Weil R. Lai

Gigapixel surface imaging of radical prostatectomy specimens for comprehensive detection of cancer-positive surgical margins using structured illumination microscopy.

Achieving cancer-free surgical margins in oncologic surgery is critical to reduce the need for additional adjuvant treatments and minimize tumor recurrence; however, there is a delicate balance between completeness of tumor removal and preservation of adjacent tissues critical for normal post-operative function. We sought to establish the feasibility of video-rate structured illumination microscopy (VR-SIM) of the intact removed tumor surface as a practical and non-destructive alternative to intra-operative frozen section pathology, using prostate cancer as an initial target. We present the first images of the intact human prostate surface obtained with pathologically-relevant contrast and subcellular detail, obtained in 24 radical prostatectomy specimens immediately after excision. We demonstrate that it is feasible to routinely image the full prostate circumference, generating gigapixel panorama images of the surface that are readily interpreted by pathologists. VR-SIM confirmed detection of positive surgical margins in 3 out of 4 prostates with pathology-confirmed adenocarcinoma at the circumferential surgical margin, and furthermore detected extensive residual cancer at the circumferential margin in a case post-operatively classified by histopathology as having negative surgical margins. Our results suggest that the increased surface coverage of VR-SIM could also provide added value for detection and characterization of positive surgical margins over traditional histopathology.

Safety and early effectiveness of robot-assisted partial nephrectomy for large angiomyolipomas.

To evaluate a multicentre series of robot‐assisted partial nephrectomy (RAPN) performed for the treatment of large angiomyolipomas (AMLs).

Nanotechnology combined therapy: tyrosine kinase-bound gold nanorod and laser thermal ablation produce a synergistic higher treatment response of renal cell carcinoma in a murine model.

To investigate tyrosine kinase inhibitors (TKI) and gold nanorods (AuNRs) paired with photothermal ablation in a human metastatic clear cell renal cell carcinoma (RCC) mouse model. Nanoparticles have been successful as a platform for targeted drug delivery in the treatment of urological cancers. Likewise, the use of nanoparticles in photothermal tumour ablation, although early in its development, has provided promising results. Our previous in vitro studies of nanoparticles loaded with both TKI and AuNRs and activated with photothermal ablation have shown significant synergistic cell kill greater than each individual arm alone. This study is a translation of our initial findings to an in vivo model.

Nondestructive Diagnosis of Kidney Cancer on 18-gauge Core Needle Renal Biopsy Using Dual-color Fluorescence Structured Illumination Microscopy.

OBJECTIVE To present a novel imaging technique used for rapid, nondestructive histological assessment of renal neoplasias using a dual-component fluorescence stain and structured illumination microscopy (SIM). MATERIALS AND METHODS After Institutional Review Board approval, 65 total biopsies were obtained from 19 patients undergoing partial or radical nephrectomy. Biopsies were stained with a dual-component fluorescent, and optically sectioned SIM images were obtained from the surface of the intact biopsies. Specimens were subsequently fixed and analyzed using hematoxylin and eosin (H&E) histopathologic methods and compared with SIM images. A single, board-certified pathologist blinded to specimens reviewed all SIM images and H&E slides, and determined the presence or absence of neoplasias. Results of blinded diagnosis of SIM were validated against traditional pathology. RESULTS Of the 19 patients, 15 underwent robotic partial nephrectomies and 4 underwent laparoscopic nephrectomies. Indications included clinical suspicion of renal cell carcinoma. In total, 65 biopsy specimens were available for review. Twenty-one specimens were determined to be neoplastic on H&E, whereas 41 represented benign renal tissue. The final sensitivity and specificity of our study were 79.2% and 95.1%, respectively. CONCLUSION SIM is a promising technology for rapid, near-patient, ex vivo renal biopsy assessment. By improving the ability to rapidly assess sufficiency of biopsy specimens and enabling immediate diagnostic capability, SIM aids in more effective biopsy performance, tissue triage, and patient counseling regarding management options. Additionally, because tissue is preserved, effective utilization of downstream diagnostic tests and molecular assessments are possible.

Nephroureterectomy with Bladder Cuff

Urothelial cancer of the upper urinary tract is an uncommon urological malignancy. In cases of high-grade malignancy and/or tumor burden not amenable to minimally invasive procedures such as endoscopic resection and/or laser versus electrocautery fulguration, the gold standard has been open nephroureterectomy with bladder cuff excision. With the advent of laparoscopy and robotic surgery, nephroureterectomy can be performed in minimally invasive fashion with comparable oncological outcomes and with decreased morbidity. In this chapter, we review the technique of minimally invasive nephroureterectomy and discuss its complications, with particular focus on those associated with distal ureterectomy and bladder cuff excision and the means to prevent such complications.

MP49-15 SAFETY AND EARLY EFFECTIVENESS OF ROBOTIC PARTIAL NEPHRECTOMY FOR LARGE ANGIOMYOLIPOMAS

transperitoneal vs. retroperitoneal group, respectively (p1⁄40.049). However, after adjustment for multiple confounders, no statistically significant difference between the two approaches was observed (OR: 1.14; 95%CI: 0.712-1.826; p1⁄40.585). Conversely, both increasing PADUA score and male gender were associated with worse surgical outcomes (p<0.001). CONCLUSIONS: In expert hands, both the transperitoneal and the retroperitoneal approach can be safely adopted to perform a RAPN, with the latter being associated with lower EBL and length of stay.

Complications and Management of Robotic Lower Urinary Tract Procedures

Since 2002, robotic-assisted urologic surgery has replaced a significant number of open surgical pelvic procedures such as radical prostatectomy and radical cystectomy. The percentage of robotic-assisted procedures has been increasing ever since. In tandem, whenever new technology-associated procedures are introduced, there is a learning curve associated with this, and as a direct consequence, so are the associated number of complications. Being an expensive and high profile technology, robotic surgery has undergone a disproportionately higher scrutiny, and all users of robotic surgery should be cognizant of this trend. This chapter reviews the complications associated with robotic lower urinary tract surgical procedures as it relates to patient positioning, intra-operative, and post-operative diagnoses and discusses management strategies.

Technology Based Treatment for UreteroPelvic Junction Obstruction

Surgical management of ureteropelvic junction obstruction (UPJO) has historically been performed with open pyeloplasty. With the advent of endourology, laparoscopy, and robotics, minimally-invasive techniques have been described and accepted as alternatives to open surgery. Each of these approaches has its own advantages and disadvantages, equipment needs, degree of invasiveness, and experience of the treating urologist. Advocates and critics have their own say as to their preferred technique. In this article, we review the chronological evolution of these techniques and discuss their current role in the management of UPJO.Abstract Surgical management of ureteropelvic junction obstruction (UPJO) has historically been performed with open pyeloplasty. With the advent of endourology, laparoscopy, and robotics, minimally-invasive techniques have been described and accepted as alternatives to open surgery. Each of these approaches has its own advantages and disadvantages, equipment needs, degree of invasiveness, and experience of the treating urologist. Advocates and critics have their own say as to their preferred technique. In this article, we review the chronological evolution of these techniques and discuss their current role in the management of UPJO.

Racial Disparities in Histology and Short-Term Renal Functional Outcomes Following Robotic Nephron-Sparing Surgery

Micro‐Abstract To identify variations in renal function and histology between Caucasian Americans (CA) and African Americans (AA) undergoing robotic nephron‐sparing surgery (NSS), a retrospective chart review was performed on patients who underwent NSS. Postoperatively, AA experienced a greater increase in serum creatinine. Final histology demonstrated greater incidence of papillary renal cell carcinoma in AA and increased likelihood for type II papillary renal cell carcinoma, a more aggressive histology. Purpose: To identify variations in renal function and histology between Caucasian Americans (CA) and African Americans (AA) undergoing robotic nephron‐sparing surgery (NSS). Methods: A retrospective chart review was performed on patients who underwent NSS. Multivariate analysis identified factors affecting postoperative estimated glomerular filtration rate (eGFR). Histology was re‐reviewed by pathology to confirm papillary type. Results: A total of 331 patients underwent NSS: CA (n = 212), AA (n = 105), Hispanic (n = 10), and other (n = 4). AA average age (60.1 years) was lower than CA (62.3 years) (P < .001), with a higher proportion of AA women (46%) than CA (37%) (P = .021). AA had a higher incidence of diabetes (58.2%) and hypertension (93.9%). Preoperative average eGFR was similar: 70.35 mL/min for AA versus 69.06 mL/min for CA. Average postoperative eGFR was 50.59 mL/min for AA and 57.85 mL/min for CA. Postoperative creatinine increased more in AA (0.44 mg/dL) versus CA (0.33 mg/dL) (P < .001) even when stratified by pathological stage. Clear cell renal cell carcinoma (RCC) was the most common histology with AA (45%) and CA (60%). A greater than 2‐fold higher incidence of papillary RCC was observed in AA (31%) versus CA (13%). AA exhibited a greater proportion of high‐grade or type 2 papillary RCC (40% and 30%) versus CA (25% and 13%). Conclusions: AA patients were treated at a younger age, with a larger proportion of women. Postoperatively, AA experienced a greater increase in serum creatinine. Final histology demonstrated greater papillary RCC incidence in AA and increased likelihood for type 2 papillary RCC, a more aggressive histology.

Preoperative Assessment and Intervention: Optimizing Outcomes for Early Return of Erectile Function

Erectile dysfunction (ED) is one of the most common treatment-related side effects following a radical prostatectomy for prostate cancer. ED is defined as the inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. To the authors’ best knowledge, while there have been no published studies evaluating the preoperative optimization of patients to increase in erectile function recovery after radical prostatectomy, there have been numerous studies done to evaluate the interventions in modifiable risk factors to improve erectile function. These studies focus on physical activity, weight loss, dietary modification, intensive lifestyle changes, smoking cessation, alcohol intake, and statin therapy. This chapter aims to review such studies and discuss potential pathways to optimize patients preoperatively for recovery of erectile function after radical prostatectomy.