Rashed Ghandour

Who Really Benefits From Nephron-sparing Surgery?

OBJECTIVE To analyze the influence of preoperative renal function on postoperative renal outcomes after radical nephrectomy (RN) and nephron-sparing surgery (NSS) for malignancy in patients stratified according to preoperative chronic kidney disease (CKD) stage and surgical extent (NSS vs RN). PATIENTS AND METHODS Retrospective review of patients undergoing renal surgery for localized renal masses stratified by surgical extent and preoperative CKD stage based on glomerular filtration rate (GFR) level: stage I (>90 mL/min/1.73 m(2)), stage II (60-89 mL/min/1.73 m(2)), and stage III (30-59 mL/min/1.73 m(2)). Survival analysis for significant renal impairment was based on freedom from the development of new-onset GFR <30 or <45 mL/min/1.73 m(2). RESULTS A total of 1306 patients were included in the analysis with preoperative CKD stage I (27.9%), II (52.1%), and III (20.1%); 41.3% and 58.7% underwent NSS and RN, respectively. NSS was associated with a lower annual rate of GFR decline in preoperative CKD stage-I (P = .028) and stage-II patients (P = .018), but not in CKD stage-III patients (P = .753). Overall, 5.0% and 15.0% developed new-onset GFR <30 mL/min/1.73 m(2) and <45 mL/min/1.73 m(2), respectively. There was no difference in the probability of developing significant renal impairment between NSS and RN in CKD stage-I or -III patients, whereas only in CKD stage-II patients was the surgical extent independently associated with development of significant renal impairment (RN: odds ratio, 9.0; P = .042 for GFR <30 mL/min/1.73 m(2) and odds ratio, 2.3; P = .003 for GFR <45 mL/min/1.73 m(2)). CONCLUSION Compared with RN, NSS is associated with a lower rate of GFR decline for preoperative CKD stage-I and -II patients, but only CKD stage-II patients demonstrated a decreased risk of developing significant renal impairment.

New agents for bacillus Calmette-Guérin-refractory nonmuscle invasive bladder cancer.

Purpose of review Radical cystectomy is the standard of care for patients who fail intravesical bacillus Calmette–Guérin (BCG) for nonmuscle invasive bladder cancer (NMIBC). For patients unwilling or unable to undergo cystectomy, numerous local therapies exist, although few are approved by the Food and Drug Administration. This review describes available therapies for this challenging clinical entity. Recent findings Combination intravesical chemotherapy, targeted therapy, and drug delivery enhancement have all been under recent investigation and are promising, although none has proven superior as of yet. Summary While BCG is standard treatment for intermediate and high-risk NMIBC, many patients fail therapy with recurrence or progression. Early cystectomy is the standard of care for BCG failure; however, many patients are unwilling or unable to undergo cystectomy. Multiple intravesical therapies have been used in this BCG failure population with moderate success, and, recently, technologies to improve drug delivery or create novel drugs have also been applied. Comparing efficacy of these therapies remain challenging as study cohorts are heterogeneous and study designs are variable. However, there are an increasing number of novel treatment options that can be offered to patients faced with recurrent NMIBC after BCG who seek bladder-sparing therapy.

Lessons Learned from Routine Intraoperative Ureteral Margin Frozen Sections during Radical Cystectomy

Introduction: We examined the practice patterns of intraoperative ureteral frozen section during radical cystectomy and the impact of ureteral margin positivity on operative characteristics and oncologic outcomes. Methods: The records of patients who underwent radical cystectomy at our institution from 2004 to 2011 were identified. Intraoperative ureteral frozen section characteristics were examined, including number, laterality, positivity, conversion to negative and final permanent section status. Logistic regression analysis was performed for predictors of operative time, change in urinary diversion, and biopsy confirmed upper tract recurrence and metastasis. Results: A total of 590 intraoperative ureteral frozen sections were sent for analysis from 241 patients (mean age 69 years). The sections were positive in 12.9% of cases and conversion to negative was accomplished in 82%. Multiple sections were associated with longer operating time (561 vs 511 minutes, p=0.011). Sensitivity for the sections was 100% and specificity was 93.6%. Taking multiple ureteral resections did not alter the planned urinary diversion in any patient or increase perioperative complication rates. At a mean followup of 22±19.8 months, 7 patients (3%) experienced upper tract recurrence. Intraoperative ureteral frozen section conversion to negative was associated with improved overall survival but not with upper tract recurrence. Conclusions: Our practice of taking intraoperative ureteral frozen sections provided excellent sensitivity and specificity, and the prolonged operative time did not translate into increased perioperative complications. Conversion of positive to negative was associated with improved overall survival, independent of patient comorbidities and post‐operative complications. No association was seen with upper tract recurrence but this was likely due to our high conversion rate to negative margins (82%), negative permanent section ureteral margin status in 97% of cases and the long followup time needed to demonstrate an association.

PD17-10 RENAL FAILURE FOLLOWING PARTIAL VS RADICAL STRATIFIED BY PREOPERATIVE CKD STAGE

METHODS: We retrospectively reviewed records of 1542 cases of RPN and 903 cases of LPN performed in 5 high volume centres across USA from 2000 to mid 2013. We limited our study renal masses ( 4 cm). Tumor complexity was assigned according to R.E.N.A.L nephrometry score (RNS). Based on RNS value, tumors were divided into simple (4-6), intermediate (7-9) and complex (10-12) group. We defined the Trifecta of negative surgical margin, zero perioperative complications and warm ischemia of less than 25 minutes, as a surrogate of ideal short-term surgical outcome. RESULTS: Total 1842 patients (1185 RPN and 657 LPN) met our inclusion criteria (tumor 4 cm). Patients in the RPN group were older (59.3 vs. 57.6 p1⁄40.003) and had higher mean Charlson Comorbidity Index (2.21 vs. 1.32 p<0.001). Higher proportions of the tumors in the RPN cohort were intermediate or complex (55.2% vs. 35.9% p<0.001). The RPN group had lower warm ischemia (19.2 vs. 26.7 minutes) time, overall complication rate (14.9 vs. 22.1%, p <0.001), and positive margin rate (3.3% vs. 9.6%, p <0.001). A significantly higher Trifecta rate was observed for RPN (70.7% vs. 32.4%, p<0.001). On multivariable analysis RPN, RNS and tumor size were predictors of achieving Trifecta. CONCLUSIONS: In this large multi-intuitional comparative series, we have demonstrated that RPN is superior to LPN in achieving the Trifecta, despite the presence of more complex tumors in the robotic cohort. Although the Trifecta does not encompass the long-term functional outcome of nephron sparing surgery, it provides us with an immediate surrogate for surgical quality control. Our results demonstrate that the robotic platform allows the surgeon to perform minimally invasive complex surgery more efficiently.

PD12-08 METFORMIN AND STATINS ACT SYNERGISTICALLY TO REDUCE BIOCHEMICAL RECURRENCE RISK IN DIABETICS FOLLOWING RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVES: The number of robotassisted radical prostatectomy (RARP) in Japan is increasing rapidly due to the application of health insurance to robotic surgery for prostate cancer since April, 2012. To maintain patient safety and high quality of surgery, the implementation of robotic surgeries in our institution were controlled by the minimal invasive surgery center (MISC), which runs robotic surgeries comprehensively. We report our experience of treating patients in MISC together with outcome of RARP. METHODS: The MISC consisted of all the departments related to robotic surgery including anesthesiology, five surgery departments, operation room nurses and medical engineers. From the view of safe implementation of robotic surgery, a certificate for surgery type and the console surgeon were authorized by MISC. Specifically, the MISC has a 0termination order0 authority, which is applied when there is excessive bleeding or surgical time. Robotic surgery must be changed into other types of surgery such as open conversion once the order is given. Each robotic surgery case in five surgery departments is checked and discussed preand post-operatively in the regular meeting held by MISC twice a month. RESULTS: The case number results stratified by robotic surgery types in the MISC over the last 2 years are shown in Table. The Urology, gynecology, respiratory surgery, digestive surgery and otorhinolaryngology departments performed 176, 22, 43, 34 and 2 cases of robotic surgeries, respectively. The number of cases with major complications including Clavien 5, 4 and 3 in all 277 cases were 0, 0 and 6 (2.2 %), respectively with one case of intra-operative open conversion. The core of robotic surgeries in MISC was RARP, and the implementation of this surgery based on the concept of pentafecta was supervised by MISC. At the median follow-up time of 11.9 (range 1.3 27.3) months, the positive surgical margin rate was 15.8 %, 91% of patients had undetectable PSA levels, and 76% of patients were not using pads. CONCLUSIONS: This is the first report of robotic surgery cases that were implemented using the constitutional framework of an academic institution. The MISC is providing immeasurable benefits from the aspects of patient safety and education for the robotic surgical team, and ultimately lead to accomplishment of pentafecta of RARP in urology.

MP54-05 MENTAL HEALTH NOT AFFECTED BY ACTIVE SURVEILLANCE FOR PATIENTS WITH SMALL RENAL MASSES: QUALITY OF LIFE RESULTS FROM THE DISSRM (DELAYED INTERVENTION AND SURVEILLANCE FOR SMALL RENAL MASSES) REGISTRY

INTRODUCTION AND OBJECTIVES: Active surveillance (AS) for patients with a small renal mass (SRM) is considered an acceptable alternative to surgery due to the slow growth of such tumors, low risk of metastasis, and presumed retention of renal function. We previously demonstrated a moderate decline in renal function for patients on AS in the Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) Registry. We now sought to compare this with the decline following extirpative modalities. We also correlated tumor growth rate with renal functional decline in AS patients. METHODS: The multi-institutional DISSRM Registry opened January 1, 2009. Patients with SRMs 4cm were entered into AS or intervention arms. Those electing AS followed an imaging protocol. Growth rates of masses were calculated based on changes in diameter. GFR was calculated with the Modification of Diet in Renal Disease formula. GFR change was calculated from the first value for surveillance patients or the pre-operative value for intervention patients, to the most recent value. Linear regression was used to determine the effects of study arm and growth rate on GFR, while controlling for the impact of demographics, comorbidities, and tumor histology. RESULTS: The difference in average GFR decline between the 66 partial nephrectomy (PN) patients and the 67 AS patients was not significant (1.9 vs 0.5, p1⁄40.270). In contrast, there was a significantly greater decline in the 15 radical nephrectomy (RN) patients compared to the AS patients (9.2 vs 0.5, p1⁄40.001). Average follow up time for AS, PN, and RN patients was 20, 19, and 16 months, respectively. On regression analysis while controlling for comorbidities, GFR was again found to decline faster in RN (p1⁄40.016) but not PN (p1⁄40.778) patients compared to AS patients. Average growth rate of masses in the AS arm was 0.19 cm/year. There was no significant difference in GFR change between AS patients whose tumors increased in size over their enrollment and those whose tumors decreased in size, as shown in the table (p1⁄40.260). On regression analysis the tumor growth rate did not significantly affect the rate of GFR decline while controlling for comorbidities (p1⁄40.915). CONCLUSIONS: AS for the small renal mass yields equivalent preservation of GFR when compared to PN, while both modalities are superior to RN. Preservation of renal function during AS is unaffected by growth rate. These renal function outcomes should be considered when making treatment decisions. N GFR Declined No change in GFR GFR Rose