Saum Ghodoussipour

Utility and significance of ureteric frozen section analysis during radical cystectomy

To assess the utility of routine frozen section analysis of ureters at the time of radical cystectomy (RC) for urothelial cancer (UC), and the long‐term outcomes of adverse ureteric pathology.

PD58-03 IS COMPLIANCE TO AN ENHANCED RECOVERY PROTOCOL AFTER RADICAL CYSTECTOMY ASSOCIATED WITH IMPROVED POST OPERATIVE OUTCOMES?

June 2014 to May 2015. The post-protocol group includes consults received from June 2015 to September 2015. RESULTS: There were 74 patients in the pre-protocol (median age 71 years, median BMI 26.0) and 18 patients in the post-protocol group (median age 75 years, median BMI 27.4). The overall incidence of catheter-associated trauma during placement was 30/71 (41.1%) in the pre-protocol and 1/17 (5.9%) in the post protocol groups (p1⁄40.005). The total incidence of false passage in the pre and post-protocol groups was 19/73 (26.0%) and 0/17 (0%), respectively (p1⁄40.02). In the preprotocol group, 39/73 (53.4%) required a procedure by a urologist, while only 2/17 (11.8%) of patients in the post-protocol group required a procedure (p1⁄40.002). CONCLUSIONS: Implementation of a Foley Project protocol consisting of system-wide nursing education, DUC algorithm, and SCN team reduced the frequency of catheter-associated trauma and subsequent procedures.

Acute lung injury following penile ischemia and reperfusion

Acute lung injury following lower torso ischemia-reperfusion has been described, typically from the lower limbs. We present a case of acute respiratory failure following removal of a metal ring from an ischemic penis.

Current controversies on the role of lymphadenectomy for bladder cancer

Significant evidence exists regarding the diagnostic and therapeutic roles of pelvic lymph node dissection at the time of radical cystectomy for patients with bladder cancer. Despite this, lymphadenectomy for bladder cancer is still underutilized and even where performed, controversies exist in regard to what defines an adequate dissection and whether or not the indications for lymphadenectomy have changed now that we are firmly entrenched in the neoadjuvant chemotherapy era. A comprehensive literature review was performed to touch on these important issues and highlight future directions and current trials that will soon provide more clarity for surgeons and patients dealing with bladder cancer.

An Update in Enhanced Recovery Following Radical Cystectomy

Purpose of ReviewThe purpose of the study is to review and summarize major additions to the literature as pertains to enhanced recovery protocols after radical cystectomy in the past year.Recent FindingsEnhanced recovery after surgery protocols is multimodal pathways that include elements to optimize all stages of care including preoperative, intraoperative and postoperative measures. Several authors have recently presented their results with initial implementation of an enhanced recovery protocol after radical cystectomy, while others have begun to examine outcomes beyond the index admission and to refine the various targeted components of the protocol.SummaryEnhanced recovery after surgery protocols has revolutionized patient care following radical cystectomy, a procedure still burdened by high complication rates and lengthy hospital stay. Although still lacking in universal implementation and standardization of the protocol, significant advancements are made each year as we move towards best practice.

Paratesticular Serous Papillary Carcinoma of High Grade and Malignant Potential: A Rare Case with a Role for Adjuvant Therapy

Paratesticular serous papillary carcinomas are very rare, with less than 40 cases reported in the literature. These neoplasms are Müllerian in origin, and more commonly seen as epithelial-type ovarian cancer. Given the rarity of this tumor in men, staging and recommended treatment options do not exist. Herein, we present the case of a 35-year-old male with high-grade invasive serous papillary carcinoma. He was diagnosed after left radical orchiectomy for paratesticular mass and subsequently treated with adjuvant chemotherapy according to existing recommendations for its ovarian counterpart. Chemotherapy was well tolerated and surveillance imaging has shown no evidence of disease. This case suggests a potential role for adjuvant therapy in patients with high-grade paratesticular serous papillary carcinoma.

Experts versus Super Experts: Differences in Automated Performance Metrics and Clinical Outcomes for Robot-Assisted Radical Prostatectomy

To evaluate automated performance metrics (APMs) and clinical data of experts and super‐experts for four cardinal steps of robot‐assisted radical prostatectomy (RARP): bladder neck dissection; pedicle dissection; prostate apex dissection; and vesico‐urethral anastomosis.

PD38-10 FACTORS INFLUENCING INTRAOPERATIVE CONVERSION FROM PLANNED ORTHOTOPIC TO NON-ORTHOTOPIC URINARY DIVERSION DURING RADICAL CYSTECTOMY

physical therapy (PFPT). METHODS: Under IRB approval, we identified 1269 patients that underwent open RC from 2002 to 2015 (ONB 74%, 85% male). From 2012, patients were prospectively followed with a validated, pictorial pad usage questionnaire. A subgroup of patients received PFPT as an intervention to assist their continence. Interventions focused on improving pelvic floor muscle strength and coordination. Manual, visual and surface EMG biofeedback training were incorporated to improve neuromuscular re-education of the pelvic floor as well as behavioral modifications for bladder re-training, timed voiding and general bladder and bowel health. Frequency of visits started from 1x/ week over 4-6 sessions, and longer thereafter. RESULTS: A total of 153 male patients with available pad usage questionnaires were followed from September 2012 to August 2015. Daytime continence rates increase from 59% at <3 months to 92% by 12-18 months postoperatively. Nighttime continence rates increased to 51% by 18-36 months postoperatively. Overall catheterization rate was 13.1%. 17 patients underwent PFPT during this period, with a median age of 70 yrs. There was no significant difference between groups for age, BMI, or Charlson comorbidity index. Univariate analysis showed there is a shorter median time to first daytime continence in PFPT group compared to non-intervention group (89 days vs 182 days respectively; p1⁄40.06), while this was not significant for the nighttime continence (median 134 vs 311; p1⁄40.12). Kaplan Meier curves also showed higher continence rates in PFPT group at 1 year (0.710.13) compared to non-PFPT ones (0.60.04), although the difference was not significant (p1⁄40.25) (figure 1). CONCLUSIONS: Following ONB, continence improves significantly by 6 months, and plateaus with 92% of patients achieving daytime continence by 12-18 months. Those who received PFPT tend to have faster return to daytime continence in the first year. Further research with bigger sample size is needed to support the value of PFPT in continence after RC and ONB.

PD38-05 PREDICTORS OF URINARY RETENTION AFTER RADICAL CYSTECTOMY AND ORTHOTOPIC NEOBLADDER

INTRODUCTION AND OBJECTIVES: Radical cystectomy and urinary diversion is the primary treatment of patients with muscle invasive bladder cancer, which is associated with peri-operative complication rates as high as 60%. Ureteroenteric anastomotic stricture (UEAS) is a potential source significant morbidity. The etiology of UEAS is thought be either due to ischemia or inflammation. We sought to evaluate our experience with benign UEAS in our orthotopic neobladder (ON) population. METHODS: We retrospectively reviewed the charts of patients who underwent radical cystectomy and ON between 2000-2015 at MD Anderson Cancer Center and had at least 6 months of follow up. We reviewed operative reports regarding the type of anastomosis (interrupted versus running), suture type (absorbable braided versus monofilament). In those patients with UEAS, we also evaluated for history of radiation therapy and urinary tract infection (UTI). RESULTS: A total of 418 patients underwent creation of ON. The average age was 59 (SD 9.4 years) and 90% were males. The mean follow up was 57 months (6-183 months). There were 37 patients (8.9%) that developed UEAS, 42 renal units. Figure 1 demonstrates the number of strictures diagnosed per year. The mean time to diagnosis was 15.8 months (0.85-90 months). Management included placement of a nephrostomy tube or stent in 47% of patients and 32% underwent revision of anastomosis; while one patient underwent nephrectomy and the remainder were not treated at our institution. UEAS occurred in 30 patients with an interrupted anastomosis and 4 had running anastomoses and 3 were unknown. We found that anastomosis type and suture type were not predictive of UEAS (p1⁄40.594, p1⁄40.586), but that perioperative UTI within 30 days of surgery and recurrent UTI were predictive of UEAS (OR 3.27 p1⁄40.002, OR 7.06 p<0.001), while radiation was not significant (p1⁄40.128). CONCLUSIONS: UEAS are associated with potentially significant morbidity following ON creation. UEAS may occur early following urinary diversion, but may also occur as late as 7 years following surgery, owing to the importance for continued observation of these patients even into survivorship. Certainly, technical factors and surgeon experience may indeed contribute to the rate of UEAS, but it appears that perioperative UTI heralds future stricture development.

Surviving Fournier's gangrene: Multivariable analysis and a novel scoring system to predict length of stay

BACKGROUND There is no contemporary scoring system to predict hospital length of stay and morbidity in Fourniers gangrene. A retrospective study was conducted to formulate a scoring system to predict duration of hospitalization, resource utilization, need for reconstruction, morbidity and mortality. METHODS A retrospective chart review was performed on 54 patients treated for FG from 2010-2016 at LAC+USC Medical Center, the largest public hospital in Los Angeles County. Strobe guidelines were followed and the study was approved by the IRB. Predictors of LOS, morbidity, mortality and resource utilization were identified and univariate linear regressions performed to determine significance. Significant univariate predictors were used to develop a novel scoring system, the Combined Urology and Plastics Index (CUPI). The CUPI score was then compared to existing scoring systems for predicting length of stay. RESULTS The mean patient age was 49.3, and the mean BMI was 28.6. Patients on average were hospitalized for 37.5 days, with a mean of 8.3 days in the ICU. Three patients (5.6%) died during their hospital stay, and 33 (61%) required reconstructive surgery. Multivariate logistic modeling showed that BMI (p = 0.001) and alkaline phosphatase (p < 0.001) correlated with decreasing length of stay, while age at admission was not significantly correlated (p = 0.369). Univariate analysis of existing scoring systems showed that FGSI, LRINEC, NLR, and CCI were not significantly correlated with length of stay, while the newly calculated CUPI score was shown to be a significant predictor of longer hospital stays (p = 0.001). DISCUSSION Early emphasis on supportive care, nutrition, and involvement of reconstructive surgeons can decrease LOS in patients with Fourniers gangrene. The CUPI score on admission may be a useful tool for predicting LOS in this population.