Thomas G. Clifford

Midline Extraperitoneal Approach to Retroperitoneal Lymph Node Dissection in Testicular Cancer: Minimizing Surgical Morbidity

BACKGROUND Retroperitoneal lymph node dissection (RPLND) is an important component of the management of testicular germ cell tumor (GCT) but carries significant surgical morbidity. OBJECTIVE To describe our experience with a midline extraperitoneal (EP) approach to RPLND for seminomatous and nonseminomatous GCT. DESIGN, SETTING, AND PARTICIPANTS From 2010 to 2015, 122 consecutive patients underwent RPLND from a prospective database. Patients requiring aortic resection or retrocrural dissection or with intraperitoneal disease were excluded. The remaining 69 patients underwent midline EP-RPLND. SURGICAL PROCEDURE Open midline EP-RPLND was performed using a standardized technique. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Perioperative and long-term outcomes were analyzed. Complications were graded using the Clavien-Dindo classification. A descriptive analysis using SAS software was performed. RESULTS AND LIMITATIONS A total of 68 patients underwent midline EP-RPLND successfully (98.6%). The median age was 28 yr (range 17-55). On preoperative imaging the size of the retroperitoneal mass or lymphadenopathy was <2cm in 29 patients, 2-4.9cm in 15 patients, and >5cm in 24 patients, of which 19 were >10cm. The median estimated blood loss was 325ml (interquartile range [IQR] 200-612.5). The median number of lymph nodes resected was 36 (IQR 24.5-49); the median number of positive nodes was one (IQR 0-4). The median time for return of bowel function was 2 d (IQR 1-2) and hospital stay 3 d (IQR 3-4). There were no cases of ileus. Eleven patients had 12 (17.6%) 90-d complications. Of these, six (55%) were Clavien grade 1, five (45%) were grade 2, and one was grade 3b (1.5%). Antegrade ejaculation rates were 91.6% in the primary group and 96.8% in the post-chemotherapy group. CONCLUSIONS Midline EP-RPLND can be performed safely without compromising the completeness of the resection. This approach is associated with rapid return of bowel function, minimal rates of ileus, and short hospital stay. PATIENT SUMMARY A midline extraperitoneal approach for retroperitoneal lymph node dissection in testicular cancer is safe and effective and leads to faster return of bowel function and earlier discharge.

Impact of Body Mass Index on Robotic Radical Cystectomy with Intra-Corporeal Urinary Diversion

To determine the impact of body mass index (BMI) on peri‐operative and oncological outcomes after robot‐assisted radical cystectomy (RARC) with intracorporeal urinary diversion.

Satisfaction With Testicular Prosthesis After Radical Orchiectomy

OBJECTIVES To determine patient satisfaction with testicular prostheses (TP) for testicular cancer. Reconstruction represents an important part of surgical oncology, yet placement of TP following orchiectomy is infrequently performed. Improved data on patient satisfaction with TP would help in counseling patients with testicular cancer. MATERIALS AND METHODS Forty patients who underwent orchiectomy and TP placement for testicular cancer participated in a survey that was blinded to the providers in an outpatient clinic (2012-2014) to evaluate TP satisfaction. Categorical variables associated with satisfaction were compared using the Fishers exact test. RESULTS Median age at TP placement was 31 years (17-59). Most patients had their prosthesis in place for >1 year (81%) at the time of the survey. No patient reported complications from the TP and none underwent explantation. All patients felt that being offered an implant before orchiectomy was important. Overall, 33 patients (82.5%) rated the TP as good or excellent, and 35 men (87.5%) would have the prosthesis implanted again. Thirty-seven patients (92.5%) found the TP to be comfortable or very comfortable. However, 44% considered the TP too firm and 20% felt the position was not appropriate. Appropriate size, appropriate position, and TP comfort were significantly associated with good or excellent overall TP satisfaction (P < .05). CONCLUSION Overall satisfaction with testicular implants after orchiectomy for testicular cancer is high. Patients should be offered a testicular prosthesis, especially at the time of orchiectomy. Efforts should be made to optimize implant firmness, and care should be given to proper size selection and positioning.

MP80-10 MIDLINE EXTRAPERITONEAL APPROACH TO RETROPERITONEAL LYMPH NODE DISSECTION IN TESTICULAR CANCER: MINIMIZING SURGICAL MORBIDITY

post-chemotherapy setting for metastatic seminoma. However, false positive results can be a problem. We sought to identify a new methodology to interpret FDG-PET scans using a more objective approach to reduce false positive results. METHODS: We identified patients who had FDG-PET imaging available for re-review with a diagnosis of germ cell tumor at our institution from 2006 to 2016. Twenty-six scans were identified. All images were re-reviewed by an experienced radiologist who was blinded to patient treatments and outcomes. Radiographic variables recorded were mass size, standard uptake values (SUV), liver and blood pool values, and date of scan. Liver and blood ratios were calculated for each scan by dividing the SUV of the index lesion by the liver and blood pool values, respectively. A ratio of 1 would be considered a negative scan. A 5-point scale was assigned to each scan based on the dominant FDG-avid lesion using a similar system to the Deauville scale for lymphoma with 5 representing significant uptake and 1 for no uptake. RESULTS: A total of 26 patients were identified. The median follow-up from the PET scan was 21 months (range 1-96). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the original PET scan interpretation was 100%, 81%, 77%, and 100% respectively. If the liver ratio was included as an objective measurement, the sensitivity, specificity, PPV, and NPV would have improved to 100%, 88%, 83%, 100%, respectively. Thus, the increase in specificity would have resulted in a decrease of false positive results. Of the 26 PET studies, 3 (12%) were false positives and 0 (0%) were false negatives. Four patients underwent a RPLND due to positive findings on the PET study. Of these, 3 were found to have seminoma and 1 had necrosis on final pathology. The median SUV value of the 3 PCRPLND patients with seminoma was 6.7, with a liver ratio of 2.68. The patient with necrosis had an SUV of 2.5, with liver ratio of 0.9. The blood ratio and 5-point scoring system did not add additional significant information. CONCLUSIONS: By including the liver ratio in interpreting PET scans, we believe we can reduce the number of false positive scans.

V6-01 MIDLINE EXTRAPERITONEAL RPLND IN TESTIS CANCER: MINIMIZING SURGICAL MORBIDITY

INTRODUCTION AND OBJECTIVES: Retroperitoneal lymph node dissection (RPLND) is an important component of the management of testicular germ cell tumor (GCT) but its surgical morbidity is not insignificant. Herein we describe our updated experience with a midline extraperitoneal (EP) approach to RPLND for seminomatous and nonseminomatous GCT. METHODS: Between 2010 and 2015, from a prospectively collected IRB approved database, 122 consecutive patients underwent RPLND. Patients requiring aortic resection, retrocrural dissection or access to intraperitoneal disease were excluded. The remaining 69 patients underwent midline EP-RPLND. All post-chemotherapy (PC) cases underwent bilateral template dissection; all primary cases underwent extended ipsilateral templates. Perioperative and long-term outcomes were analyzed and a descriptive analysis using SAS was performed. RESULTS: 68 patients underwent midline EP-RPLND successfully (98.6%). Median age was 28 years (range1⁄417-55). Median follow up was 15.3 months (IQR: 5.7-24.3). On pre-operative imaging the size of retroperitoneal mass or lymphadenopathy was <2 cm in 29 patients, 2-5 cm in 15 patients, and >5 cm in 24 patients, of which 19 were >10cm. 3 patients underwent cavectomy. Median EBL was 325 mL (IQR: 200-612.5). Median number of lymph nodes (LN) resected was 36 (IQR: 24.5-49); median number of positive nodes was 1 (IQR: 04). Median return of bowel function was 2 days (1-3) and LOS was 3 days (2-4). There were no cases of ileus. 13 patients (19.1%) had complications within 90-days: 12 were Clavien grade 2 (17.6%), there was 1 grade 3b complication (1.5%). Antegrade ejaculation rates were 91.6% in the primary group and 96.8% in the PC group. CONCLUSIONS: Midline EP-RPLND can be performed safely without compromising completeness of resection. This approach is associated with a faster return of bowel function, lower rates of ileus and shorter LOS.

PD38-09 PROSPECTIVE EVALUATION OF CONTINENCE FOLLOWING OPEN RADICAL CYSTECTOMY AND ORTHOTOPIC URINARY DIVERSION AND THE EFFECT OF PELVIC FLOOR PHYSICAL THERAPY

INTRODUCTION AND OBJECTIVES: Continent cutaneous diversion (CCD) is a less commonly utilized diversion choice following open or robotic cystectomy. We have previously described a novel technique for robotic intracorporeal CCD. Meanwhile, continent cutaneous augmentation cystoplasty (CCAC) is a viable option for patients with neurogenic bladder. There is limited worldwide experience performing intracorporeal CCD and no studies describing intracorporeal CCAC. Principles developed in robotic CCD can be readily applied to robotic CCAC. We share our experience with these novel robotic procedures. METHODS: Robotic cystectomy was performed in patients undergoing CCD using a standard 6-port technique. The patient and robot were then repositioned for intracorporeal bowel mobilization and segmentation, ileocolonic anastomosis, uretero-colonic anastomoses, pouch construction, tapering of catheterization channel, reinforcement of ileocecal valve, and stoma creation. All patients were placed on an evidencebased Enhanced Recovery after Surgery protocol postoperatively. Operative times, intraoperative blood loss (EBL), length of stay (LOS), and complications occurring within 90 days of surgery were reviewed. RESULTS: Ten robotic intracorporeal right colon urinary diversions, including four robotic intracorporeal CCAC and six robotic intracorporeal CCD, were performed. Mean total operative times for cystectomy and intracorporeal urinary diversion were 7.8 and 10 hours for CCAC or CCD respectively (5.4-9.5; 7.9-12.9). Mean EBL was 181ml (75-300) for CCAC and 250ml (100-500) for CCD. Mean LOS for CCAC and CCD groups was 10 and 8.8 days respectively (5-18, 4-18). A single CCAC patient required transfusion postoperatively. Two high grade complications (Clavien III or greater) were reported in the CCAC group (50%). One high grade complication was reported in the CCD group (17%). Within 30 days of surgery, no CCAC and two CCD patients required readmission (0%, 33%). With a median follow up of 17 months, no incontinence was reported and all patients were able to catheterize without difficulty. CONCLUSIONS: We demonstrate that robotic intracorporeal CCD and CCAC are technically feasible and safe with good functional outcomes. Further evaluation of these novel surgical techniques along with comparative studies are needed.

MP20-10 STRUCTURED LEARNING FOR ROBOTIC SURGERY UTILIZING A GENERIC PROFICIENCY SCORE

age was 25.5 and 53.8% were females. The average “Tubes” score for the dV-Trainer and dVSSS were 10/100 and 48.5/100 respectively. Scores of MS and JR were similar (p1⁄40.36). GEARS scores of participants who initially used the dVSSS compared to the dV-Trainer were significantly higher (21/25 vs. 17.2/25, p1⁄40.04). Similarly, RACE scores of participants who used the dVSSS were also significantly higher compared to the dV-Trainer (23.2/25 vs. 17.8/25, p1⁄40.02). Scores of MS and JR were similar for GEARS (p1⁄40.50) and RACE score (p1⁄40.57). Intraclass correlation coefficient for the GEARS and RACE scoring were 72.6 and 89.3 respectively. CONCLUSIONS: The dVSSS trainer lead to superior scores in performing UVA in the OR for both MS and JR compared to the dVTrainer. The dVSSS can be used to improve teaching in surgical trainees in a safe and effective manner.