy in patients with nonmuscle invasive bladder cancer who underwent transurethral resection of the bladder, as well as the impact of procedural changes governing its use. Methods: A retrospective review of our bladder cancer database identified patients who underwent transurethral resection of the bladder with mitomycin C therapy during January 2008 to July 2014. Since our mitomycin C protocols were revised during 2013, patients were stratified based on date of service. Patient demographics and data describing mitomycin C use were tabulated. Results: During January 2008 to May 2013, 276 of 737 (37.5%) ideal patients received mitomycin C (not accounting for patients in whom mitomycin C was contraindicated). Conversely 461 of 737 patients (62.5%) did not receive mitomycin C. Shortages of mitomycin C were responsible for nonuse in 18.4% of cases while no specified reason for nonuse was given in 59%. When cases in which mitomycin C use was contraindicated were taken into account, mitomycin C was used in 51.6% overall. After the implementation of new mitomycin C operating procedures, mitomycin C use increased significantly to 76.0% (p <0.001) (accounting for appropriate nonuse). During this period mitomycin C shortages were not responsible for any case in which mitomycin C was not used. Conclusions: During 2008 to 2013 mitomycin C was not used in a significant proportion of patients who underwent transurethral resection of the bladder. The implementation of a revised protocol governing mitomycin C use significantly and positively impacted mitomycin C use. Importantly, pharmacy shortages no longer contribute to the nonuse of mitomycin C in patients with bladder cancer. These data highlight the impact of continual improvement initiatives on standard clinical practice.

MP48-20 WEIGHTED GLEASON SCORES DO NOT OUTPERFORM STANDARD CLINICAL GLEASON SCORES IN PREDICTING PATHOLOGIC GLEASON SCORE, MARGIN STATUS AND RECURRENCE IN PATIENTS WITH DISCORDANT PROSTATE BIOPSIES

purpose was to evaluate the performance of cognitive target MRI-TRUS fusion biopsies of MRI detected PI-RADS (Prostate Imaging Reporting and Data System) 4 and 5 lesions. The correlation between the apparent diffusion coefficient (ADC) and Gleason outcome was also studied. METHODS: 52 consecutive patients in the period from 12/ 2013-06/2014 with increased PSA and PI-RADS 4 or 5 lesions on MRI (3T Siemens-skyra, protocol and reporting according to ESUR guidelines) were included. All patients underwent target biopsies using TRUS (B&K, Falcon 2101) which were performed by the same urologist and radiologist with MRI images and structured report available. In patients with a negative biopsy, MRI-guided biopsy was advised. A bi-variate pearson correlation was performed for ADC and Gleason outcome in positive cases. RESULTS: A total of 52 patients were included (16 PIRADS 4 and 36 PIRADS 5 lesions). Mean PSA and PSA-density value was respectively 9,88 (SD 6,1) and 0.20 (SD 0.11). Mean lesion size was 13.95 mm (SD 6.26 mm). 9 PIRADS 4 lesions (56%) and 26 PIRADS 5 lesions (72%) were found positive for prostate cancer. The correlation between the ADC value and histology outcome is showed in figure 1. Overall 67% of the biopsies were positive for prostate cancer using cognitive target MRI-TRUS fusion biopsies. The additional MRI-guidedbiopsies that were performed from the negative cases proved in 50% to be malignant (0/2 for PI-RADS 4 and 3/4 for PI-RADS 5 lesions). A significant correlation between ADC and Gleason value was found (-0.363 P<0.01) CONCLUSIONS: Cognitive target MRI-TRUS fusion biopsies are an effective first step in the evaluation of PIRADS 4 and 5 MRI detected lesions. Additional MRI-Guided-Biopsies of negative results for at least PIRADS 5 lesions are mandatory.

Oncological and functional outcomes of salvage renal surgery following failed primary intervention for renal cell carcinoma.

Purpose To assess the oncologic and functional outcomes of salvage renal surgery following failed primary intervention for RCC. Materials and Methods We performed a retrospective review of patients who underwent surgery for suspected RCC during 2004-2012. We identified 839 patients, 13 of whom required salvage renal surgery. Demographic data was collected for all patients. Intraoperative and postoperative data included ischemic duration, blood loss and perioperative complications. Preoperative and postoperative assessments included abdominal CT or magnetic resonance imaging, chest CT and routine laboratory work. Estimated glomerular filtration rate (eGFR) was calculated according to the Modification of Diet in Renal Disease equation. Results The majority (85%) of the patients were male, with an average age of 64 years. Ten patients underwent salvage partial nephrectomy while 3 underwent salvage radical nephrectomy. Cryotherapy was the predominant primary failed treatment modality, with 31% of patients undergoing primary open surgery. Pre-operatively, three patients were projected to require permanent post-operative dialysis. In the remaining 10 patients, mean pre- and postoperative serum creatinine and eGFR levels were 1.35 mg/dL and 53.8 mL/min/1.73 m2 compared to 1.43 mg/dL and 46.6 mL/min/1.73 m2, respectively. Mean warm ischemia time in 10 patients was 17.4 min and for all patients, the mean blood loss was 647 mL. The predominant pathological stage was pT1a (8/13; 62%). Negative surgical margins were achieved in all cases. The mean follow-up was 32.9 months (3.5-88 months). Conclusion While salvage renal surgery can be challenging, it is feasible and has adequate surgical, functional and oncological outcomes.

Infected Urachal Cyst Following Laparoscopic Cholecystectomy

Introduction: In an era of ultrasonography and computed tomography (CT), urachal remnants have been detected with increasing frequency. If these remnants become infected, they can mimic a variety of intra-abdominal pathologies. We present the case histories of two patients with an infected urachal cyst that developed after laparoscopic cholecystectomy and necessitated excision. Case Descriptions: Patient 1: Four years after a laparoscopic cholecystectomy, a 36-year-old man presented with dysuria, abdominal pain, leukocytosis, and fluid leakage from the umbilical port site. CT imaging revealed an infected urachal cyst with an adherent loop of sigmoid colon. Antibiotic treatment preceded laparoscopic excision of the urachal cyst with partial cystectomy and closure of the sigmoid-to-urachus fistula. In a 3-year follow-up, there was no recurrence. Patient 2: A 68-year-old woman presented 11 months after laparoscopic cholecystectomy with abdominal pain, intermittent fever, and leukocytosis. CT imaging revealed an infected urachal cyst with an associated phlegmon in the abdominal wall. Antibiotic treatment preceded two incision-and-drainage procedures. Six weeks later, the patient underwent robotic excision of the urachal cyst and partial cystectomy. A 3-year follow-up showed no recurrence. Discussion: The urachus can be punctured during laparoscopic periumbilical port placement and convert into a draining sinus or abscess. Subsequent infection can present with umbilical drainage, abdominal pain, urinary symptoms, and systemic infection. Surgical excision is a reasonable option once the acute infection has been treated. Any images that include the urachus should be reviewed before procedures involving an umbilical port, as puncture of urachal cysts may increase the risk of infection.