2013 NS-AUA Abstracts

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):362.

P1: R.E.N.A.L Nephrometry Scores Are Associated With Perioperative Outcomes Following Partial Nephrectomy

Abhijith D Mally ¹, Zeyad Schwen ¹, Julie Riley ¹, Li Wang ¹, Ronald Hrebinko ¹, Stephen V Jackman ¹

Abstract

Background:

To externally validate the relationship of R.E.N.A.L nephrometry score to perioperative outcomes following partial nephrectomy

Methods:

We retrospectively reviewed our institutions database for any patient undergoing a partial nephrectomy from January 2011 to January 2012. R.E.N.A.L nephrometry score was compared with different pathologic features of these tumours.

Results:

A total of 79 patients underwent partial nephrectomy and had imaging studies available. Higher R.E.N.A.L score was associated with increased blood loss (p<0.001), increased hospital stay (p<0.001), increased preoperative (p=0.035) and pathologic tumour size (p<0.001) and increased risk of complications (p=0.015). However, there were no significant differences with respect to demographic characteristics, type of procedure and renal ischemia time (Table 1).

Conclusions:

Increasing R.E.N.A.L score is associated with increased blood loss, hospital stay and complications.

Table 1.

P1.

	All patients N=79	Low complexity (NS: 4–6) N=32	Moderate complexity (NS: 7–9) N=32	High complexity (NS: 10–12) N=15	p value
Age, year (median, Q1, Q3)	64.0 (54.0, 71.0)	62.5 (55.5, 68.75)	66.0 (55.0, 72.8)	61.0 (54.0, 69.0)	0.483
BMI, kg/m² (median, Q1, Q3)	29.4 (25.2, 33.6)	28.4 (24.7, 32.4)	31.0 (25.9, 34.5)	29.3 (24.3, 32.7)	0.362
Type of procedure, n (%)					0.079
Robotic/laparoscopic procedure	7 (8.9)	6 (18.8)	1 (3.1)	0(0)
Open procedure	72 (91.1)	26 (81.2)	31 (96.9)	15 (100)
EBL, mL	600.0 (200.0, 1000.0)	300.0 (100.0, 725.0)	750.0 (300.0, 1200.0)	900.0 (650.0, 3500.0)	0.001
Ischemia time, min (n=40)	10.5 (8.0, 17.3)	13.0 (8.3, 24.5)	10.0 (7.3, 12.8)	12.5 (7.8, 17.0)	.474
Hospital stay, days	3.0 (2.0, 4.0)	3.0 (2.0, 3.0)	3.0 (3.0, 4.0)	4.0 (3.0, 5.0)	<0.001
Any complication (CCS 1–5), n (%)	10 (12.7)	1 (3.1)	4 (12.5)	5 (33.3)	0.015

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BMI: body mass index; EBL: estimated blood loss; CCS: Clavien-Dindo classification system.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):362–363.

P2: Renal Lesions With High R.E.N.A.L Nephrometry Score Are Associated With More Aggressive Renal Cell Carcinomas

Abhijith D Mally ¹, Zeyad Schwen ¹, Julie Riley ¹, Li Wang ¹, Ronald Hrebinko ¹, Stephen V Jackman ¹

Abstract

Background:

To externally validate the relationship of R.E.N.A.L nephrometry score to pathologic features of renal lesions surgically excised.

Methods:

We retrospectively reviewed our institutions database for any patient undergoing a partial or radical nephrectomy from January 2011 to January 2012. R.E.N.A.L nephrometry score was compared with different pathologic features of these tumours.

Results:

A total of 124 renal masses were surgically extirpated and had imaging studies available. Higher R.E.N.A.L. score was associated with higher grade tumours (grade III/IV) (p<0.05), and higher stage tumours (pT2, pT3+, p<0.001). Though R.E.N.A.L score was not able to distinguish malignant from benign lesions (Table 1).

Conclusions:

Increasing R.E.N.A.L score is associated with higher grade RCC, confirming the utility of more aggressive management in these patients

Table 1.

P2.

Variables, n/N (%)	Low (RENAL 4–6)	Med (RENAL 7–9)	High (RENAL 10–12)	P for Linear trend
Total	36 (29.0)	49 (39.5)	39 (31.5)
Benign	12/36 (33.3)	9/49 (18.4)	8/39 (20.5)	.201
RCC	23/36(63.9)	40/49 (81.6)	26/39 (66.7)	.829
T1a	19/23 (82.6)	27/40 (67.5)	3/25 (12.0)	<.001
T1b	4 /23 (17.4)	10/40 (25.0)	7/25 (28.0)	.395
T2	0/23 (0)	3/40 (7.5)	8/25(32.0)	.001
T3+	0/23 (0)	0/40 (0)	7/25 (28.0)	<.001
Grade I/II	18/23 (78.3)	24/39 (61.5)	12/25 (48.0)	.032
Grade III/IV	5/23 (21.7)	15/39 (38.5)	13/25 (52.0)	.032

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Can Urol Assoc J. 2013 Sep-Oct;7(9-10):363.

P3: The CCP Score: A Novel Genetic Test for Prostate Cancer

Michael Brawer ¹, Jack Cuzick ², Matthew Cooperberg ³, Greg Swanson ⁴, Stephen Freedland ¹, Julia Reid ⁵, Gabrielle Fisher ², Jerry Lanchbury ⁵, Alexander Gutin ⁵, Steven Stone ⁵, Peter Carroll ³

Abstract

Background:

The natural history of prostate cancer is highly variable and difficult to predict accurately. Improved tools are needed to match treatment more appropriately to a patient’s risk of progression. Therefore, we developed an expression signature composed of genes involved in cell cycle progression (CCP score) and tested its utility in prostate cancer.

Methods:

We developed an expression signature composed of 31 cell cycle progression and 15 housekeeper genes. An expression score (CCP score) was derived as the mean of all cell cycle progression genes. The signature was tested at disease diagnosis in two conservatively managed cohorts (N=337 and 349), after radical prostatectomy in two additional cohorts (N=366 and 413), and after external beam radiation therapy (EBRT) (N=141) in a final cohort. All studies were retrospective.

Results:

The cell cycle progression signature was a highly significant predictor of outcome in all five studies. In conservatively managed patients, the CCP score was the dominant variable for predicting death from prostate cancer in univariate analysis (p=6.1 × 10–22 after diagnosis by TURP and p=8.6 × 10–10 after diagnosis by needle biopsy). In both studies, the CCP score remained highly significant in multivariate analysis, and in fact, was a stronger predictor of disease-specific mortality than other prognostic variables. After radical prostatectomy, the CCP score predicted biochemical recurrence (BCR) in univariate analysis (p=5.6 × 10-9 and p=2.23 × 10-6) and provided additional prognostic information in multivariate analysis (p=3.3 × 10-6 and p=9.5 × 10-5). After EBRT, the CCP score predicted BCR (Phoenix criteria) in univariate (p=0.0017) and multivariate analysis (p=0.034). In all five studies, the hazard ratio per unit change in the CCP score was remarkably similar, ranging from 1.89 to 2.92, indicating that the effect size for the CCP score is robust to clinical setting and patient composition.

Conclusions:

The CCP score predicts prostate cancer outcome in multiple patient cohorts and diverse clinical settings. In all cases, it provides information beyond clinicopathologic variables to help differentiate aggressive from indolent disease.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):363.

P4: Process of Care Variables Explaining the Influence of Surgical Volumes in Bladder Cancer Outcomes: A Population-Based Study

D Robert Siemens ¹, Gavin Li ¹, William Mackillop ¹, Chris Booth ¹

Abstract

Background:

Procedure volume is related to operative morbidity and mortality after cystectomy. However its effect on cancer-specific survival is not well characterized. Here we describe the relationships between hospital volume, surgeon volume, and late survival after cystectomy for muscle invasive bladder cancer (MIBC).

Methods:

Electronic records of treatment and surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients who underwent cystectomy for MIBC in Ontario, Canada. Process of care factors examined to explain any volume effect included adjuvant chemotherapy use, lymph node dissection (LND) and surgical margin status. Volume was divided into quartiles and determined based on mean annual number of hospital/surgeon cystectomy cases per 5-year period. A Cox proportional hazards regression model was used to explore the associations between volume and survival.

Results:

The study included 2738 cystectomy cases for MIBC treated between 1994 and 2008. Five-year overall (OS) and cancer-specific survival (CSS) for all cases were 30% (95% CI 28–31%) and 34% (95% CI 32–36%). In comparing the highest volume quartile to the lowest, the higher volume hospitals were more likely to have utilized adjuvant chemotherapy (27% vs. 15%, p<0.001) and were more likely to have performed a LND (83% vs. 53%, p<0.001). The highest volume hospitals were also associated with a lower 90-day mortality (6% vs. 10%, p=0.032). Low volume hospitals were associated with lower 5-year OS 28% (95% CI 24–31%) and CSS 32% (28–36%) compared to high volume centres 35% (31–38%) and 38% (33–42%) respectively. In multivariate analysis, hospital volume was associated with both cancer specific (p=0.013) and overall survival (p=0.002). Compared to the highest volume centres the HR for OS in the low volume centres was 1.24 (95% CI 1.09–1.41); the HR for CSS was 1.21 (95% CI 1.04–1.40). When individual surgeon volume was added into the model, almost all of the hospital volume effect on OS and CSS disappeared (1.07 [95% CI 0.90–1.27] and 1.05 [95% CI 0.86–1.27], respectively). The point estimate for the volume effect diminished, but did not disappear when LND was included in the model whereas utilization of adjuvant chemotherapy and margin status did not mediate the effect.

Conclusions:

Greater cystectomy volume is associated with improved 5-year CSS and OS in MIBC in the general population and this effect appears to be explained best by individual surgeon volumes as opposed to hospital volume.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):363–364.

P5: Pathological Features of Surgically Managed Small Renal Lesions: Analysis of Contemporary Series

Andres F Correa ¹, Bishoy A Gayed ², Milon Amin ¹, Amir Toussi ¹, Jodi K Maranchie ¹

Abstract

Background:

Recent studies have reported a 20% incidence of benign pathology following resection of small renal masses. Most series conclude that small renal cell carcinomas (RCC) trend toward low-grade histology with only a 10% incidence of high-grade features. This correlation has made the surgical management of small renal masses controversial, and prompted use of active radiographic surveillance. We analyzed the pathological findings of surgically managed small renal masses, 3 cm or less, for frequency of benign disease and correlation with low-grade malignancy.

Methods:

We retrospectively reviewed of all patients that underwent surgical resection of renal masses under 3 cm in diameter between 2008 and 2012 at a single institution. Tumours were grouped as <1 cm, 1–2 cm and 2–3 cm in diameter for analysis. All pathology specimens were reviewed by a single urological pathologist for diagnosis, histological subtype, TNM stage, nuclear grade, angiolymphatic invasion or extra-capsular extension.

Results:

A total 388 renal tumours had histological information available for analysis. Detailed pathological features are found in Table 1. Sixty-six were benign (17%), which comprised 50% of tumours <1 cm, 20% of 1–2 cm and 15% of 2–3 cm tumours (p=0.09). The most common histology was conventional clear cell carcinoma, which was identified in 62% of tumours 1–2 cm in diameter and 72% of tumours 2–3 cm in diameter (p=0.4) There was a significant increase in the incidence of high-grade features in lesions >2 cm (32%) relative to 1–2cm lesions (19%) (p<0.01).

Conclusions:

In our series of small renal masses the incidence of benign pathology is comparable to that reported in recent published studies. However, we observed a higher incidence of high-grade features than previously reported, particularly for tumours 2–3 cm in diameter. These findings add to the data available for counseling patients with small incidental renal masses regarding active surveillance versus immediate intervention.

Table 1.

P5. Pathological Features of 388 renal masses

	<1	1.0–1.9	2.0–3.0
Overall	4	140	244
Histology
Clear cell	2	87 (62)	175 (72)
Papillary	-	20	29
Chromophobe	-	2	9
Stage
T1a	2	110	197
T3a		2	11
Metastasis	-	-	4
Low-grade features
Fuhrman grade 1&2	2	92 (65)	142 (57)
High-grade features	-	27 (19)^*	79 (32)^*
Fuhrman grade 3&4	-	20 (14)^*	66 (27)^*
Angiolymphatic invasion	-	5	16
Benign	2	28 (20)	36 (15)
Angiomyolipoma	-	20	26
Oncocytoma	1	7	8
Nephrogenic adenoma	-	1	2
Papillary adenoma	1	-	-
Surgical approach
Radical nephrectomy	-	10 (7)	39 (16)
Laparoscopic	-	47 (33)	91 (37)

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^*

Statistical significance.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):364.

P6: The First National Experience Of Intravesical Injection Of The TraceIT™ Tissue Marker Under A Local Anesthesia For Imaging Visualization Of Muscle-invasive Bladder Cancer For The Targeted Imrt

Joel Bass ¹, Neil Mariados ¹, Po Lam ¹, Christopher Pieczonka ¹, Patrick Campbell ², David M Albala ¹, Howard Williams ¹, Vladimir Mouraviev ¹

Abstract

Background:

The treatment of musle invasive bladder tumours remains challenging for urologic oncologists. Targeted radiation therapy coupled with chemotherapy has become as a promising treatment modality comparable with a radical cystectomy according to the cancer control results. Radiation oncologists often combine, or fuse, MR and CT images to improve dose planning. accuracy. However, most markers do not have equivalent visibility on both CT and MR, creating a permanent image artifact in areas of particular interest and limiting their usefulness for image fusion. The TraceIT™ Tissue Marker (Augmenix, Waltham, MA) is an injectable polyethylene glycol based hydrogel marker designed to be visible under CT, cone beam computed tomography (CBCT), MR and ultrasound imaging for three months after implantation, and then to absorb within seven months.

Methods:

Patient M., 80 years with history of left nephrureterectomy for upper tract urothelial carcinoma 1.5 years ago diagnosed with recurrent bladder cancer. Cystoscopy was performed where a large papillary tumour more than 5 cm on anterior wall was found and resected by TURBT. The histology confirmed a high-grade muscle-invasive urothelial carcinoma with possible lymphatic invasion. Patient declined radical cystectomy and chose combination radiotherapy and chemotherapy. In order to outline a bladder tumour margins, the patient agreed to undergo an injection of TraceIT™ Tissue marker before IMRT. Under local anesthesia (intraurethral 2% lidocaine gel and intravesical 1%-lidocaine) a rigid 20 Fr. resectoscope was introduced into bladder, systematic cystoscopy was performed and of tumour was localized. TraceIT™ was injected using a 23G needle with 0.3 mL into 6 locations around tumour resection bed within 1 cm from cancer border in total amount of 1.8 mL were injected .

Results:

Patient tolerated a procedure well and immediately underwent planning CT scan following the injection. The patient was discharged following completion of the planning CT scan. Three days later, IMRT radiation therapy was started for a planned dose of 65 Gy in total on the Varian image-guided linear accelerator using Rapid Arc technology. The exact outlining of tumour margins on CBCT provided with TracelIT hydrogel™ allowed us to use a targeted boost IMRT regimen that led to successful cancer eradication with minimal toxicity.

Conclusions:

Next generation absorbable tissue markers such a TraceIT hudrogel™ extends our ability to exactly map the tumour margins for targeted radiation therapy.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):364.

P7: Pure And Dominant Gleason Pattern 3 Prostate Cancer Has Limited Invasive And Metastatic Potential.

Benjamin T Ristau ¹, Jeffrey J Tomaszewski ¹, Elen Woldemichael ¹, Joel B Nelson ¹

Abstract

Background:

The potential for local invasion and metastatic spread of pure and dominant Gleason pattern 3 prostate cancer appears to be limited. As such, its clinical significance is becoming increasingly questioned. To address this question, the biochemical recurrence, pathological extent and survival of a large cohort of men with pure and dominant Gleason 3 pattern in the prostate after open radical prostatectomy (RP) were examined.

Methods:

2755 patients underwent open RP by a single surgeon from 1999–2012. Patients were stratified by pathologic Gleason grade: pure 3+3=6 (Group 1), 3+3=6 with any higher tertiary grade (Group 2), and pure 3+4=7 (Group 3). Univariate and multivariable analyses were used to compare biochemical recurrence (defined as PSA ≥0.2 ng/mL or any adjuvant treatment), overall and cancer-specific survival, pathological features and margin status among groups.

Results:

A total of 622, 144 and 925 patients were categorized into Groups 1, 2, and 3, respectively. At a median follow-up of 58 months (IQR 29–95), biochemical recurrence occurred in 1.6%, 5%, and 6.8% in Groups 1, 2 and 3 (p<0.001). There was no difference in overall survival among groups and only one patient experienced a prostate cancer specific death (group 3). Group 1 patients had significantly smaller tumour nodules and percentage of tumour within the prostate (p<0.001). Tumours were organ confined in 96% (group 1), 91% (group 2) and 79% (group 3). Three patients had lymph node metastases, all from pure 3+4=7 primary tumours. Positive surgical margins occurred in 2.4% 8.3% and 5.3% in Groups 1, 2 and 3, respectively.

Conclusions:

Pure and dominant Gleason pattern 3 prostate cancer has limited invasive and metastatic potential. Pure Gleason 3+3=6 lesions are particularly indolent lending further support for initial active surveillance of these tumours. Biochemical recurrence rates should be in the single digits after RP, reflecting the quiescent biological nature of these cancers.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):364–365.

P8: An Analysis of Hospital Readmissions Following Radical or Partial Nephrectomy for Renal Cell Carcinoma

Lunan Ji ¹, Terry Creighton ¹, Diana Mehedint ¹, Jeffrey Spencer ¹, Eric Kauffman ¹, Thomas Schwaab ¹

Abstract

Background:

Retrospective comparisons suggest higher postoperative complication rates for partial nephrectomy (PN) compared to radical nephrectomy (RN), but readmission rates based on surgical approach are poorly documented. Postoperative hospital readmissions have a major economic impact and are utilized as surgical quality indicators. We set out to investigate the impact and reasons for post-RN and PN hospital readmissions.

Methods:

We queried a single centre prospectively maintained IRB-approved kidney cancer database for all patients who underwent RN or PN between February 1999 and January 2013. Reasons for readmissions were recorded and patients were stratified into RN versus PN and open versus minimally invasive approaches. Readmission rates within 30 and 90 days of surgery were recorded.

Results:

Among 864 consecutive patients undergoing nephrectomy, 426 underwent RN and 438 underwent PN. Of the total cohort, 57 (6.6%) were readmitted within 90 days of surgery, including 7 patients (1%) readmitted twice. We compared readmission rates between different surgical techniques and found a higher readmission rate for laparoscopic (including robotic) radical nephrectomies compared to laparoscopic partial nephrectomies (9% vs. 5%, p=0.045). We did not find a significant difference in readmission rates between open radical and open partial nephrectomies (6.5% vs. 6.8%, p=0.928). Readmission rates between laparoscopic and open approaches were also similar (6.6% vs. 6.6%, p=0.991). When analyzing the reasons for readmission between radical and partial nephrectomies, we noted higher rates of readmissions due to post-op ileus (1.9% vs. 0.5%, p=0.052), disease progression (2.35% vs. 0%, p=0.001), and biliary or lymphatic leakage (1.2% vs. 0%, p=0.024) in radical patients. For partial nephrectomies, readmission due to bleeding (1.4% vs. 0.2%. p=0.061) occurred at a numerically but not statistically higher rate than radicals. When stratified by tumour size and stage, there were no differences in readmission rates observed, despite the higher rate of disease progression for RN.

Conclusions:

Our analysis indicates a higher rate of readmissions for laparoscopic radical nephrectomies compared to laparoscopic partial nephrectomies. Further investigation is needed to assess the impact of standardized postoperative care pathways on reduction of postoperative readmissions.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):365.

P9: Is Smoking A Risk Factor For Non-clear Cell Renal Cell Carcinoma Subtypes?

Neel H Patel ¹, Terry T Creighton ¹, Diana C Mehedint ¹, Thomas Schwaab ², Eric C Kauffman ³

Abstract

Background:

Renal cell carcinoma is comprised of multiple cancer subtypes with different histologies, genetics, and clinical behaviors. Smoking remains among the best established clinical risk factors for RCC, however the risk among individual RCC subtypes has not been thoroughly studied. We investigated the relation between smoking and the diagnosis of individual RCC subtypes.

Methods:

A single institutional database of 691 consecutive nephrectomy patients, including 639 with renal tumours and 52 without neoplasms, was retrospectively reviewed. Data on smoking at the time of surgery were collected prospectively on all patients and tested for statistical association with RCC subtype or benign tumour diagnosis.

Results:

Mean age for patients with renal tumours was 60.6 years with a 1.6:1 male:female ratio, compared to 60.8 years and 1.3:1 male:female ratio for patients without neoplasms. The overall rate of smoking (active or former) was significantly higher among patients with renal tumours (51%) compared to those without tumours (33%; p=0.01). However, among the chromophobe RCC patients (31%), smoking incidence was similar to that of non-neoplastic nephrectomy patients (p=1.0), and significantly lower than clear cell RCC (52%, p=0.03) or papillary RCC (56%, p=0.02) patients. Compared to tumour-free patients, the relative incidence of smoking was 1.6, 1.7 and 1.0 for patients with clear cell RCC, papillary RCC and chromophobe RCC, respectively. Similarly, active smoking was quite uncommon among chromophobe RCC patients (6%), benign tumours (12%) and patients without neoplasms (14%), compared to clear cell RCC (22%) and papillary RCC (25%; p=0.03 and p=0.03, respectively, compared to chromophobe RCC). The likelihood of diagnosis of either chromophobe RCC or benign tumour was more than double among non-smokers compared to smokers, while an active smoking history increased the chance of a papillary RCC or clear cell RCC tumour diagnosis to 94%.

Conclusions:

Traditional understanding of smoking as a risk factor for RCC applies to both clear cell RCC and papillary RCC, but not chromophobe RCC. Absence of smoking increases the likelihood of a favorable histologic diagnosis with either chromophobe RCC or benign pathology. These findings underscore distinct molecular carcinogenic mechanisms underlying the different RCC subtypes, and clinically may aid in risk stratification of renal tumour patients lacking known histologic diagnosis.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):365.

P10: Cost Comparison between Active Surveillance and Surgical Intervention for Small Renal Masses

Anne G Dudley ¹, Ronald M Benoit ¹

Abstract

Background:

The incidental detection of small, solid renal lesions is now a common occurrence. Although surgical resection remains the gold standard for these lesions, in elderly patients and patients with limited life expectancy evidence suggests active surveillance is also a reasonable option as these lesions have a low risk of metastasis. The present study compares the costs of immediate resection to active surveillance.

Methods:

Total costs were calculated for both active surveillance and up front surgical resection in patients with a solid, enhancing mass less than 4 cm. Costs were calculated over a 10 year period using a discount rate of 5%. The active surveillance protocol consisted of an office visit and renal ultrasound at 3, 6, 12, 18 and 24 months after diagnosis, and then annually if the mass was stable. Surgical excision consisted of either open, laparoscopic, or robotic partial nephrectomy. Patients in the upfront surgical arm were seen post-operatively at two weeks and three months after the procedure, and then annually for an office visit, ultrasound, and comprehensive metabolic panel. Patients were discharged from follow-up if they remained without evidence of disease five years after surgery. Procedure costs were estimated from reported costs in the literature. Costs of office visits, imaging studies and bloodwork were based on Medicare reimbursement.

Results:

Total cost of active surveillance after 10 years was $2,053, assuming no patients crossed over to surgical intervention. If CT was used to monitor patients instead of ultrasound, costs increased to $3,499. The cost of up front surgical intervention after 10 years was $16,623, including follow-up care. If procedural costs were increased or decreased by 20%, costs after 10 years would be $19,663 and $13,583, respectively. If the annual crossover rate from active surveillance to surgical intervention was 4% (or 33.5% of all patients after 10 years), the costs of the active surveillance increased to $5,818. Even if all patients eventually crossed over to surgical intervention, active surveillance remains less costly than up front surgical intervention.

Conclusions:

Active surveillance is clearly much less costly than up front surgical intervention for patients with small renal masses. If the risk of metastasis from these lesions is indeed low, active surveillance should be strongly considered in elderly patients and patients with limited life expectancy given its markedly decreased costs.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):365–366.

P11: Testosterone Replacement Therapy for Hypogonadism in Men After Radiation for Prostate Cancer

Oluwaseun Akinola ¹, Charles Welliver Jr ¹, Joseph Mahon ¹, Clay W Mechlin ¹, Andrew McCullough ¹, Ronald P Kaufman ¹

Abstract

Background:

Testosterone replacement therapy (TRT) for hypogonadism after treatment of localized prostate cancer (pCa) remains controversial. Published data is sparse for TRT in the post radiation setting. We assessed the long term risk of biochemical recurrence in patients on TRT for symptomatic hypogonadism after primary pCa treatment with radiation.

Methods:

We retrospectively reviewed the records of patients treated with brachytherapy, external beam radiation therapy, or combination brachytherapy with external beam radiation therapy for localized pCa between 1989 and 2012 who subsequently underwent TRT for T <350 ng/dL and clinical symptoms of hypogonadism. Demographic and clinical data, pre/post TRT total testosterone and PSA data were obtained. Records were captured by ICD-9 codes.

Results:

Twenty six patients received TRT after radiation treatment for pCa at a median of 2.5 yrs. Median follow-up was 8.5 yrs. Total serum testosterone rose from a median of 137 ng/dL (range 6–325) to 685 ng/dL (range 83–5376) during TRT. Eighteen patients reported improvement of hypogonadal symptoms on TRT. One patient had a biochemical recurrence (BCR) at 22 years after initial cancer treatment. His recurrence was noted four years after initiation of TRT. A biopsy after BCR, showed residual Gleason 6 pCa. He was then treated with salvage brachytherapy resulting in an undetectable PSA and resumed TRT a year after treatment.

Conclusions:

TRT improves total testosterone and reported symptoms of hypogonadism in patients previously treated with radiation for pCa. While this study does show one patient with biochemical evidence of recurrence (who was able to be salvaged with additional brachytherapy), there is still an overall very low incidence of recurrence in this cohort, supporting the safety of TRT in this group of patients. Standard pCa follow-up remains important in these patients.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):366.

P12: Predictors of Testosterone Recovery in Patients with Castrate Resistant Prostate Cancer who have Stopped Hormonal Therapy

Michael Organ ¹, Derek Wilke ¹, Lori Wood ¹, Tina Cheng ², Scott North ³, Ricardo A Rendon ¹

Abstract

Background:

Intermittent androgen deprivation therapy (ADT) is widely used a treatment for advanced prostate cancer. Predictors for recovery of testosterone after cessation have been reported to be length of time on luteinizing hormone-releasing hormone (LHRH) agonist as well as age. In castrate resistant prostate cancer (CRPC) there is no current data on predictors of recovery of testosterone if LHRH agonist therapy is withdrawn, as patients generally stay on LHRH agonist or antagonist therapy. We retrospectively reviewed patients of a multi-institutional randomized control trial of intermittent versus continuous LHRH agonist in CRPC (recently published) to see if predictors of recovery of testosterone could be determined in this unique group of patients.

Methods:

A multi-institutional randomized control trial compared intermittent to continuous LHRH agonist therapy in patients with CRPC, with patients being re-initiated on LHRH agonist if their testosterone off hormone rose to above castrate levels. The data was retrospectively reviewed to determine if age or length of time on hormones were predictive of patients recovering their testosterone to above castrate levels.

Results:

18 patients with CRPC were in the intermittent hormonal therapy arm. 12 had to be re-initiated on hormones (mean time off hormones 252 days), while 8 did not recover their testosterone levels to above castrate levels before they died. The mean age was 71.7 years and the mean time off hormones prior to discontinuing them was 4.3 years. Those that were re-started on hormones and older than 74 years had a median time to re-initiation of hormones of 1.43 years while those younger had a median re-initiation at 0.79 years. Patients on hormonal therapy longer than 4.2 years prior to discontinuing them had a median of 1.5 years before re-initiating therapy versus 0.65 years in those on hormones less than 4.2 years. Age and length of time off hormones were not predictive of re-initiation of therapy or not.

Conclusions:

This is the first study to look at predictors of recovery of testosterone in men with CRPC. In these patients with CRPC who stopped their LHRH agonist, time on hormones as well as age showed a trend to being predictive of re-initiation of hormones when castrate levels of testosterone were recovered. Considering the low number of men in the intermittent arm of this study, these results should be interpreted cautiously.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):366.

P13: Tumour Complexity by R.E.N.A.L Nephrometry Score Predicts Malignant Disease and High-Grade Pathology for Small Renal Masses 3 cm or less in size

Andres F Correa ¹, Amir Toussi ¹, Bishoy A Gayed ², Milon Amin ¹, Jodi K Maranchie ¹

Abstract

Background:

The small renal mass (SRM) poses a diagnostic and management dilemma, as it may represent a wide spectrum of pathologies from benign lesions to high-grade RCC. Management of these lesions, especially masses less than 3 cm, continues to be debated with options including active surveillance, surgical resection or ablation. Recently R.E.N.A.L. nephrometry score calculator, have been proposed as a useful tool to determine pathology and high-grade malignancy. Here we intend to validate the use of the R.E.N.A.L. nephrometry score calculator as a predictor of pathology and high-grade malignancy in masses 3 cm or less in diameter.

Methods:

We retrospectively reviewed patients that underwent surgical resection of renal masses under 3 cm in diameter between 2008 and 2012 at a single institution. Patients with imaging available for analysis were included in the study. Tumour complexity was determined according to the R.E.N.A.L. nephrometry score calculator. Logistic regression analyses were performed to test the association between tumour complexity on imaging and tumour pathological characteristics. All pathology specimens were reviewed by a single urological pathologist for diagnosis, histological subtype, TNM stage, nuclear grade, angio-lymphatic invasion or extra-capsular extension.

Results:

A total 198 renal tumours had histological and radiological information available for analysis. Thirty-five masses were benign (18%), accounting for 19 % of all low and 14% of intermediate complexity masses. Increasing tumour complexity failed to predict malignancy (p=0.385). On subtype analysis high endophitic/exophytic ratio and closeness to the collecting system predicted malignancy (each p<0.01). The most common histology was conventional carcinoma accounting for 51% of all low, 65% intermediate and 79% high complexity masses. Fifty masses were found to be high grade (HG) which accounted for 31% of all RCC. On multivariate analysis, high complexity R.E.N.A.L. nephrometry score predicted high-grade pathology and clear cell histology (each p<0.05). On subtype analysis of low and intermediate complexity masses, no individual or combination of tumour characteristics predicted HG malignancy.

Conclusions:

On evaluation of masses less than 3 cm diameter, R.E.N.A.L. nephrometry score predicted malignancy on masses highly endophytic and central in nature. High complexity nephrometry scores predicted HG pathology and clear cell histology when comparing all RCCs. However, R.E.N.A.L. nephrometry score failed to predict HG pathology when comparing low and intermediate complexity masses.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):366.

P14: Withdrawn

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):366–367.

P15: No Impact on Survival with the Addition of Urologic Reconstructive Surgery in Patients undergoing Hyperthermic Intraperitoneal Chemotherapy

Jamie Uy ¹, Peter Hinds ¹, Matthew P Holtzman ¹, James F Pingpank ¹, David L Bartlett ¹, Benjamin Davies ¹

Abstract

Background:

Cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) has been used effectively in select patients with peritoneal carcinomatosis. Frequently, urologic reconstructive surgery is needed, yet there have been no reports of the long-term impact on survival in these patients.

Methods:

Data were extracted from a prospective database of patients with malignant peritoneal disease who underwent cytoreductive surgery with HIPEC and any urologic surgery under the same anesthetic. Information including number and type of urologic procedure (ureterolysis, ureterectomy, partial cystectomy) and patient characteristics was obtained. To compare demographic and clinical characteristics between groups, the independent t-test was used for continuous variables, and the χ² test was used for categorical variables. Kaplan-meier analysis was used to calculate average survival from the date of the cytoreductive surgery and HIPEC procedure to date of last follow-up. Multivariable linear regression was also used to control for patient characteristics. Institutional Review Board approval was obtained.

Results:

Between 2001 and 2012, among the 1088 patients who underwent cytoreductive surgery with HIPEC, 282 (26%) underwent a urologic procedure. Procedures included 24 partial cystectomies, 13 ureterectomies and 263 ureterolysis. Patients who required a ureterectomy at the time of cytoreductive surgery and HIPEC were more likely to have had previous chemotherapy (69% vs. 50%, p=0.28) or surgery (92% vs. 75%, p=0.26) than patients not requiring a ureterectomy. Additionally, patients receiving a ureterectomy had longer average operative times (569 vs. 468, p=0.055), and shorter average survival (3.1 vs. 4.7, p<0.05) than patients not receiving a ureterectomy. However, on multivariate analysis when controlling for disease type and type of urologic procedure no significant urologic factors independently impacted survival.

Conclusions:

There appears to be no difference in survival in patients undergoing HIPEC and concomitant urologic reconstruction at the time of their surgery. Patients and physicians can be re-assured that additional urologic surgery at the time of HIPEC should not impact their clinical outcome.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):368.

P16: Selection and Timing of Urinary Drainage in Pediatric Grade 4 Blunt Renal Trauma with Collecting System Injury

Jeremy Reese ¹, Janelle Fox ¹, Michael Ost ¹

Abstract

Background:

Conservative management of high-grade blunt renal trauma in the pediatric population is gaining support. While literature supports the success of non-operative approaches, limited data exists on the timeframe and predictive factors associated with failure of conservative management. This prompted an institutional review at a level 1 trauma centre.

Methods:

Records were retrospectively reviewed for 104 children with blunt renal trauma (2001–2012). We identified children 0–18 years old with Grade 4 renal laceration, categorizing clinical outcomes, radiographic variables and rationale for intervention. Statistical significance was determined with Chi-square and Mann-Whitney U tests for categorical and continuous variables.

Results:

Twenty- six children (median age 11.5, 69% male) sustained Grade 4 renal laceration. Conservative management was attempted in 16 patients, but failed in 7 (with 3 hospital re-admissions and a median time to intervention of 13 days). In addition to these 7 children with delayed intervention, 10 children were selected for early intervention (within 72 hours of presentation); therefore a total of 17 (65%) patients required stents or percutaneous drains to control urinary extravasation. Outcomes are categorized in figure 1, noting a trend toward prolonged median length of stay with early and delayed intervention (9 and 8 days) versus conservative management (5 days) (p = 0.064). Radiographic comparison of CT scans at presentation revealed differences in four investigated variables, when comparing children who were managed entirely conservatively versus required delayed intervention. Collecting system clot was present in 3 (33%) versus 7 (100%) patients, respectively (p = 0.006). A dissociated renal fragment was seen in one (11%) versus 4 (57%) patients, respectively (p=0.067). Median urinoma size was 1.1 cm versus 3.7 cm (p=0.005), respectively. Finally, fewer total CT scans were performed in those who succeeded conservative management (mean: 2 and 3 respectively) (p= 0.030).

Conclusions:

When conservative management is successful for children with Grade 4 renal lacerations, there is potential for reduced length of hospital stay. However, a subset may require readmission and delayed intervention. Children at greatest risk for delayed intervention had evidence of intrapelvic clot, initial urinoma size >3 cm, or >2 total CT scans.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):368.

P17: Objective Findings of Mesh-Related Complications in Patients Presenting with Mesh Complaints

Ali Syed ¹, Alosh Madala ¹, Dmitriy Nikolavsky ¹

Abstract

Background:

The aim of this study was to evaluate the true incidence of mesh related complications among patients presenting with “mesh anxiety”, describe objective findings and report on outcomes of treatment in these patients.

Methods:

From August 1, 2012 to April 30, 2013, a total of 25 patients presented with complain related to perceived mesh complications. Past operative reports were obtained for most patients and all patients underwent a complete history and physical examination including pelvic exam and cystoscopy. If objective findings of mesh extrusion, erosion or exposure were found, the patients were offered appropriate corrective surgery.

Results:

A total of 25 patients with average age was 61 years (range: 34–85) presented with complaints of mesh related complications. Presenting complaints included incontinence in 12/25 patients (48.0%), pelvic pain in 6/25 (24.0%), pelvic pain and incontinence in 3/25 (12.0%), and other (e.g., recurrent UTI, dysuria, stranguria, recurrent incontinence) in 4/25 (16.0%). Average time from implantation to presentation was 65 months (11–276 months). Initial procedures were performed due to pelvic organ prolapse (POP) in 7/25 (28.0%), incontinence in 12/25 (48.0%), and combination of POP and incontinence in 6/25 (24.0%). Operative reports indicated that 22/25 (88.0%) patients had a mesh and 1/25 (4.0%) patient had no mesh; operative reports were not available for 2/25 (8.0%) patients. Objective findings in 12 patients (48.0%) demonstrated mesh-related complications. Complications included extrusion into vaginal epithelium in 6 (24.0%), erosion into urinary tract in 2 (8.0%), and point tenderness over the arms of the mesh in 4 (16.0%). A total of 8/25 (32.0%) patients were offered mesh excision: 4/8 (50.0%) patients underwent an operation, 3/8 (37.5%) patients are awaiting their procedures and 1/8 (12.5%) deferred the operation. All other patients were treated conservatively. All patients treated with mesh excision reported complete resolution of presenting symptoms.

Conclusions:

In this study, half of the patients presenting with perceived mesh-related complaints do not have objective findings of mesh complications or sometimes even a history of mesh placement. However approximately 50% do have objective findings of mesh complications. In this sub-population of patients the removal of the mesh often alleviates their symptoms.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):369.

P18: Patient Reported Quality of Life and Timing of Discharge After Outpatient or Short-Stay Urethroplasty

Ilija Aleksic ¹, Alosh Madala ¹, Dmitriy Nikolavsky ¹

Abstract

Background:

While traditionally patients after urethral reconstruction required 3–4 days admission for immobilization and pain control recent literature has demonstrated the safety and feasibility of urethroplasty as an outpatient procedure. Our study was designed to assess quality of life of patients undergoing urethroplasty treated in the outpatient or a short hospital stay.

Methods:

Charts of 19 consecutive patients who underwent anterior or posterior urethroplasty between 9/2012 and 5/2013 were reviewed. Perioperatively patients were given a choice to be discharged after surgery or to remain overnight. EuroQuol-5 (EQ-5), a validated quality of life (QOL) questionnaire was administered to assess mobility, self-care, usual activities, pain or discomfort, and anxiety/depression. The choices were moderate, severe and no problems. One more question assessing timing of discharge was added to the interview.

Results:

Mean age was 45.8 year (17–75). Mean length of urethral stricture was 55.8 mm (4–160mm), including three panurethral strictures. Procedures performed included excision primary anastomosis (EPA) (5), augmented anastomotic urethroplasty (AAU) (2), Staged urethroplasty with buccal mucosal graft (BMG) (4), single-stage Kulkarni dorsal onlay urethroplasty (6) and posterior urethroplasty (2).

All patients, with the exception of two posterior urethral disruptions, were offered a choice of discharge time. Six patients (35.03%) chose to be discharged immediately, while 11 patients (64.71%) chose to stay overnight. The two patients after posterior urethral repairs were discharged within 23 hours. Furthermore, 18/19 patients (94.7%), were discharged within 23 hours of surgery.

16/19 patients responded to the EQ-5 within a day at a 88.9% response rate, after the elimination of the one pediatric patient (Table 1). In the short-stay and the outpatient cohort, 85.7% and 66.7% respectively felt they were discharged on time.

There have been no emergency room visits, readmissions to the hospital or recurrences from either cohort.

Conclusions:

Majority of patients discharged immediately feel that it was proper time for discharge and their quality of life as indicated by the EQ-5 was only minimally affected. Urethral reconstruction as outpatient or a short hospital stay could minimize health care cost without compromising QOL or affecting a perception of discharge timing negatively.

Table 1.

P18. Number (percentage) peporting on EQ-5 and discharge time

	Problem

EQ5; n=16	Severe	Moderate	No problem	Median

Mobility
All responders	0 (0.0)	9 (56.3)	7 (43.8)
Short-stay n=10		6 (60.0)	4 (40.0)	2
Outpatient n=6		3 (50.0)	3 (50.0)	2.5
Self-care
All responders	1 (6.3)	3 (18.8)	12 (75.0)
Short-stay	1 (10.0)	3 (30.0)	6 (60.0)	3
Outpatient	0 (0.0)	0 (0.0)	6 (100.0)	3
Usual activities
All responders	5 (31.3)	6 (37.5)	5 (31.3)
Short-stay	4 (40.0)	2 (20.0)	4 (40.0)	2
Outpatient	1 (16.7)	4 (66.7)	1 (16.7)	2
Pain/discomfort
All responders	1 (6.3)	14 (87.5)	1 (6.3)
Short-stay	1 (10.0)	8 (80.0)	1 (10.0)	2
Outpatient	0 (0.0)	6 (100.0)	0 (0.0)	2
Anxiety/depression
All responders	1 (6.3)	3 (18.8)	12 (75.0)
Short-stay	1 (10.0)	3 (30.0)	6 (60.0)	3
Outpatient	0 (0.0)	0 (0.0)	6 (100.0)	3

	Time
Discharge; n=14	Too late	Too soon	On time

Timing of discharge
All responders	0 (0)	3 (21.4)	11 (78.6)
Short-stay n=8		1 (12.5)	7 (87.5)
Outpatient n=6		2 (33.3)	4 (66.7)

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Can Urol Assoc J. 2013 Sep-Oct;7(9-10):369–370.

P19: Complex Urethroplasty with <23-Hour Stay: Early Functional Outcomes

Ali Syed ¹, Osama Zaytoun ¹, Dmitriy Nikolavsky ¹

Abstract

Background:

Urethroplasty has been traditionally considered a major urological procedure that requires long postoperative hospitalization for pain control and immobilization. The aim of the current study is to report functional outcomes of complex urethral reconstruction performed as an outpatient or a total hospital stay of less than 23 hours.

Methods:

A retrospective chart review identified 12 patients with long or panurethral strictures (5), hypospadius cripple (5), and post pelvic fracture urethral disruption defect (2). The procedures included single stage Kulkarni dorsal onlay urethroplasty (5), staged urethroplasty with buccal mucosal graft (5), or posterior urethroplasty (2). Patients with short strictures treated with excision and primary anastomosis (5) or augmented anastomotic urethroplasty (2) were excluded. Preoperative variables included patient age, etiology of the urethral stricture, anatomical location of the stricture according to preoperative retrograde urethrogram (RUG), uroflowmetry (Qmax) and post voiding residual urine (PVR). Postoperative parameters included Qmax and PVR which were evaluated in a 1 to 4 month follow-up visit after surgery. Postoperative emergency calls, ED admissions or unscheduled office visits were also recorded.

Results:

The median age was 41.5 years (18–75). Median length of urethral defect was 52.5 mm (20–150 mm). There were no readmissions or reoperations. There was one unscheduled office visit and one ED visit related to post-RUG pain. There were no short-term recurrences. Preoperative and postoperative Q max and PVR data were available in 8 patients out of 12 (66.7%). Median preoperative and postoperative Qmax were 1.0 (0–36) and 22.0 (12–40) mL/sec, respectively. Median preoperative and postoperative PVR were 177.0 ml (0–1000 mL) and 34.0 ml (0–200 mL), respectively. The increase in the Qmax and decrease in PVR was 19.5 mL/sec and 140 ml, respectively.

Conclusion:

In our experience, complex urethroplasty as an outpatient procedure is feasible and safe. Consistent with published data, it shows a significant improvement of urine flow and residual urine volumes. Complex urethral reconstruction procedures with short hospital stay result in excellent short-term functional outcomes without increasing the burden of post-operative care.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):370.

P20: Lower Urinary Tract Symptoms in Bladder Pain Syndrome/Interstitial Cystitis; In-Depth Analysis in Women

Jerzy B Gajewski ¹, Janusz Springer ²

Abstract

Background:

The aim of this study is to determine if the patient’s age and the severity of the lower urinary tract symptoms (LUTS; including suprapubic pain) were associated with the cystoscopic findings in women with a diagnosis of Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC). Furthermore, we checked the correlation between the lower urinary tract symptoms and the maximum cystoscopic capacity (MCC) under anesthesia.

Methods:

We conducted a retrospective analysis of 447 female patients who in the years 1993–2012 were diagnosed with Bladder Pain Syndrome/Interstitial Cystitis BPS/IC based on the ESSIC Criteria. LUTS were recorded by systematic interview. All patients underwent cystoscopy under general anesthesia following a protocol of bladder distention at 80 cm height of irrigating fluid. Cystoscopic findings were described according to ESSIC criteria. Spearman correlation quotient (R) and p quotient were calculated using Statistica. Statistical significance was set at p<0.05

Results:

Average patient’s age was 45 years (16–91), SD 14.21. We found statistically significant (p<0.05) positive correlations between the severity of cystoscopic findings and the severity of suprapubic pain (SPP) (R=0.15; p=0.0017) and the severity of urinary frequency (R=0.16; p=0.0008), respectively. The severity of stress urinary incontinence (SUI) (R=−0.14; p=0.0028) and urgency urinary incontinence (UUI) (R=−0.14; p=0.0027) were inversely correlated to the severity of cystoscopic findings. We also observed positive correlations between urinary frequency (R=−0.12; p=0.0123) and nocturia (R=−0.16; p=0.0006) with MCC. However SUI (R=−0.01; p=0.7688) and UUI (R=−0,1; p=0.0285) were negatively correlated with MCC. Surprisingly, the patients’ age was inversely correlated with severity of cystoscopic findings (R=−0.12; p=0.01).

Conclusions:

Our study confirms our clinical impression that the severity of SPP and the severity of urinary frequency correlate to the severity of bladder inflammation. However, we could not confirm the same correlation with nocturia. We also found that younger patients have more severe bladder changes. In conclusion, suprapubic pain and urinary frequency in younger patients correlate to severity of disease.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):370.

P21: Retrograde Leak Point Pressure Measurement Improves Outcomes Of The Virtue Male Sling For Post-prostatectomy Stress Urinary Incontinence

Michael W Sourial ¹, Le-Mai Tu ¹

Abstract

Background:

Male slings were introduced in the 1990s and have been shown to be safe and efficacious alternatives to the artificial urinary sphincter. We report our single institution experience of the Virtue Male Sling. Objectives of the study are to evaluate the efficacy and complication rate of the Virtue Male Sling for the treatment of post-prostatectomy incontinence (PPI) with and without per-operative retrograde leak point pressure (RLPP) measurement, and to evaluate the subjective satisfaction rate from patients regarding quality of life (QoL) after treatment.

Methods:

Retrospective evaluation of continence rate and complications in 34 men consecutively treated with the Virtue Male Sling for PPI between March 2009 and February 2013. Adequate sling tensioning was verified with cystoscopy in the first 18 patients, while per-operative measurement of RLPP was carried out in the last 16 patients. Follow-up schedule was at 2, 6, and 12 months, then yearly. Patient Global Impression of Improvement (PGI-I) scale was used to measure subjective satisfaction at the last follow-up visit.

Results:

Mean (range) follow-up was 15.9 (1.8–45) months. Mean (range) age was 66 (53–75) years. Eleven (32%) patients had mild, 17 (50%) patients had moderate, and 6 (18%) patients had severe PPI. Of the first 18 patients who did not have RLPP measured during the surgery, 11 (61%), 3 (17%), and 4 (22%) patients had no improvement, improvement, and cure of their PPI respectively, compared to 2 (12.5%), 2 (12.5%), and 12 (75%) of the last 16 patients who did have RLPP measured. Final mean (range) per-operative RLPP measurement was 41.1 (35–58) cm H2O. 11 (61%) of the 18 patients who did not, compared to 1 (6%) of 16 patients who did have RLPP measured had subsequent surgical treatments for unimproved PPI. Transient pain occurred in 2 (11%) of the 18 who did not, compared to 10 (62%) of the 16 patients who did have RLPP measured. In the group with RLPP measurement, 1 patient had a wound dehiscence which was debrided and primarily closed, and another patient had urinary retention requiring catheterization for two days. Five (28%) of the 18 patients who did not, compared to 12 (75%) of the 16 patients who did have RLPP measured were very satisfied with their device.

Conclusions:

The Virtue Male Sling is a safe and valuable treatment option for mild and moderate PPI. Per-operative RLPP measurement significantly improves cure and satisfaction rates.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):370–371.

P22: VCUGs Not Necessary in Evaluation of Symptomatic UPJ Obstruction

Lorraine Liang ¹, Mary Cantin ¹, Oleg Mironov ¹, Robert A Mevorach ¹, William C Hulbert ¹, Ronald Rabinowitz ¹, Jimena Cubillos ¹

Abstract

Background:

Ureteropelvic junction obstruction (UPJO) is a common collecting system anomaly that can lead to progressive renal damage, pain, stone formation, nausea, vomiting and failure to thrive. Prenatal ultrasound helps identify 90% of congenital UPJO in the first year of life. The remaining 10% of pediatric UPJO are diagnosed in childhood due to presence of symptoms including hematuria, pain or episodic vomiting. Voiding cystourethrogram (VCUG), is routinely used in the workup of neonatal hydronephrosis to determine need for antibiotic prophylaxis to identify vesicoureteral reflux (VUR). About 10% of patients with UPJO have concurrent VUR. Traditionally, all children with UPJO undergo VCUG prior to surgical correction. The purpose of our study is to determine the role of VCUG in the management of children who present with symptomatic UPJO.

Methods:

This retrospective study was approved by the institutional review board. We identified all patients with diagnosis code for UPJO from 2007 to February 2013. Exclusion criteria were pre- and neo-natal hydronephrosis, febrile urinary tract infection necessitating VCUG and incidentally found asymptomatic UPJO.

Results:

230 patients with UPJO were identified. 171 patients were excluded for aforementioned reasons. An additional 12 were excluded because they did not undergo VCUG. Eleven of those underwent pyeloplasty. Of the 36 VCUGs performed, 2 were aborted due to patient discomfort, 1 revealed grade 1 reflux on the affected side, 1 revealed bladder diverticuli, and 32 VCUGs were normal.

27 boys (mean age 10) and 9 girls (mean age 8.8) were identified. Presenting symptoms included pain (n=26), nausea and or vomiting (n=9), hematuria (n=4), hypertension (n=2), anorexia (n=2) and incontinence (n=2). 15 patients underwent open and 21 underwent robotic pyeloplasty. Intraoperative findings included 4 patients with ureteral stenosis, 9 patients with crossing vessels, and 9 patients who had other abnormalities including scarring, abnormal kinking during peristalsis, and high insertion. Follow-up ranged from 20 days to 6.6 years with a median follow-up of 8.7 months. Thirty-five patients had resolution of their symptoms and radiological improvement. One patient had recurrent obstruction and was treated with balloon dilation. He reported resolution of symptoms at his 1-year follow-up. None of the patients with or without VCUG evaluation had recurrent febrile urinary infections or sepsis postoperatively.

Conclusion:

VCUGs are falling out of favor due to cost, radiation exposure and patient discomfort. This study supports omission of VCUG in workup of patients with symptomatic UPJO.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):371.

P23: Management of Undescended Testis May Be Improved With Educational Updates For Referring Providers

Himanshu Aggarwal ¹, Alexandra Rehfuss ¹, Jean G Hollowell ¹

Abstract

Background:

Several studies have demonstrated that ultrasound is not helpful in diagnosis of undescended testis (UDT) and is not recommended. In spite of that a large proportion of boys referred for UDT have had an ultrasound (US) prior to referral. The first goal of our study was to objectively assess the severity of this problem in our area. The second aim was to determine if educational services for the referring providers (RP) resulted in decreasing USs for UDT. We also categorized all providers referring a UDT case by specialty (pediatrician, family practice, other) to determine if there was a subgroup more likely to order US. This is the first study to assess results of educational services focused on reducing wasted medical care dollars in our field.

Methods:

A chart review was done on new patients referred for UDT from January 2010 through June 2012. Data collection included date of pediatric urology office visit, whether or not an US had been obtained and provider ordering the US. All providers who referred a boy for UDT during the study period were categorized as (1) pediatrician, (2) family practice physician or (3) other. Several types of educational services on UDT management were provided to our RPs. The proportion of boys presenting to our practice who had US prior to referral was tracked for each month of the study period.

Results:

Of 338 boys referred for UDT, 62 (18%) had an US and presented to our practice during the study period. Of 159 pediatricians and 60 family practice providers referring patient(s) for UDT during the period, 35 (22%) pediatricians and 16 (27%) family practice providers ordered an US for one or more patients. This difference was not statistically significant. Five USs were ordered by general urologists.

Over the period of our educational updates there was a statistically significant trend downward of patients having US ordered by the RPs (Chi Square trend test, p<0.01)

Conclusions:

Obtaining unnecessary US for UDT is similar in our area to that reported in other parts of the country, suggesting this is a nationwide problem. This translates into tens of millions of health care dollars wasted each year. It was encouraging to see a significant decrease in USs following our educational services. We believe that subspecialists should provide educational updates for referring providers to promote cost effective care as well as better medical care.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):371.

P24: Do Gastroesophageal and Vesicoureteral Reflux Share A Common Pathophysiologic Mechanism? A Population-based Study

Heather Thomas ¹, Dawn MacLellan ², RLP Romao ², Eva Szudek ³

Abstract

Background:

Clinical anecdotal observation suggests that GER and VUR are concomitantly diagnosed at a higher rate than would be expected. One other study has explored this relationship using ultrasound diagnosis in a selected population (Pooli, Int Urol Nephrol, 2012). Both disease processes result from a deficiency in an anti-reflux mechanism and have a similar time-line for presentation and resolution. If a correlation could be documented between these two conditions, it may allow for earlier identification and avoidance of morbidity for some patients through early recognition and intervention if appropriate.

Methods:

A retrospective database review of individuals aged 0–16 years registered in the Nova Scotia (NS) Medical Service Insurance (MSI) Database from January 1997 to December 2012 was completed. Individuals must be registered in this database to receive medical care paid for by the government in the province of NS, Canada. ICD9 billing codes for the diagnosis of VUR and GER were used to identify patients of interest. The baseline prevalence of GER and VUR was calculated for the population of individuals aged 0–16 years registered in the MSI database for the same time period (n=407,609). Proportions of VUR patients with and without GER were compared using the chi square test (p<0.05). The association between VUR and GER was further explored using logistic regression controlling for gender and age.

Results:

Of eligible individuals, 7.46% had a diagnosis of GER (n=30,418), 0.33% had a diagnosis of VUR (n=1,344), and 0.001% had concomitant GER and VUR (n=340). Among patients with GER, the prevalence of VUR was 1.12%, compared to 0.27% in patients without GER (p<0.0001). The risk of being diagnosed with VUR was higher in the presence of GER (OR 4.2; CI 3.74–4.79; p<0.0001) and that association persisted after adjusting for gender. Patients with GER between 1 and 5 years of age were much more likely to be diagnosed with VUR compared to infants (0–1 years (OR 7.1 [CI 6.3–8.2]) and older children (≥5 years of age OR 8 [CI 6.9–9.2]).

Conclusions:

In Nova Scotia, there is evidence of a true difference in the prevalence of VUR in pediatric patients with a concomitant diagnosis of GER versus those without GER. A diagnosis of VUR is more than 4 times more likely in an individual with GER, suggesting that clinicians should have a higher suspicion for the diagnosis of VUR in pediatric patients with GER.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):371–372.

P25: Prospective Tracking Of Radiation Exposure In Pediatric Stone Patients: The Time Is Now.

Benjamin T Ristau ¹, Daniel P Casella ¹, Omaya Banihani ¹, Janelle A Fox ¹, Glenn M Cannon Jr ¹, Francis X Schneck ¹, Steven G Docimo ¹, Michael C Ost ¹

Abstract

Background:

The incidence of pediatric nephrolithiasis is increasing. Some radiation exposure in children is a necessary consequence. Unfortunately, higher levels of radiation exposure are associated with increasing risk of solid and hematologic malignancies. Thus, it is important for pediatric institutions to assess historical use of radiation in patients with stone disease and develop protocols to minimize future exposure.

Methods:

We reviewed a historical cohort of patients treated for pediatric nephrolithiasis from 2005–2012. Patients were stratified by procedure into three groups: cystoscopy with stent placement (CS), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL). Patient demographic information, stone size, stone location, number of radiographic images, and fluoroscopy times were determined.

Results:

A total of 136 patients (61% female) underwent 263 urologic procedures (54 CS, 186 URS, 23 PCNL) with a median follow-up of 19 months (IQR 6–42). Mean patient age at time of stone treatment was 12.2±4.7 years. At presentation, 136 stones (52%) were ureteral and 127 (48%) were renal. Of 64 patients on whom 24h urine collections were performed, 49 (77%) had abnormal results, most commonly hypercalciuria. Patients underwent an average of 1.5±1.4 CT scans and 1.3±1.7 abdominal x-rays. Median fluoroscopy times were 51 (IQR 27–95), 90 (IQR 51–135), and 456 (IQR 288–915) seconds for CS, URS, and PCNL respectively. Stone size correlated positively with fluoroscopy time (r=0.41, p<0.001). No new malignancies were identified during the limited follow-up period.

Conclusions:

Radiation exposure in pediatric stone patients from diagnostic studies and interventional fluoroscopy is not trivial. Urologists should closely monitor the amount of fluoroscopy used, particularly in percutaneous cases with large stone burdens. Prospective studies are currently underway to elucidate precise dose measurements and localize sites of radiation exposure in children during stone treatment.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):372.

P26: Dextranomer/hyaluronic Acid Copolymer (deflux) Injections In A Teaching Centre: How Looking At Our Practice Changed The Future - Or Not

Georges Gaba ¹, Orchidée Djahangirian ¹, Diego Barrieras ¹, Anne-Marie Houle ¹, Julie Franc-Guimond ¹

Abstract

Background:

We previously presented the long-term effectiveness of endoscopic treatment of vesicoureteral reflux (VUR) performed at our teaching hospital, where we use a modified sting procedure using Deflux and allow all team members to participate. Our surgical successes after one injection did not measure up with the best results reported by those who do many, operate themselves and often use larger amounts of injected material.

Therefore, we decided to analyse our latest data wondering if knowing our previous institutional results made a difference in our approach (patient’ selection, degree of reflux, case complexity, amount of debulking agent injected, etc).

Methods:

Only 48 children (14 males and 34 females, mean age of 5.8 years) in 2009–2012 underwent endoscopic correction of primary VUR with Deflux (Q-Med Scandinavia, Uppsala, Sweden) compared to 101 over a similar period in 2005–2008. Reflux was unilateral in 27 cases and bilateral in 21 (69 ureters). Reflux was grade I in 6 (9%) cases, II in 24 (35%), III in 28 (40%) and IV–V in 11 (16%) vs. 9, 38, 40 and 13% in the first study. All patients underwent endoscopic correction as a day procedure. A modified sting procedure was used and performed by attendings or residents/fellows under attending’s supervision. One patient with bilateral reflux had a contralateral ureteral reimplantation. In addition to routine parameters, post-operative cystograms were performed at an average of 4.4 months.

Results:

68 refluxing ureters were injected with Deflux. Complete postoperative information was available for review in 40 patients (62 ureters). The reflux was corrected in 43/62 ureters (69%) after one injection (success rate by patient of 43%). Twelve patients with persistent VUR (5 bilateral) chose to have another injection (7/12 cured). An average bolus volume of 1,22ml and 1.7ml was used for first and second injections (vs. 0.81ml for the previous study). Successes by grade (I to V) after the first injection were 83%, 75%, 62%, 63% and 50%.

Conclusions:

Although cohorts are unpredictably very similar, much less sting procedures have been performed over a similar period for a comparable institutional practice. We did however notice a trend towards injecting larger volumes and getting cystograms sooner without significant changes in the outcome. Therefore, it appears that modifying our practice, intentionally (less procedures, larger bolus) or unintentionally, did not affect the surgical outcomes considerably.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):372.

P27: Acellular Dermal Matrix Bladder Neck Sling: An Adjunct to Augmentation Cystoplasty And Continent Catheterizable Stoma Procedure In Pediatric Patients With Neurogenic Bladder

Stephen A Blakely ¹, Jonathan V Riddell ¹

Abstract

Background:

Acellular dermal matrix slings have been used with varying success in adult urinary incontinence surgery. Currently, no data has been reported on the use of acellular dermal matrix bladder neck sling in the pediatric neurogenic bladder population. The objective of this study is to report the short-term results of two pediatric patients with neurogenic bladder managed with augmentation cystoplasty, continent catheterizable stoma procedure and acellular dermal matrix bladder neck sling.

Methods:

Between January 2012 and April 2013, 16 augmentation cystoplasties were performed by a single surgeon at our academic institution. Eleven patients had a concomitant bladder outlet procedure. The most common bladder outlet procedure was autologous rectus fascial sling. In two cases rectus fascia was limited due to closure of a cutaneous vesicostomy in the setting of prior abdominal surgeries. In these two cases, acellular human dermal matrix was substituted. The graft was wrapped circumferentially around the bladder neck, elevated, and secured to the periosteum of the pubis.

Results:

Patient 1, a 15 year old female with sacral agenesis, had daily urethral incontinence despite having a patent cutaneous vesicostomy. In 90 days of postoperative follow-up, patient 1 has had no episodes of urethral incontinence. Patient 2, a 6 year old female with neurogenic bladder associated with multiple congenital anomalies, had daily urethral incontinence despite a patent cutaneous vesicostomy and demonstrated an open bladder neck on preoperative video urodynamic evaluation. In 60 days of follow-up, this patient had one episode of urethral leakage which preceded a large volume catheterization. Neither patient experienced a complication related to the bladder outlet procedure during follow-up.

Conclusion:

The use of acellular dermal matrix when autologous fascia is not available appears to be a viable option in the management of the bladder outlet in pediatric patients undergoing augmentation cystoplasty and continent catheterizable stoma procedures. Longer follow-up and more extensive experience is required to determine the durability and reliability of our results.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):373.

P28: Urinary Stone Risk after Colon Surgery: The Inflammatory Bowel Disease Bias

Zeyad Schwen ¹, Julie M Riley ¹, Timothy D Averch ¹

Abstract

Background:

Previous studies investigating urinary stone risk after colon surgery have demonstrated significant reductions in urinary pH, volume, citrate, and magnesium that correspond to an increased incidence of kidney stones. These studies, however, have consistently included patients with inflammatory bowel disease (IBD) which may bias their findings due to known urinary abnormalities present prior to surgery and differences in length of bowel removed compared to other types of colon surgery. This study aims to evaluate urinary stone risk after colon surgery in patients with and without IBD.

Methods:

Retrospectively, baseline 24-hour urine samples of 21 kidney stone patients with a history of colon resections were evaluated from a data set of over 800 patients. Urinary chemistries of those who required colon surgery for IBD (9 patients) and non-IBD reasons (12 patients) were compared to each other and a control of 52 first-time stone formers without bowel disease.

Results:

The IBD colectomy group had a significantly lower urinary pH (5.55 vs. 6.08, p=0.003), magnesium (41.8 mg/d vs. 103.7 mg/d, p=0.0002), citrate (109.8 mg/d vs. 230.4 mg/d, p=0.0001), sodium (95.2 mmol/d vs. 7.9 mmol/d, p=0.013), and calcium (109.8 mg/d vs. 230 mg/d, p=0.01) than the control. The non-IBD colectomy group had lower pH (5.69 vs. 6.09, p=0.015) and higher supersaturation of uric acid (1.62 vs. 0.87, p=0.015) compared to the control. The IBD colectomy group revealed a lower magnesium (p=0.04), citrate (p=0.007), and sodium (p=0.045) than the non-IBD colectomy group. 66% of the colectomies in the IBD group were total while 100% of the colectomies in the non-IBD group were partial.

Conclusions:

The urinary stone risk of colectomy patients with IBD is significantly different from colectomy patients without IBD and is more reflective of abnormalities present in IBD patients prior to surgery such as low citrate, magnesium, and urinary pH. It is likely the IBD patients biased the findings of previous studies investigating the urinary stone risk after colon surgery. Patients who underwent colon surgery for non-IBD reasons, however, have few urinary abnormalities and a urinary risk more similar to first-time stone formers. The difference in urinary risk of colectomy patients with and without IBD may be explained by the intrinsic stone risk present in IBD and the differences in length of bowel removed.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):373.

P29: A Multicentre, Randomized, Double-blind, Placebo-controlled Study of Silodosin to Facilitate Medical Expulsion of Ureteral Calculi

Roger L Sur ¹, Ojas Shah ², Scott M Olsen ³

Abstract

Background:

Medical expulsive therapy using alpha blockers is a common practice in treatment of ureteral calculi. We evaluated the efficacy of silodosin 8 mg as medical expulsive therapy for proximal, mid, and distal ureteral calculi.

Methods:

After Institutional Review Board approval was obtained in 34 academic and community sites throughout the United States, 246 subjects with a unilateral ureteral calculus (4–10 mm) were randomized, with blinding and concealment, to receive either placebo or silodosin 8 mg once daily for up to 4 weeks. A total of 232 subjects received study medication and completed the study follow-up. Univariate logistic regression was utilized to compare the primary endpoint of stone passage at 4 weeks with intention-to-treat analysis. If there was no stone passage after 4 weeks, or if the patient required intervention at any point, the study was terminated. Secondary endpoints included time to stone passage, need for emergency department visits, surgical intervention, pain assessment scores, and analgesic use.

Results:

For subjects with stones located in the distal ureter, treatment with silodosin resulted in significant improvement in the spontaneous expulsion rate at 4 weeks (69.2% vs. 45.8%, p=0.0138). A trend towards improvement in passage rate was observed for all ureteral stones collectively but not for the subsets of proximal or mid-ureteral stones. Among all patients, larger stones (6–10 mm) had higher passage rates with silodosin than with placebo (33% vs. 9.1%, p=0.0573). For subjects with distal ureteral stones, time to stone passage was lower in subjects receiving silodosin, approaching statistical significance. Subjects with distal ureteral stones receiving silo-dosin reported significantly greater improvements in average pain scores at study exit (Table 1).

Conclusions:

This investigation represents a large, multi-institutional, level I study demonstrating that silodosin 8 mg is effective over placebo in improving the passage of distal ureteral calculi. In particular, the spontaneous passage of large ureteral stones (6–10 mm) was positively affected by silodosin.

Table 1.

P29

Spontaneous stone passage at 4 weeks (primary endpoint)
	Silodosin 8 mg	Placebo	p value
Distal stones (n=111)	36/52 (69.2%)	27/59 (45.8%)	0.0138

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Can Urol Assoc J. 2013 Sep-Oct;7(9-10):374.

P30: Ultrasonography-guided Shock Wave Lithotripsy for the Treatment of Radioluscent Urolithiasis: A Retrospective Study

Ioana Popa ¹, Orchid Djahangirian ¹, Alzexis Rompré-Brodeur ¹, François Péloquin ¹

Abstract

Background:

Ultrasonography-guided shock wave lithotripsy is one of the non-invasive treatment strategies for radioluscent intra-renal and ureteral stones. Currently, there are few urologists in Quebec who have an expertise in this technique. Our objective was to determine the efficacy of ultrasonography-guided shock wave lithotripsy in our tertiary care centre, the CHUM (Centre Hospitalier de l’Université de Montréal), depending on the size and site of calculi and the complications associated.

Methods:

One hundred forty-three ultrasonography-guided shock wave lithotripsies were performed in our centre between January 2007 and March 2013. Twenty-one patients were excluded from our study because of missing data. We therefore retrospectively reviewed the operative procedures, imaging and follow-up of 122 patients. Analysis of the efficiency and complications of ultrasonography-guided shock wave lithotripsy was performed. Success rates were cumulated depending on the size and location of the calculi. Success was defined as no need of a further intervention. Patients were stratified in three size groups (15 mm) and seven location groups (superior calyx, medial calyx, inferior calyx, renal pelvis, superior ureter, medial ureter and inferior ureter).

Results:

In our study, 56.5% of patients treated by ultrasound-guided shock wave lithotripsy had renal pelvis stones. Fifteen percent of the patients had stones in the medial calyx, 10.7% in the superior calyx and 9% in the inferior calyx. Nine percent of the patients had ureteral calculi. First treatment success rates for renal pelvis stones were 60% for the 15 mm group. In the superior calyx group first treatment success rates were between 0% and 45.4% with a 45.4% success rate in the 15 mm calculi. In the medial calyx group success rates were between 25% and 100%: 88.9% in the 15 mm group. In the inferior calyx group success rates were between 71.4% and 75%: 71.4% in the <10 mm group, 75% in the 10-15 mm group. No patients were treated in the >15 mm group. Success rates between 40% and 100% were estimated for ureteral stones. There were few complications in our study. Five patients presented slight macroscopic hematuria, one Steinstrasse event was reported and one urinary tract infection without sepsis.

Conclusions:

Ultrasound-guided shock wave lithotripsy is an efficient treatment option for radioluscent renal or ureteral calculi associated with few complications. Succes rates vary according to size and emplacement of the stones with better results for intra-renal urolithiasis less than 15 mm.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):374.

P31: Validation of a Clinical Nomogram to Predict the Successful Shockwave Lithotripsy of Renal and Ureteral Calculi

Andrea G Lantz ¹, Daniela Ghiculete ¹, Kirsten Foell ¹, Tarek Alzahrani ¹, R John D’A Honey ¹, Kenneth T Pace ¹

Abstract

Background:

Although shockwave lithotripsy (SWL) outcomes are dependent on patient and stone-related factors, there are few reliable algorithms predictive of treatment success. We previously created a clinical nomogram to use pre-treatment patient and stone variables to predict successful SWL outcomes, based on patients treated on the Phillips Lithotron. The purpose of this paper is to validate that nomogram in a different, more current set of patients who underwent treatment on a different lithotripter to determine if the nomogram is valid and generalizable.

Methods:

Data from patients treated at our lithotripsy unit from June 2010 to September 2012 were reviewed. Analysis was restricted to patients with a solitary renal or ureteral calculus <20 mm in maximum dimension, with a pre-treatment CT scan within 4 weeks of SWL, and follow-up at our institution. Demographics, stone, patient, treatment and follow-up data were collected from a prospective database. All patients were treated on the Storz Modulith SLX-F2 lithotripter.

Results:

In total, 270 patients (67.5% male) were analyzed. Mean stone size was 52±37 mm² for ureteral stones and 66±54 mm² for renal stones, with 82 (50.3%) of the renal stones located in the lower pole. The single treatment success rates for ureteral and renal stones were 62% and 75%, respectively. On univariate analysis, predictors of SWL success, regardless of stone location, were age (p=0.04), body mass index (p=0.048), stone size (p<0.01), mean stone density (MSD; p<0.01), gender (p=0.029), stone location (p<0.01) and skin-to-stone distance (SSD; p<0.01). By multivariate logistic regression, stone area, stone location, MSD and SSD remained significant predictors, with an area-under-curve (AUC) of 0.79.

Conclusions:

Patient and stone parameters have been identified to create a nomogram that predicts SWL outcomes. These parameters have been validated in two independent cohorts of patients treated on entirely different lithotripters (one elctrohydraulic machine, the other electromagnetic). Use of a clinical nomogram can facilitate optimal treatment-based decisions and provide patients with more accurate single-treatment success rates for SWL that are tailored to patient-specific situations.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):374.

P32: No Difference In 24-hour Urine Parameters Between Patients With Obstructing And Non-obstructing Urolithiasis Presenting to a Tertiary Referral Centre

Tarek Alzahrani ¹, Daniela Ghiculete ¹, Andrea G Lantz ¹, Kenneth T Pace ¹, Jason Y Lee ¹, R John D’A Honey ¹

Abstract

Background:

Metabolic work-up of stone formers often includes at least one 24-hour urine collection. Conventional teaching has been to perform the 24-hour urine collection after an acute stone event and after obstruction has been relieved. However, by the time a patient is seen in follow-up some stone prevention counseling is likely to have occurred, altering the 24-hour urine collection results (“clinic effect”). At our institution, patients bring a 24-hour urine collection to the initial assessment for extracorporeal shockwave lithotripsy (SWL). The study objective is to determine if there are differences in 24-hour urine parameters for patients with obstructing versus non-obstructing stones.

Methods:

In 2011, 2670 SWL treatments were performed at our institution. Newly referred, unstented patients with pre-SWL 24-hour urine data were reviewed (n=849). Institutional axial imaging was available for retrospective review in few patients; therefore, patients were grouped into renal versus ureteral stones assuming most renal stones are non-obstructing and unstented ureteral stones have some degree of obstruction.

Results:

615 renal and 191 ureteral stones were included. 65.4% were male with more males in the ureteral stone group (73.8% vs. 62.8%, p=0.005). Average age was 51.3 years (±13.1) with an average BMI of 27.5 kg/m² (±5.4). Mean stone size was similar between groups (p=0.898). The rate of hypercalciuric patients was significantly higher in the renal group (17.3% vs. 11.1%, p=0.039) but no other parameters differed between groups.

Conclusions:

There are few differences in 24-hour urine parameters between obstructive and non-obstructive urolithiasis when location of stone is used as a proxy for obstruction. Only urinary calcium was statistically different between groups but this may be of little clinical significance. This study may support earlier 24-hour urine evaluation, in order to minimize the “clinic effect,” regardless of urinary obstruction.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):374–375.

P33: Validity of Administrative Coding for Pregnant Patients with Urolithiasis

Anne G Dudley ¹, Julie M Riley ¹, Michelle J Semins ¹

Abstract

Background:

Administrative databases are frequently used for retrospective study of patients with urolithiasis. While coding has been validated for urolithiasis in the general population, pregnancy remains a unique condition where kidney stone diagnosis is challenging, and thus the validity of coding in this group is unknown. We aim to define the validity of ICD-9 codes for upper urinary tract stone disease in the pregnant population.

Methods:

All patients from 2001–2011 with an ICD-9 coding diagnosis of pregnancy (640–648, V22.0, V22.1, V22.2) and upper tract urinary calculus (592, 592.0, 592.1, or 592.9) at a tertiary women’s hospital were identified. 75 randomly chosen patients underwent further chart review. Patients were deemed not to be appropriately coded if no imaging was performed, no renal colic was present, no stone or hydronephrosis was identified on imaging, negative ureteroscopy was performed, and/or no stone passed.

Results:

A total of 417 patients were identified as being coded for pregnancy and nephrolithiasis. Of the 75 selected for thorough chart review, 36 correctly had a urinary calculus while 39 did not. In the pregnant population on administrative chart review, only 48% of patients were correctly coded based on ICD-9 diagnosis code for upper tract urolithiasis.

Conclusions:

ICD-9 coding for urinary calculi in the pregnant population is not valid and should not be used in administrative databases to study stone disease in this group of patients unless diagnosis can be confirmed on an individualized basis.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):375.

P34: Radiation Practice Patterns and Exposure in the High-Volume Endourologist

Anne G Dudley ¹, Michelle J Semins ¹

Abstract

Background:

Endourology is an evolving field with minimally invasive procedures often guided by fluoroscopy. To date, research has focused on radiation risk to the patient, however limited literature exists to characterize surgeon exposure. We aim to define radiation exposure and practice patterns among endourologists by evaluating high-volume surgeons with varying experience.

Methods:

Surveys were obtained from the Research in Calculus Kinetics (R.O.C.K.) Society members from 14 different institutions across North America. All surgeons practice at high volume academic institutions as surgical stone specialists. Protective equipment, fluoroscopy variables and practice patterns were recorded. Dosimeter readings for the past year were obtained from those available and analyzed. Effective delivered dose was examined as a function of the practice variables studied.

Results:

15 surveys were returned, with a response rate of 94%. Fluoroscopic procedures comprised 87% of surgeon cases. Surgeon mean experience was 12.4 years (range 1–32). On average, surgeons operated with a fellow 30.4% of cases, with a resident 92.9% of the time, and scrubbed for 70.1% of cases. Lead aprons were worn in 99.3% of cases, thyroid shields in 98.7%, radiation glasses in 52.7%, and lead gloves in 9.7%. About 2/3 of surgeons controlled the foot pedal themselves and less than half used a dedicated radiology technologist. Only 33.3% of surgeons regularly wore dosimeters. Of these surgeons, average deep dose equivalent was 816.6 mrem/year, or 68.1 mrem/month. Lens dose equivalent was 1303.4 mrem/yr or 108.6 mrem/month. Shallow dose equivalent was 1286 mrem/year or 102.8 mrem/month. With only 4 surgeons having dosimeter readings, comparisons were limited, but there did appear to be a trend when comparing those surgeons with equal to or greater than 10 years of practice experience to less experienced surgeons (25.3 mrem/month compared with 110.7 mrem/month). All surgeons with dosimeter readings used pedal control of fluoroscopy and obtained their own access for percutaneous nephrolithotomy.

Conclusions:

Endourologists receive moderate radiation exposure, which can be further reduced with practice experience and improved education. As low as reasonably achievable (ALARA) principles should be in place and judiciously followed. Dosimeter use remains quite low, limiting analysis of other potentially significant variables. Improved monitoring and education should assist with reduction of radiation exposure to both the patient and endourologist.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):375.

P35: Pioneering Outpatient PCNL: The McGill/Queen’s Experience

Sero Andonian ¹, Mohamed A Elkoushy ¹, Andrea Kokorovic ², Darren Beiko ²

Abstract

Background:

Traditionally, patients are admitted following PCNL. The concept of discharging a patient a few hours following PCNL has not been widely adopted and in fact has been seen by some thought leaders as substandard care. Consequently, there remains a paucity of studies on outpatient PCNL. The purpose of this study is to challenge tradition by assessing the safety and efficacy of outpatient PCNL in two “early adopter” Canadian centres.

Methods:

A retrospective review of all outpatient PCNL cases between March 2007 and May 2013 at McGill and Queen’s Universities was performed, including collection of preoperative, intraoperative and postoperative data. Strict criteria were used in the selection of candidates for outpatient PCNL: ASA class 1 or 2; no intraoperative complications; minimal intraoperative bleeding; no collecting system perforation; no obvious residual stones; hemodynamically stable postoperatively; adequate pain control; reliable patient with supportive family.

Results:

Forty-five outpatient PCNL cases were performed, including 2 calyceal diverticula. All patients were discharged the same day, within hours of PCNL. No patients were admitted overnight in a 23/24-hour short stay ambulatory unit. With the exception of 1 of the calyceal diverticulum patients who received a nephrostomy, all PCNL cases were performed using a tubeless technique. Presently, complete follow-up is available on 42 of 45 patients, as follow-up on the 3 most recent patients is pending. Five patients (11.9%) returned to the emergency room within the first 7 postoperative days. Three patients had flank pain/stent colic and were discharged and 2 patients (4.8%) were admitted - 1 with multiresistant E. coli and 1 with uncomplicated flank pain. Stone-free rate was 95.2% (40/42 patients). Importantly, there were no major complications or deaths.

Conclusions:

This study represents the largest series to date of outpatient PCNL cases. In properly selected patients, outpatient PCNL is feasible. With a postoperative readmission rate of less than 5% and a stone-free rate of greater than 95%, outpatient PCNL appears to be safe and effective, respectively. Furthermore, same day discharge following PCNL could potentially add value to the healthcare system through significant cost savings. Prospective studies comparing standard PCNL to outpatient PCNL are warranted.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):375–376.

P36: Urinary Tract Injury During Hysterectomy: Robotic-Assisted versus Conventional-Laparoscopy versus Laparotomy

Anees Fazili ¹, Jorge Carrillo ¹, Smitha Vilasagar ¹, Franca Kraenzlin ¹, Jason Birnbaum ¹, Laura Carrillo ¹, Changyong Feng ¹, Louis Eichel ², Fred Howard ¹

Abstract

Background:

Given the enhanced visualization and dexterity afforded by robotic surgery, we sought to evaluate whether there was a lower incidence of urinary tract injury during robotic-assisted hysterectomy, as compared to conventional-laparoscopic and laparotomic hysterectomy.

Methods:

Retrospective chart review was performed on all robotic-assisted, conventional-laparoscopic, and laparotomic hysterectomies at our institution from January 2009 to June 2012. Patients were excluded if they had concomitant urogynecologic procedures, laparoscopic-assisted vaginal hysterectomy, cesarean-hysterectomy, or prior abdomino-pelvic radiation. Gynecologic-oncology patients were included. 2558 patients met our inclusion/exclusion criteria. Medical records were reviewed for patient and operative characteristics, as well as for urinary tract injury characteristics and potential risk factors.

Results:

Among our 2558 patients, 756 were conventional-laparoscopic, 570 were robotic-assisted, and 1232 were laparotomic hysterectomies. 57 patients sustained 60 urinary tract injuries, including 41 cystotomies and 19 ureteral injuries, yielding an overall incidence of 2.22%. The incidences of urinary tract injury were: robotic-assisted, 1.92%; conventional-laparoscopy, 1.85%; and laparotomy, 2.59%. These differences were not statistically significant (p=0.54). When comparing high & low volume surgeons within each cohort, significant differences in urinary tract injury rates were only observed among laparotomic surgeons (p=0.02). On multi-variate analysis, the only factors that influenced urinary tract injury were EBL (OR 1.001, p<0.0001), supracervical approach (OR 0.32, p=0.0018), and oncology status (OR 0.44, p=0.037). On subgroup analysis, when controlling for supracervical approach, a significant difference in urinary tract injury rates was only observed in the conventional-laparoscopic group compared to the laparotomic group (0.6% vs. 2.3%, p=0.029). There was no significant effect of c-section history on incidence of cystotomy (p=0.072), nor was there any effect of oophorectomy on ureteral injury (p=0.16). Cystoscopy was performed in 24.3% of cases, with significant differences in utilization between groups: 47% conventional-laparoscopic, 20% robotic-assisted, and 13% laparotomic (p<0.0001). Cystoscopy had a sensitivity of 84.6% and specificity of 99.7% for detection of urinary tract injury. Ureteral stents were utilized in 1.5% of cases, with no significant differences between groups. There was a trend towards improved intra-operative detection of ureteral injuries with stents, but this was not statistically significant (p=0.11).

Conclusions:

Incidence of urinary tract injury during hysterectomy was only influenced by EBL, a supracervical approach and oncology status. Among supracervical hysterectomies, the conventional-laparoscopic cohort had a significantly lower rate of injury than the laparotomic cohort. Robotic-assisted hysterectomy was not associated with decreased rates of urinary tract injury.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):376.

P37: Robotic Assisted Simple Prostatectomy for Recurrent Giant Benign Prostatic Hyperplasia Following TURP

Alejandro R Rodriguez ¹

Abstract

Background:

Recurrent benign prostatic hyperplasia (BPH) can occur after transurethral resection of the prostate, especially after more than 5 years from surgery. Some patients report severe lower urinary tract symptoms (LUTS) due to giant anomalous intravesical regrowth of the prostate. We report our experience with robotic assisted simple prostatectomy for giant recurrent BPH in patients with a prior transurethral resection of the prostate (TURP).

Methods:

From November 2011 to May 2013, 15 patients were treated surgically for giant recurrent BPH causing severe LUTS. All patients had had a prior TURP procedure. Patient demographics, pre-operative and peri-operative data was analyzed.

Results:

Patient mean age and body mass index was 68 years (60–78) and 31 (28–34). All patients had a robotic assisted transperitoneal transvesical simple prostatectomy. Two patients had an additional umbilical hernia repair, and one patient had removal of a 15 cm bladder stone at the same time of the procedure. Mean robotic console time was 120 minutes (90–150 min). The mean estimated blood loss, jackson-pratt drainage days, hospital stay, and days of Foley catheter was 150 cc, 2, 3, and 7 days, respectively. The mean pre and post IPSS score was 25 and 7, respectively (p<0.05). Mean follow-up was 7 months (1–12 months). There were no blood transfusions performed and no perioperative complications.

Conclusions:

Robotic assisted transvesical simple prostatectomy is a real alternative for patients that suffer of severe LUTS due to giant recurrent BPH.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):376.

P38: Influence of Intraoperative Fluids on Surgical Outcomes in Partial Nephrectomy

Eric Arnone ¹, Richard Ahn ¹, Kristopher Attwood ², Terry Creighton ², Diana Mehedint ², Eric Kauffman ², Thomas Schwaab ²

Abstract

Background:

The type and amount of fluids given intra-operatively has an effect on post-operative renal function and outcomes in renal transplantation. Data in the context of partial nephrectomy are scarce. We set out to investigate the influence of type and amount of intraoperative fluid on surgical outcomes for partial nephrectomies.

Methods:

The prospectively maintained IRB-approved kidney cancer database at Roswell Park Cancer Institute was queried. All patients with normal contralateral kidney and normal renal function who underwent elective open, laparoscopic or robot-assisted partial nephrectomy between 1997 and 2012 were included in the study. Patients were excluded if data on postoperative renal function was unavailable. Patients were separated into three groups: open, laparoscopic, and robotic-assisted. Patient characteristics were compared between surgery groups using the Wilcoxon rank sum test and Chi-Square tests. The association between independent variables (ie. age, BMI, OR time, EBL, warm ischemia, renal score, pre-op Cr/GFR, fluids etc.) and response variables (change in Cr/GFR) were assessed using Spearman correlation coefficients and odds ratios. The relationship between the independent variables and responses were then adjusted for surgery type using linear and logistic regression models.

Results:

A total of 334 patients were identified (34 open, 165 laparoscopic, 135 robotic-assisted). Demographics were equal between groups except pre-operative Cr which was higher in open procedures (1.22 vs. 1.07 [lap] vs. 1.08 [robot] p<0.001). OR time, EBL, and warm ischemia time were all significantly greater in open procedures. Amount of LR given intra-operatively was greater in open procedures (33.34 vs. 26.13 vs. 20.58 mL/kg/hr p<0.001). Hextend administration was greatest in open surgeries (9.92 vs. 4.50 vs. 7.73 mL/kg/hr p<0.001). Immediate change in post-operative GFR was greatest in open cases (−0.20 vs. −0.10 vs. −0.08). On univariate analysis, OR time, EBL, warm ischemia, renal score, and amount of LR given had a significant effect on post-operative Cr. When adjusting for the amount of LR given, there was a significantly greater effect in open cases (−0.066 vs. −0.003 vs. −0.010 p<0.001). The amount of Hextend administered did not have a significant effect on renal function.

Conclusions:

The amount of LR given was less in laparoscopic and robotic surgeries. LR had a significant effect on post-operative renal function demonstrated by decreased Cr in all surgery groups. However, this effect was greatest in open surgeries.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):376–377.

P39: 2-year Oncologic Outcomes in Non-organ Confined Bladder Cancer after Robot-Assisted Radical Cystectomy.

Dmitry Koulikov ¹, Ali Al-Daghmin ¹, Rakeeba Din ¹, Aabroo Khan ¹, Yi Shi ¹, Gregory Wilding ¹, Eric C Kauffman ¹, Khurshid A Guru ¹

Abstract

Background:

Oncologic outcomes of pT3 and pT4 bladder cancer after Robot-Assisted Radical Cystectomy (RARC) are poorly defined. We define the oncologic outcomes of non-organ confined bladder cancer treated with RARC and pelvic lymphadenectomy (PLND).

Methods:

Prospectively collected and maintained clinical and pathological data were retrospectively reviewed for 114 patients with pT3 and pT4 bladder cancer who underwent RARC between 2005 and 2012. We reported the 2-year overall survival (OS), cancer-specific survival (CSS) and progression-free survival (PFS) after RARC and PLND for pT3 and pT4 bladder cancer using Kaplan-Meier survival curves. Multivariate analysis was used for secondary outcomes included identification of predictors of poor oncologic outcomes.

Results:

The median age was 71 (36–90). The mean follow-up was 17 months (0.2–85). 2-year OS, CSS, and PFS were 47% (95% CI 35%, 57%), 68% (95% CI 56%, 78%), and 37% (95% CI 25%, 49%), respectively. The median number of lymph nodes (LN) was 24 (range 0–63) and 52 (46%) patients had LN metastasis. Surgical margins were positive in 11 patients (10.6%). OS, CSS and PFS rates differed by pathologic stage (p=0.03, 0.004 and 0.02, respectively). Additionally, LN metastasis adversely affected OS, CSS and PFS (p=0.01, 0.04 and 0.02, respectively). Positive surgical margin decreased OS, CSS and PFS (p=0.003, 0.01 and 0.012, respectively). Meanwhile, lymph-vascular (LVI) only adversely affected CSS (p=0.04). pT stage was independent predictor of poor PFS and CSS outcomes (p=0.02 and 0.014, respectively) while LN metastasis was independent predictor of poor OS (p=0.02).

Conclusion:

Oncologic outcomes after RARC for patients with locally advanced bladder cancer are poor, similar to open RC series. Tumour stage (T4 vs. T3), LN metastasis, positive surgical margins and LVI were independent predictors of some adverse oncologic outcomes.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):377.

P40: The Reclassification of Preoperative High Risk Prostate Cancer Patients after Robotic Assisted Laparoscopic Prostatectomy

Ilija Aleksic ¹, Matt Kardjian ², Po N Lam ², Angelo R Rosalio ², Elan W Salzhauer ², Harvey A Sauer ², Matvey Tsivian ³, Christopher M Pieczonka ², Jeffrey J Sekula ², Vladimir Mouraviev ², David Albala ²

Abstract

Background:

The most commonly used definition criteria for prostate cancer risk-stratification (D’Amico and Epstein) do not necessarily reflect the complexity and biological behavior of this disease. They include tissue diagnosis data (biopsy results) along with clinical (clinical stage) and biochemical parameters (PSA level). The aim of this study was to compare histologic high risk features preoperatively with final pathological results.

Methods:

30 (5.5%) patients from 550 consecutive RALP cases performed from 2009 to 2011 had high-risk preoperative features based on the D’Amico-Epstein definition (Gleason Score ≥8, pT3 or positive lymphatic nodes). These pathological results were compared with final pathological results after RALP.

Results:

Of the 30 patients who had high Gleason score on biopsy (≥8), 15 (50%) were reclassified to a lower risk based on final pathology (Gleason <8, organ-confined disease and negative lymph nodes). Patients with a lower biopsy Gleason score were more likely to be down-staged (67% for Gleason 8, 17% in Gleason 9 and 0 in Gleason 10, p<0.05). Similarly, lower preoperative PSA levels and fewer positive cores were associated with increased likelihood of reclassification (p<0.05).

Conclusions:

50% of men with preoperative high-risk prostate cancer were reclassified to a lower risk category bases upon final pathological results. Histopathologic features alone may guide clinicians away from definitive treatment such RALP. In the future, we believe more comprehensive pre-procedurual staging, including advanced imaging as well as molecular and genetic testing to better correlate risk in the future.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):377.

P41: The Treatment Trends for Localized Prostate Cancer in Large Urology Group

Vladimir Mouraviev ¹, Matt Kardjian ¹, Po N Lam ¹, Elan W Salzhauer ¹, Angelo R DeRosalio ¹, Christopher M Pieczonka ¹, Ilija Aleksic ², Vladimira Mouravieva ¹, Neil Mariados ¹, Herbert I James ¹, Sasha Pavlov-Shapiro ¹, Richard M Kronhaus ¹, Paul M Kardjian ¹, Weil F Muakkassa ¹, David M Albala ¹

Abstract

Background:

Robotic assisted laparoscopic prostatectomy (RALP) is an increasingly utilized modality for primary definitive therapy. da Vinci Surgery is considered “Minimally Invasive Robotic-Assisted Surgery” (MIRS). When compared to open surgery, da Vinci Surgery provides patients with the following potential benefits: shorter hospital stay, less blood loss, lower risk of complications, less pain and faster recovery and return to normal activities.

Methods:

We analyzed the results of the 1243 patients who underwent the definitive treatment for localized prostate cancer in our group from January 2009 to December 2011 in order to define treatment trends. The following treatment modalities were used: RALP, open prostatectomy, radiation therapy (IMRT or brachytherapy), cryoablation and active surveillance (AS).

Results:

The age distribution of our cohort was the following: 40–49 years - 3%, 50–59 years - 25%; 60–69 years - 35% and ≥70 years - 37%. The predominant modality utilized was radiation therapy (mostly IMRT) in148 cases during 2009, 269 cases in 2010 and 321 cases in 2011. However, RALP is rapidly rising from 118 cases in 2009 to 154 in 2010, and 269 in 2011. Open radical prostatectomy has been performed in sporadically: 4 cases in 2009, 2 cases in 2010 and 3 cases in 2011.

Conclusions:

Our results suggest in increase in surgical intervention for the treatment of localized prostate cancer. Radiation therapy still plays an important role in the treatment of prostate cancer. Current studies are examining these trends for 2012 and 2013.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):377.

P42: Robotic Assisted Radical Prostatectomy in High-grade Prostate Cancer: Experience From Two Tertiary Centres

Ilija Aleksic ¹, Vladimir Mouraviev ², Matt Kardjian ², Naif Al-Hathal ³, Assaad El-Hakim ³, Alain Hueber ³, Kevin C Zorn ³, David M Albala ²

Abstract

Background:

The use of radical prostatectomy as part of the treatment algorithm in high-grade prostate cancer (HGPCa) remains controversial. On the other hand, there are well-known limitations of conventional TRUS-guided biopsy such as insufficient tissue sampling, pathologist experience etc. Such limitations raise concerns about the accuracy of Gleason grading as a main predictor of PCa aggressiveness. Based on validation by the final pathology assessment of prostatectomized specimens, we searched a cohort of patients with Gleason downgrading regarding association with other pathology characteristics, oncological and functional outcomes.

Methods:

Among a total of 965 collective RARP consecutive cases, 59 (6.17%) patients with high-grade PCa underwent RARP at two, high-volume tertiary centres from October 2006 to August 2012. We assessed the rate of pathological Gleason downgrading, status of surgical margins, extarcapsular extension, seminal vesical invasion, lymph node involvement, biochemical recurrence (PSA ≥0.20 ng/mL) and recovery of urine continence (0 pads usage).

Results:

Median follow-up was 12 months (range 1–24). Sixteen patients (27.1%) had positive surgical margins, majority (70%) where pT3-disease. Nineteen men (32.3%) had extra-capsular extension and eight (13.5%) had seminal vesicle invasion. Six patients (10.1%) did not reach undetectable PSA on initial postoperative visit and were treated with ADT, 3 of which had positive lymph nodes. Overall biochemical recurrence was observed in a total of 7 patients (11.8%) with median time for recurrence 12 months. Only four men had PSA ≥0.20, the remaining had early salvage EBRT with PSA <0.20. Nine patients (15.2%) underwent adjuvant/salvage EBRT ± ADT. In total, 34 patients (57.6%) were downgraded to Gleason 7 on final surgical pathology, and yet another two patients downgraded to Gleason 5 and 6. Finally, pad-free urine continence at 3 and 12 months were 64.5% and 82.9%, respectively.

Conclusions:

In spite of advances in prostate biopsy diagnosis of HGPCa, we observed a significant likelihood for disease downgrading on final pathology. Most patients had organ/specimen confined disease, adequately served by RARP and avoided ADT, while maintaining known advantages of RARP. Therefore, it should be taken into consideration by robotic surgeons that not necessarily all biopsy proven HGPCa will have these features at final pathology.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):378.

P43: Self-Assessment of Surgical Technique Leads to Reduction of Positive Surgical Margins in Partial Nephrectomy

Igor Sorokin ¹, Michael A Feuerstein ², Paul Feustel ¹, Ronald P Kaufman Jr ¹

Abstract

Background:

To examine potential causes for a positive surgical margin (PSM) and develop strategies to improve surgical outcomes. The oncological goal of partial nephrectomy (PN) for renal cell carcinoma (RCC) is to achieve a negative surgical margin, the significance of which is controversial. In our initial experience with PN, we experienced a higher than expected rate of PSM which made us reevaluate our technique.

Methods:

A retrospective review of consecutive PN cases for RCC was performed. We divided the patients into 2 groups. The first group consisted of the first 67 renal tumours in 65 patients that underwent our early surgical technique. The second group consisted of the next 45 renal tumours in 39 patients that underwent the revised surgical technique which included wider resections and robotic ultrasound. Our primary outcome was margin status and secondary outcome was disease recurrence. Demographic, operative, and perioperative data were compared between both groups. Univariate and multivariate analyses were performed to determine patient, surgical, and tumour characteristics that resulted in PSM.

Results:

Positive margins were detected in 19 out of 67 (28%) renal tumours in the early technique group compared to 1 out of 45 (2%) positive margins in the revised technique group (p<0.001). Patients undergoing the revised technique experienced a significantly shorter clamp time (22 min vs. 35min, p<0.001), although there was no difference in % decrease of estimated glomerular filtration rate between the two groups. On multivariate analyses, only technique modification (OR 0.04, p=0.003) and larger tumour size (OR 0.41, p<0.05) were significant predictors of a lower rate of PSM. Smaller tumours were more common in robotic assisted partial nephrectomies which had a higher rate of PSM on univariate analyses (OR 3.51, p<0.05). Only 1 patient with a PSM experienced a systemic disease recurrence.

Conclusions:

In our experience, self-assessment and technique modifi-cation resulted in a dramatic PSM improvement. Smaller tumours were associated with PSM. It is important for all surgeons to look at their own surgical outcomes and modify their surgical technique accordingly.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):378.

P44: Routine En Block Stapling of the Renal Hilum During Laparoscopic Nephrectomy is Safe and Effective

David M Albala ¹, Po N Lam ¹, Elan W Salzhauer ¹, Angelo R DeRosalia ¹, Havey A Sauer ¹, Jeffrey J Sekula ¹, Benjamin R McHone ¹, Vladimir Mouraviev ¹

Abstract

Background:

En block hilar ligation is not routinely performed due to the concern for risks of arteriovenous (AVF) fistula formation. Traditionally, most urologists dissect out both the renal artery and vein and ligate them separately using either clips or staples. This can cause increased operative times and an increased risk of vascular injury.

Methods:

A retrospective chart review was performed on patients undergoing laparoscopic nephrectomy between 2010 and 2013. We identified 188 consecutive patients that underwent laparoscopic nephrectomy. Approximately 87 patients underwent en block hilar stapling while 101 patients underwent dissection of the artery and vein individually. Radical nephrectomy was carried out for a variety of different renal pathologies. Tumour characteristics, pathologic stage, operative time, blood loss, follow-up imaging modalities, clinical exam for evidence of abdominal bruit or complications were evaluated.

Results:

Eighty-seven patients underwent laparoscopic nephrectomy with en block stapling of the renal hilum using a vascular stapler (46 right renal units, 41 left renal units). The mean operative time was 160 minutes (range 80–350 minutes). The mean estimated blood loss (EBL) was 122 mL (range 50–400 mL). The mean tumour size was 6.6-cm, (range 4.3–11.9 cm). Seventy-six percent of patients received post procedure imaging: 21% had a CT scan with IV contrast, 20% had a non-contrast CT scan, 12% had an ultrasound with Doppler and 24% had an MRI with contrast. The predominant pathology was renal cell carcinoma in most of the patients. Other pathology included oncocytoma and XGP. No complications were noted at the time of surgery. No patients (0%) developed clinical evidence of an AVF with a mean follow-up of 19 months (no abdominal bruit and the lack of a palpable abdominal thrill). Imaging studies confirmed the absence of AVF.

Conclusions:

Ligation of the renal hilum with en block stapling during laparoscopic nephrectomy is a safe and effective procedure. No patients in our cohort developed any immediate surgical complications as a result of en block ligation. Also, no patients developed any clinical or radiological evidence of AVF on follow-up.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):378.

P45: The Treatment Trends for Localized Kidney Cancer in Large Urology Group

Vladimir Mouraviev ¹, Colin Okeefe ¹, Elan W Salzhauer ¹, Benjamin R McHone ¹, Angelo R DeRosalia ¹, Po N Lam ¹, Jeffrey J Sekula ¹, David M Albala ¹

Abstract

Background:

Robotic assisted laparoscopic partial nephrectomy (RALPN) is an increasingly utilized modality for primary definitive therapy. When compared to open surgery, RALPN provides patients with the following potential benefits: shorter hospital stay, less blood loss, lower risk of complications, less pain and faster recovery and return to normal activities.

Methods:

We analyzed the results of 550 patients who underwent definitive treatment for localized kidney cancer in our group from January 2008 to August 2012 in order to define a treatment trends. The following treatment modalities were used: RALPN, open nephrectomy, and laparoscopic nephrectomy.

Results:

A total of 175 RALPN were performed while 375 laparoscopic and open radial nephrectomies were done during the 4.5 years of the study. The recurrence rates after RALPN was 2/175 (1%) patients while after radical nephrectomy was 15/375 patients (4%). In the last 2 years there has been an increasing usage of RAPLN in our practice

Conclusions:

Our results confirm the general treatment trends towards more wide implementation of robotics in the nephrons-sparing techniques for renal masses. The data suggests there will be a continuous rise in the use of RALN when treating patients with renal masses

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):378–379.

P46: Robot-Assisted versus Pure Laparoscopic Radical Nephrectomy: Are Additional Costs Offset by Technical Gains?

Scott Tobis ¹, Anees Fazili ¹, Helen Levey ¹, Justin Houman ¹, Deep Trivedi ¹, Bryce Allio ¹, Tamara John ¹, Emelian Scosyrev ¹, Jean Joseph ¹, Hani Rashid ¹, Guan Wu ¹

Abstract

Background:

Radical nephrectomy is still performed in a pure laparoscopic fashion in some centres with access to a robot, primarily due to concerns over cost effectiveness. The objective of the present study was to compare traditional and robot-assisted laparoscopic radical nephrectomy with respect to operative outcomes and cost data.

Methods:

Patients undergoing laparoscopic or robot-assisted laparoscopic radical nephrectomy at our institution between 2007 and 2011 were included in this retrospective study. Hospital financial records were analyzed for each patient’s surgical hospitalization. Charges, expected revenues, and costs generated during the surgical admission were obtained from the hospital finance department. Distributions of continuous variables were compared between the laparoscopic versus robotic cases using the Wilcoxon-Mann-Whitney test or the t-test (as appropriate). Distributions of categorical variables were compared with Fisher’s exact test.

Results:

Of the 207 patients included, 114 were laparoscopic and 93 robot-assisted procedures. There were no significant differences in the age, BMI, or Charlson score of either group. Among patients with a tumour, robotic cases were performed on significantly higher clinical stages compared to laparoscopic cases (p=0.02). Mean estimated blood loss was higher in the robotic group, 230 mL (range, 20–1650) versus 146 mL (20–1000), p=0.006. Mean operative times were 190 min (117–416) and 187 min (82–325) in the robotic and laparoscopic groups, respectively (p=0.95). Retroperitoneal lymph node dissection was performed more frequently in the robotic group (42% vs. 8%, p<0.001). Pathologic stage T2–4 disease was more common on final pathology in the robotic group (46%) compared to the laparoscopic group (25%, p<0.001). There were no significant differences in positive margins (4 robotic, 2 laparoscopic) or major complications (Clavien grade ≥ 3b) between the two groups (5 each). Mean revenues expected for each procedure were similar (laparoscopic $12,663 and robotic $13,257, p=0.39), but the average total cost was significantly lower in the laparoscopic group ($7,979) compared to the robotic group ($10,554), p<0.0001.

Conclusions:

Surgical outcomes are relatively similar between laparoscopic and robot-assisted laparoscopic radical nephrectomy procedures. Costs are significantly lower with pure laparoscopic procedures. However, higher stage tumours and retroperitoneal lymph nodes are more readily removed when the robot is used.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):380.

P47: The Role of 5-HT2 on Pudendal Inhibition of Micturition Reflex in Cats

Abhijith D Mally ¹, Yosuke Matsuta ¹, Zeyad Schwen ¹, Bing Shen ¹, Jicheng Wang ¹, James R Roppolo ¹, William C de Groat ¹, Changfeng Tai ¹

Abstract

Background:

The role of 5-HT2 and opioid receptors in pudendal inhibition of bladder activity induced by intravesical infusion of saline or 0.25% acetic acid (AA) was investigated in anesthetized cats using methysergide (a 5-HT2 receptor antagonist) and naloxone (an opioid receptor antagonist).

Methods:

Repeat cystometrograms (CMG’s) were performed in 20 alpha-chloralose anesthetized cats by infusing the bladder with saline or 0.25% acetic acid (AA). Pudendal nerve stimulation at multiples of threshold (T) intensity for inducing observable anal twitch was used to suppress AA-induced bladder overactivity. Various doses of methysergide and nal-oxone were administered prior to CMG’s.

Results:

AA irritated the bladder and significantly (p<0.0001) reduced bladder capacity to 27.0±7.4% of saline control capacity. Pudendal nerve stimulation (PNS) at multiples of threshold (T) intensity for inducing anal sphincter twitching restored bladder capacity to 60.1± 8.0% at 1–2T (p<0.0001) and 92.2±14.1% at 3–4T (p=0.001) of the saline control capacity. Methysergide (0.03-1 mg/kg, i.v.) suppressed low intensity (1–2T) PNS inhibition but not high intensity (3–4T) inhibition, and also significantly (p<0.05) increased control bladder capacity at the dosage of 0.3–1 mg/kg. During saline infusion without AA irritation, PNS significantly increased bladder capacity to 150.8±9.9% at 1–2T (p<0.01) and 180.4±16.6% at 3–4T (p<0.01) of the saline control capacity. Methysergide (0.1–1 mg/kg) significantly (p<0.05) increased saline control bladder capacity and suppressed PNS inhibition at the dosage of 0.03–1 mg/kg. After methysergide treatment (1 mg/kg), naloxone significantly (p<0.05) reduced control bladder capacity during AA infusion but had no effect during saline infusion. Naloxone also had no influence on PNS inhibition.

Conclusions:

These results suggest that 5-HT2 receptors play a role in PNS inhibition of reflex bladder activity and interact with opioid receptors in micturition reflex pathway. Understanding neurotransmitter mechanisms underlying pudendal neuromodulation is important for the development of new treatments for bladder disorders.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):380.

P48: Urothelial Carcinoma Exosomes Contain Del1/edil-3 And Facilitate Bladder Cancer Progression

Carla J Beckham ¹, Christopher Silvers ¹, Peng-Nien Yin ¹, Chia-Hao Wu ¹, Jayme Olsen ¹, Huei-Ju Ting ², Fred Hagen ¹, Emelian Scosyrev ¹, Edward Messing ¹, Yi-Fen Lee ¹

Abstract

Background

Exosomes are 30–200nm membrane-bound vesicles that contain biologically active mRNA, miRNA, and proteins. A growing body of literature has emerged in support of roles for exosomes in normal and pathological processes. Here we show that exosomes isolated from high-grade muscle invasive (HGMI) urothelial cell lines and urine of patients with HGMI disease promotes angiogenesis, invasion and migration.

Methods

Exosomes from high-grade urothelial carcinoma (HGUC) cell line TCC-SUP versus control cell lines were subjected to mass spectrometry. The tumour-associated protein EDIL-3/Del-1 was identified and selected for further analysis. Exosomes from TCC-SUP were applied to human umbilical vein endothelial cells (HUVECs) in a tube-forming assay. Migration and invasion was tested by trans-well and scratch migration assays, respectively. Exosomes purified from shEDIL-3 TCC-SUP cells were also tested in angiogenesis, migration and invasion assays. qRT-PCR based pathway focused arrays were used to identify conserved factors that may be affected by EDIL-3 and confirmation of key components were validated. rEDIL-3 was used in a scratch migration assay to test for sufficiency of EDIL-3 activity. Western blot analysis was used to identify the presence of EDIL-3 in exosomes isolated from the urine of patients with HGMI disease versus healthy controls. Urinary exosomes from patients with HGMI were also tested for their ability to promote angiogenesis, migration and invasion.

Results

Mass spectrometry of exosomes from TCC-SUP identified EDIL-3/Del-1 in TCC-SUP but not in control SV-HUC exosomes and was confirmed with western blotting. TCC-SUP exosomes promote angiogenesis in a tube-forming assay and facilitate migration of both endothelial and urothelial carcinoma cells. In addition, HGUC exosomes promote invasion in a trans-well assay. Importantly, shEDIL-3 exosomes did not facilitate migration of endothelial or urothelial cells, or angiogenesis. rEDIL-3 applied to cell lines demonstrates that EDIL-3 is sufficient to facilitate migration. Pathway analysis identified several conserved angiogenic and motility factors affected by EDIL-3 via EGFR and ERK1/2 signaling pathways. Western blotting of exosomes isolated from the urine of patients with HGMI disease identified EDIL-3. Moreover, exosomes from the urine of patients with HGMI disease facilitated migration, angiogenesis and invasion.

Conclusions

HGUC exosomes contain the tumour-associated protein EDIL-3 and can promote tumour progression. We demonstrate that EDIL-3 is necessary for angiogenesis and sufficient for migration of urothelial cells. Critically, this protein was also identified in urinary exosomes from patients with HGMI disease, suggesting a role for EDIL-3 in bladder cancer progression and may serve as a novel therapeutic target.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):380–381.

P49: Combination of Foot Stimulation and Tolterodine Treatment Eliminates Bladder Overactivity in Cats

Zeyad Schwen ¹, Yosuke Matsuta ², Bing Shen ², Jicheng Wang ², James R Roppolo ², William C de Groat ², Changfeng Tai ²

Abstract

Background:

Recent clinical evidence supports the concept of neuromodulation and antimuscarinic combination therapy as a treatment for overactive bladder (OAB) to increase treatment efficacy and reduce side effects rates due to antimuscarinic treatment. Our previous studies in cats demonstrated transcutaneous foot stimulation is a novel, noninvasive form of neuromodulation to effectively inhibit bladder overactivity. The purpose of our study is to investigate the efficacy of combined low-dose tolterodine, a first-line antimuscarinic, and transcutaneous foot stimulation in cats to noninvasively inhibit bladder overactivity and lower adverse antimuscarinic effects.

Methods:

Cystometrograms were performed on alpha-chloralose anesthetized cats (N=6) by infusing 0.25% acetic acid (AA) to induce bladder overactivity. Foot stimulation (5 Hz) was applied at 2 and 4 times the threshold (T) intensity for inducing toe movement to inhibit the bladder overactivity. Cumulative doses of tolterodine (0.003–0.3 mg/kg i.v.) were also administered to determine the effect of combination treatment on bladder overactivity.

Results:

AA irritation of the bladder significantly (p<0.0001) reduced bladder capacity to 23.6±7.1% of saline control capacity. Foot stimulation alone at 2T and 4T inhibited bladder overactivity and significantly (p<0.0001) increased bladder capacity to 50.7±6.8% and 79.0±11.6% of saline control, respectively. Tolterodine alone at 0.3 mg/kg significantly (p<0.05) increased bladder capacity to 65.6±15.5% of saline control. However, when tolterodine at a threshold dose (0.3 mg/kg) was combined with foot stimulation, the bladder capacity was significantly (p<0.05) increased to 86.2±6.2% and 107.9±10.6% by 2T and 4T stimulation, respectively. Complete inhibition of bladder overactivity could be achieved at a lower tolterodine dose (0.1 mg/kg) when combined with 4T stimulation (97.0±11.2% of saline control). The amplitude of micturition contraction was not changed by tolterodine treatment.

Conclusions:

This study suggests a novel, efficacious, and non-invasive OAB treatment by combining foot stimulation with a lower dose tolterodine to potentially limit the adverse effects due to antimuscarinic therapy and increase patient compliance. It also provides the first objective evidence supporting an additive therapeutic benefit of neuromodulation and antimuscarinic combination treatment. If shown to be clinically efficacious, foot stimulation combined with a low dose tolterodine could significantly improve the treatment for OAB.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):381.

P50: Involvement of 5-HT₃ Receptor In Pudendal Inhibition of Bladder Overactivity in Cats

Zeyad Schwen ¹, Yosuke Matsuta ¹, Bing Shen ¹, Jicheng Wang ¹, James R Roppolo ¹, William C de Groat ¹, Changfeng Tai ¹

Abstract

Background:

Pudendal neuromodulation is an effective treatment for refractory overactive bladder (OAB) that initial studies have shown to be superior to sacral neuromodulation, however the neurotransmitter mechanism behind pudendal neuromodulation is currently unknown. The purpose of this study was to examine the involvement of the 5-HT₃ receptor, which has been shown to mediate neuromodulation therapy for somatic pain, in both pudendal neuromodulation and the micturition reflex in anesthetized cats using the 5-HT₃ antagonist, ondansetron. Understanding the neurotransmitter mechanism behind pudendal neuromodulation and the micturition reflex is important for the development of new drugs for the treatment of OAB and to enhance current neuromodulation therapies.

Methods:

Cystometrograms (CMGs) were performed in a total of 18 adult under alpha-chloralose anesthesia under both normal and overactive bladder conditions induced by intravesical infusion of saline and 0.25% acetic acid (AA), respectively. Pudendal nerve stimulation (PNS) was applied (5 Hz) at multiples of the threshold intensity (T) for inducing anal twitching via a tripolar cuff electrode at low intensity (1.5–2T) and high intensity (3–4T) stimulation. In both the saline (N=6 cats) and acetic acid (N=12 cats) groups, CMGs were performed with and without PNS under increasing cumulative doses (0.003 to 3mg/kg, i.v.) of intravenous ondansetron, a 5-HT₃ antagonist.

Results:

AA irritation significantly reduced bladder capacity to 16.5±3.3% of saline control capacity, while PNS restored the capacity to 82.0±12% (p=0.0001) and 98.6±15% (p<0.0001) at 1.5–2T and 3–4T, respectively. Ondansetron, a 5-HT₃ receptor antagonist, (1–3mg/kg, i.v.) eliminated low intensity (1.5–2T) PNS inhibition and reduced high intensity (3–4T) PNS inhibition of bladder overactivity. During saline distention, PNS significantly increased bladder capacity to 173.2±26.4% (P=0.036) and 193.2±22.5% (p=0.008) of saline control capacity at 1.5–2T and 3–4T, respectively, but ondansetron (0.003–3 mg/kg, i.v.) had no effect on PNS inhibition. Ondansetron also significantly (p<0.05) and dose-dependently increased control bladder capacity during both AA irritation (0.3–3 mg/kg) and saline distention (0.1–3 mg/kg) without stimulation to a maximum capacity of 70.3±15.5% and 230.8±46.6% of saline control, respectively.

Conclusions:

This study reveals that 5-HT₃ receptors partially mediate PNS inhibition of bladder overactivity. In addition ondansetron alone significantly inhibited bladder overactivity indicating the 5-HT₃ receptor is excitatory in the micturition reflex pathway and may be used as a potential treatment for OAB. Understanding neurotransmitter mechanisms underlying pudendal neuromodulation will help to find novel targets for drug development and improve current neuromodulation therapies for bladder disorders.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):381.

P51: Reduction in Hospital Admissions with the Addition of Prophylactic IM Ceftriaxone Prior to Transrectal Ultrasound-Guided Prostate Biopsies

Benjamin Luong ¹, Michael Duff ², Ognjen Visnjevac ¹, Margaret Suraf ², K Kent Chevli ²

Abstract

Background:

This IRB-approved retrospective study evaluated the sepsis rates in the two pre-prostate biopsy antibiotic protocols.

Methods:

Prior to October 2011, the prophylactic protocol required ciprofloxacin 500mg bid starting one day pre-biopsy and continuing for 3 days post-biopsy (4 days total) (CiproAlone). Diabetic patients were prescribed ciprofloxacin for 4 days post-biopsy. Regional infection rates and bacterial sensitivities were studied and the antibiotic protocol was changed. To reduce infection rates, patients were prescribed one dose of ciprofloxacin 500 mg PO one hour prior to the biopsy and Ceftriaxone 1 g IM at the time of the biopsy (CiproCeft). No additional doses of antibiotics were given. Both protocols required a Fleet enema the night before or morning of the biopsy. Data were collected from biopsies performed from October 2010 through September 2012. Hospitalization rates between the CiproAlone versus CiproCeft protocols were examined. Post-biopsy hospitalizations were reviewed for relevant clinical history, laboratory results, antibiotic resistance testing, and other details of hospitalization. Sepsis was identified based on Standard Systemic Inflammatory Response Syndrome (SIRS) criteria.

Results:

4128 biopsies included-2093 in the CiproAlone cohort and 2035 in the CiproCeft cohort. The post-prostate biopsy infection hospitalization rate was 0.6% (14 patients) in the CiproAlone group versus 0.0% (0 patients) in the CiproCeft group (p<0.0001 using Fisher’s exact test). Of hospitalized patients, 64% fit SIRS criteria. Five hospitalized patients fit the Sepsis (SIRS and source of infection) criteria. Positive cultures (urine and/or blood) were obtained from 64% (n=8) of hospitalized patients. Of patients with positive cultures hospitalized on CiproAlone, 75% (6 of 8) had Fluoroquinolone resistant Escherichia coli (E. coli), and one had a strain resistant to Cephalosporins. Other antibiotic resistances included one gentamicin resistant E. coli strain, and 3 of 8 strains with TMP-SMX resistant E. coli. Diabetes mellitus was also associated with an increased risk of infectious complications after prostate biopsy (p=0.041) in our study population, but there was no difference between the two groups in the rates of diabetes mellitus (p=0.43, Fisher Exact Test). Patient age, PSA, number of biopsy cores obtained, and race were not found to be independent predictors of post-TRUS biopsy hospitalization for infection using a multivariate regression analysis.

Conclusions:

A prophylactic pre-biopsy protocol including two classes of antibiotics reduced post-biopsy sepsis and hospitalization rates. Additional analysis of additional factors involved in the success of the new protocol (patient compliance, resistance rates for specific antibiotics) is warranted.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):381–382.

P52: Valproic Acid Decreases Thrombospondin-1 Expression In A Mouse Model Of Superficial Bladder Cancer

Timothy Byler ¹, Mark Woodford ¹, Oleg Shapiro ¹, Gennady Bratslavsky ¹, Edward Messing ², Jay Reeder ¹

Abstract

Background:

The primary challenge in treating superficial bladder cancer is the risk of recurrence which requires intense surveillance. Valproic acid (VPA) is a seizure medication and histone deacetylase inhibiter that has been potential as an anti-neoplastic agent. We have previously demonstrated reduction of bladder tumour volume in mice treated with VPA. Bladder cancer cell lines treated with VPA have reduced proliferation and increased expression of RNA encoding the anti-angiogenic protein thrombospondin-1 (TSP-1). We examined TSP-1 expression in UPII-SV40T mice in response to VPA administration.

Methods:

UPII-SV40T transgenic mice express the oncogenic simian virus 40 T protein in the urothelium and develop exophytic bladder tumours. Animals were treated between 4 and 6 months of age, when median time to detectable tumour is reached. Wild-type and UPII-SV40T mice were implanted with osmotic pumps delivering VPA for two weeks at a daily dose of approximately 50 mg/kg. The whole bladders were harvested to liquid nitrogen. RNA was isolated using Qiagen RNeasy kit and subjected to quantitative real-time PCR. TSP-1 expression was analyzed relative to sex, UPII-SV40T genotype, age, and VPA.

Results:

There was no treatment related toxicity. Levels of TSP-1 mRNA did not differ between wild-type, UPII-SV40T untreated and wild-type treated mice. UPII-SV40T mice treated with VPA showed TSP-1 RNA levels decreased significantly. Relative expression of TSP-1 for the treated mice was 2 fold lower than other animals. On both univariate and multivariate analysis, VPA administration was the only factor associated with TSP-1 expression.

Conclusions:

In contrast to our in vitro studies with bladder cancer cell lines VPA administration lowered TSP-1 RNA levels in the bladders of UPII-SV40T mice. Lower TSP-1 gene expression in mice could be due to feedback regulation in long duration treatment (compared to short-term tissue culture) or muscle and stromal versus tumour response. Further work will be needed to dissect the anti-tumour activity of VPA in bladder cancer.

Footnotes

Supported by American Cancer Society Institutional Research Grant, IRG-11-052-01

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):382.

P53: Distinguishing Insignificant versus Aggressive Prostate Cancer Based on sentinel ncRNAs

Igor Sorokin ¹, Wei-Lin Winnie Wang ², Sridar Chittur ², Hugh Fisher ¹, Martin Tenniswood ²

Abstract

Background:

Active surveillance (AS) for prostate cancer is becoming an increasingly popular treatment option. Eligibility for AS protocols is often based on prostate biopsies, PSA, and PSA kinetics, and each has its own shortcomings. The emergence of non-coding RNAs (ncRNA) as novel biomarkers in prostate cancer may provide powerful diagnostic and prognostic tools. Two important classes of ncRNAs are microRNAs (miRNA) which negatively regulate gene expression and small nucleolar RNAs (snoRNA) which target the modification of ribosomal RNA (rRNA) and small nuclear RNA (snRNA), affecting translational efficiency and mRNA splicing. We hypothesize that changes in ncRNAs precede the morphological changes in tumour pathology and that combining ncRNA profiling with pathological staging of core biopsies will refine AS selection criteria.

Methods:

Formalin fixed paraffin embedded (FFPE) prostate tissue was obtained from patients undergoing diagnostic core biopsies. The biopsy material included cores with pathological evidence of prostate cancer; cores with no evidence of prostate cancer from the same patients; and cores from patients with no histological evidence of prostate cancer which were used as benign controls. FFPE sections were de-paraffinized and RNA extracted using the miRNeasy FFPE Kit (Qiagen). The presence of small RNA (<200 nucleotides) was quantitated on the Bioanalyzer 2100. All samples were interrogated on Affymetrix GeneChip miRNA 3.0 Arrays. Data were analyzed using Partek Genomics Suite software. Entities with fold changes greater than 1.5 were considered different and selected for further analysis

Results:

A training set of 40 biopsy samples have been interrogated on the Affymetrix 3.0 arrays. Out of a total of 5639 ncRNA probes we found 202 ncRNA that are significantly different between benign and tumour core biopsies, including 129 miRNAs, 24 H/ACA box snoRNAs, and 49 C/D box snoRNAs. These ncRNAs can be binned into two categories:

ncRNAs that correlate tightly with Gleason grade, and provide molecular correlates of the Gleason score, but cannot be used to distinguish between insignificant and aggressive prostate cancer.
ncRNAs that are poorly correlated with Gleason Score, and therefore may be indicative of molecular progression in prostate cancer prior to histological changes.

Conclusions:

We have identified a cohort of sentinel ncRNAs that may be associated with aggressive prostate cancer. The data generated in this training set can now be used as a testing set to establish the ability of ncRNA profiles to distinguish between insignificant and aggressive prostate cancer, improving patient selection for active surveillance.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):382.

P54: The Emerging Role of NOX and ATM Proteins in Renal Fibrosis

Diana Cardona-Grau ¹

Abstract

Background:

Regardless of etiology, renal fibrosis is a common pathological process in the progression of chronic kidney disease. The role of TGF-β1 mediated SMAD dependent pathways has been studied in fibrosis; however, the role of non-SMAD dependent pathways in TGF-β1 signaling in fibrosis is yet to be elucidated. We investigated the relationship between free radical generation (ROS) and TGF-β1 as well as the role of NADPH oxidases (NOX), sources of ROS generation, and ataxia-telangiectasia mutated kinase (ATM), a downstream target of ROS in renal injury, in TGF-beta induced gene changes.

Methods:

Using the normal rat kidney fibroblast cell line (NRK 49f), ROS generation in response to TGF-β1 was tested using carboxy 2–7,dichloro-fluorescein (DCFDA) assay. In separate follow-up studies diphenylenei-odonium chloride (DPI), a NOX inhibitor, and N-acetylcysteine, an inhibitor of ROS generation, were used to pretreat the cells. In a further study the cells were treated with an ATM inhibitor (KU55933) before stimulation with TGF-β1. Western immunoblotting was performed to evaluate the effect of these conditions on markers of fibrosis. Immunohistochemical staining of wild type mouse kidneys (WT) with surgically induced unilateral ureteral obstruction (UUO), sham operated kidneys (SHAM), and the contra lateral kidney (CON) was performed for pATM^{Ser 1981} staining.

Results:

We determined that TGF-β1 induces ROS generation rapidly in a sustainable fashion in NRK49f cells. Pretreatment with DPI demonstrated dose dependent inhibition of TGF-β1 mediated PAI-1 expression suggestive of NOX involvement. Pretreatment with N-acetylcysteine dose dependently suppressed PAI-1 expression, supporting the role of ROS in TGF-β1 induced fibrosis. ATM inhibition with KU55933 also dose dependently suppressed PAI-1 expression in renal fibroblasts suggesting involvement of ATM proteins. Immunohistochemical staining of UUO kidneys showed an increased staining of pATM^{Ser 1981} in the fibrotic kidney compared to contralateral controls suggestive of activated ATM pathway in TGF-β1 driven fibrosis.

Conclusions:

These findings support further investigation of non-SMAD dependent pathways for TGF-β1 signaling in the progression of fibrosis, specifically that of ROS and ATM downstream of TGF-β1. These alternative pathways may prove useful as future therapeutic targets for amelioration of renal fibrosis.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):382–383.

P55: A Novel Survival Model of Pelvic Floor Dysfunction after Rabbit Pelvic Floor and Transvaginal Electrical Stimulation

Amy D Dobberfuhl ¹, Sara Spettel ¹, Catherine Schuler ², Robert M Levin ², Andrew H Dubin ¹, Elise De ¹

Abstract

Background:

Existing data supports a relationship between the levators and pelvic organ function, however there is a paucity of animal models for chronic pelvic floor dysfunction. We previously developed an acute model of pelvic floor dysfunction in the rabbit and demonstrated that direct electrical needle stimulation of the pubococcygeous muscle resulted in cystometry (CMG) and electromyography (EMG) changes consistent with dysfunctional voiding; larger bladder capacity, longer interval between contractions and prolonged contraction duration. The current experiment seeks to explore the in vivo effects of needle and transvaginal electrical stimulation using a survival model.

Methods:

Twelve female adult virgin white New Zealand rabbits were housed in metabolic cages to record baseline voiding and defecation for 3-days. Anesthetized CMG/EMG was performed before and after treatment animals (n=9) received bilateral tetanizing needle stimulation (4 trains 10s apart, 15mA, 25Hz, 0.2ms, 10 pulses/train) to the pubococcygeous muscle and controls (n=3) sham needle placement. After 7-days of metabolic recording, all animals were subjected to tetanizing transvaginal stimulation (5 minutes, 6.5mA, 10Hz, 0.1ms repetitive) and CMG/EMG. After 5-days, a final CMG was performed and bladder with pelvic floor muscles collected.

Results:

Throughout the experiment mean fecal weight and urine production were similar between groups. At baseline, animals demonstrated heterogeneous voided volume and frequency behavior. Needle tetanizing stimulation of the pubococcygeous muscle significantly prolonged interval between CMG contractions with mean time to third contraction rising from 38 to 53 minutes (p=0.008 vs. pre-stimulation), representing a significant mean increase of 15 minutes (p=0.022 vs. 1 minute for control). Vaginal stimulation also significantly increased time to third contraction from 37 to 47 minutes (p=0.015 vs. pre-stimulation). On linear regression analysis of cage parameters, needle stimulation resulted in larger voided volumes and less frequent voids. Of the rabbits that underwent needle stimulation 7/9 (78%) demonstrated voiding dysfunction versus 6/12 (50%) after transvaginal stimulation, with little change in cage parameters seen one day after vaginal stimulation.

Conclusions:

Both direct pubococcygeous and transvaginal electrical stimulation resulted in prolonged intervals between CMG contractions. Changes in cage parameters were primarily seen after direct stimulation of the pelvic floor, with larger volume and less frequent voids noted. This model supports the findings of our prior experiment, with changes after stimulation consistent with dysfunctional voiding behavior, thus reiterating the central role of the pelvic floor in coordinated voiding function.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):383.

P56: Ketamine Induced Cystitis: Man To Mouse?

Gillian Stearn ¹, Mark R Woodford ¹, Ronald W Wood ¹, Steve K Landas ¹, Henry Okafor ¹, Jay E Reeder ¹

Abstract

Background:

Interstitial cystitis or bladder pain syndrome is a chronic pelvic/perineal pain syndrome with unknown cause. Clinically these patients experience urinary urgency, frequency, and pelvic pain. These symptoms are usually waxing and waning, but are debilitating in nature. Symptoms and physical findings vary between patients, making diagnosis and treatment difficult. Interstitial cystitis is seen sporadically in cats, but no reliable inducible animal model exists. Ketamine is a widely used anesthetic that has become a popular drug of abuse. Chronic users develop a small capacity bladder with symptoms of bladder pain, frequency and urgency, similar to what is seen in patients with interstitial cystitis. Hypothesis: Chronic ketamine will induce a small volume, high frequency voiding pattern in mice similar to that seen in human interstitial cystitis.

Methods:

Mice were acclimated to metabolism cages and baseline voiding function assessed for four weeks in three hour sessions two to three times per week for four weeks. Urine production was continuously recorded allowing calculation of void volume and frequency. Group one mice were initially started on daily injections of ketamine at a dose of 40 mg/kg then escalated to 80 mg/kg over 13 weeks. They were then transitioned back to saline injections for two weeks. Group 2 mice were injected with saline for seven weeks and then switched to 80 mg/kg of ketamine for six weeks. Group 3 mice were injected with saline only for the entire study to serve as a control. At least twice weekly, the mice were placed in metabolism cages and offered 6 mL of sweetened water to trigger urine production. Bladders were harvested at necropsy for histological evaluation.

Results:

Individual mice displayed characteristic voiding patterns throughout the study that were not significantly influenced by ketamine. However, a trend toward an increase in voided volume with associated decrease in frequency in mice on ketamine was noted. Group 1 mice had evidence of fibrosis throughout most specimens. Subepithelial lymphocytic infiltrates organized in follicles as well as smooth muscle hypertrophy was noted in Group 2, while Group 3 mice showed no evidence of disease.

Conclusions:

Chronic ketamine administration did not produce signs and symptoms characteristic of human IC. Results do suggest ketamine may decrease sensation of bladder fullness in mice. Ketamine triggered bladder inflammation and fibrosis.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):383.

P57: Nuclear Localization of Fatty Acid Synthase Correlates with Gleason Grade in Prostate Cancer

Kevin J Rycyna ¹, Allison A Madigan ¹, Milon Amin ¹, Anil Parwani ¹, Dean J Bacich ¹, Denise S O’Keefe ¹

Abstract

Background:

Fatty acid synthase (FASN) acts as an oncogene in prostate carcinogenesis. FASN is thought to be a primarily cytoplasmic protein; however we have recently observed expression of FASN in the nucleus of prostate cancer patient tissue. We investigated whether nuclear localization of FASN correlates with Gleason scores of prostate cancer.

Methods:

Prostate specimens were obtained from 30 patients who had undergone radical retropubic prostatectomy for prostate cancer and from two organ donors. Immunohistochemical staining for FASN was performed on 28 specimens while four were exposed to the secondary antibody only, as negative controls. Within the most representative regions of cancer, the percentage of cells with strong nuclear staining was quantified using automated image analysis software. Benign glands were similarly analyzed in the donor prostate tissue. Pathology of all analyzed areas was confirmed through review with our institution’s urologic pathologist. The scoring output by the image analysis software was converted into a composite nuclear (c-nuclear) staining score in order to allow appropriate comparison between specimens. A two-sample Wilcoxon rank-sum test was performed to detect a difference in the median percentages of strongly staining nuclei between different cancer grades.

Results:

Out of the 30 cancer specimens, 27 had cancer regions of acceptable quality to include in the analysis. Of these 27, four were used as negative controls with secondary antibody only staining. There were two Gleason score (GS) 3+3= 6 negative controls and two GS 3+4=7 negative controls. The remaining 23 specimens composed six GS=6, ten GS=7, and seven GS >= 8, with two additional specimens from benign tissue donors. The median c-nuclear score for the benign glands, GS = 6, GS = 7, and GS>=8 were 0.43, 3.39, 19.87, and 43.59, respectively. The median c-nuclear scores for GS=6 and GS=7 negative controls were 0.25 and 1.6, respectively. The Wilcoxon rank-sum test demonstrated a significant increase in nuclear FASN staining between GS=6 and cancers that were GS=7 and above (p=0.0078). Additionally, a significant increase in nuclear FASN staining existed between only GS=6 compared to GS=7 cancers (p=0.0067).

Conclusions:

To our knowledge, this is the first report demonstrating a correlation between nuclear FASN staining and Gleason grade. Nuclear-specific FASN, rather than previously reported cytoplasmic staining, suggests a potential novel role for FASN as a marker of clinical progression and warrants further investigation.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):383–384.

P58: Biodistribution of Indocyanine Green formulation in Mice after Intravenous and Intraperitoneal injections

Henry T Okafor ¹, Mark Woodford ¹, Jedsian Cheng ¹, Jay Reeder ¹

Abstract

Background:

Indocyanine Green (ICG) has been used in medical diagnostics, including angiography. We have developed formulations of ICG that lead to improved fluorescence and demonstrated its utility when enhanced with milk and other embodiments in imaging of the upper urinary tract to identify ureteral injuries. It is known that ICG is excreted via the bile ducts after intravenous (IV) administration. In this study we sought to identify the biodistribution of different ICG-formulation in mice after intravenous injection and intraperitoneal (IP) injection.

Methods:

Nine Wild type mice were obtained for this study; the mice were divided into four groups (G1–4). Under anesthesia, a depilatory cream was applied to the ventral side of the mice to remove hair and facilitate imaging. The first group received IV injections which were done via the mice tail. Near-infrared Fluorescence imaging (NIRF) was then used to observe the initial profile of the ICG dispersion. G1 was injected IV with 0.2 mL of a formulation of ICG and DMSO (2.5 g/mL ICG). G2 received IV ICG in intralipid enhanced fluorescent composition (0.2 mL of 5 μg/mL ICG) G3 got IP injections of ICG+DMSO, while G4 got IP injections of ICG in intralipid. The mice were then allowed to regain consciousness and additional NIRF imaging done at 4, 18, and 24 hours.

Results:

G1 (2 mice) showed immediate uptake into the liver after IV injection, at 4 hours the GI tract and the gall bladder were fluorescent confirming that this is the primary means of excretion, At 18 hours only the GI tract was fluorescent, and at 24 hours there continued to be fluores-cence of the GI tract in fecal pellets. In G2 (2 mice) the fluorescence was concentrated in the tail at 4 and 18 hours but by 24 hours, fluorescence was noted to be in similar distribution to G1. G 3 (2 mice) and G4 (3 mice) had similar results. In the IP injections, fluorescence was initially concentrated within the peritoneum and injection site at 4 hours. By 18 and 24 hours, the gut fluoresced similar to G1.

Conclusions:

We have previously demonstrated that the fluorescence of ICG is enhanced on NIRF by the addition of sterile milk, Intralipid and DMSO. We have now demonstrated that metabolism of our ICG formulations remain the same and it is excreted through the gastrointestinal tract. We hope to demonstrate safety and efficacy of our ICG formulations in humans.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):384.

P59: Urology Residency and Cloud Computing: Enhancing Learning Experience with a Scalable and Modifiable Education Resource Base Specific to Training Program

Vitor DaSilva ¹, James D Watterson ¹, Matthew Roberts ¹, Anthony J Bella ¹

Abstract

Background:

Surgical education in residency is a continuously evolving and dynamic process that must be adapted to the specific needs of trainees. The current availability of online resources facilitates the dissemination and accessibility of information. The vast amount of easily accessible information can prove to be overwhelming, particularly for the junior trainee. Cloud computing is hosted outside a defined and controlled home network, and allows access to all resident staff regardless of physical location. Box.com offers content management security, uptime guarantee, and high-grade SSL encryption on transit and 256-bit AES encryption at rest, thereby offering secure, scalable content-sharing. We have set out to develop a program specific online resource database to serve as an adjunct to the current urological training program at our institution.

Methods:

Using a commercially available online storage “cloud”, a program specific resource database was created.

Results:

Full privilege access was given to all residents and staff. Over the course of 5 years, this database was continually grown and updated with open input and contribution from users. This includes surgical videos, staff specific OR outlines, round presentations, and study guides. All of the content is continually updated as new procedures and techniques are introduced so as to cover the entire scope of surgical practice at our institution. Access patterns and utility of content is reviewed.

Conclusions:

There has been tremendous use and support of this resource within our program. We have found this to be an excellent adjunctive resource for surgical education not only as an introduction to surgical techniques for junior trainees, but also as a means for dynamic academic collaboration.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):385.

P60: When Active Surveillance Fails: An Analysis of Manitoba Prostate Centre Surveillance Patients Who Undergo Treatment

Kamaljot Kaler ¹, Darrel Drachenberg ¹

Abstract

Background:

PSA screening has resulted in a significant increase in the diagnosis of low risk prostate adenocarcinoma. Treating these cancers would cause significant morbidity with radical treatment. Active surveillance (AS) is an alternative to radical treatment for these cancers and to monitor them with the intent to treat radically once the cancer progresses.

Methods:

In this retrospective study, patients treated at the Manitoba Prostate Cancer with an active diagnosis of Prostate Adenocarcinoma with Gleason ≤3+4, multiple biopsies, ≤t2b (with one exception), and PSA <20 (two exceptions) were analyzed for changes in PSA, PSA doubling time, PSA density, Prostate volume changes, triggers for biopsy, triggers for treatment, types of treatment, changes in Gleason grading, pathological changes such as cores involved, percent minimum and maximum. Further biopsy intervals were assessed, follow-up time, and surgical pathology if available. Consent was obtained.

Results:

Manitoba Prostate Centre has 194 patients on Active Surveillance¼ 64 of whom received treatment. Of the treated patients the median age was 65 with an average follow up of 5.3 years, and average of 2.6 biopsies each. Median interval to first biopsy was 9.5 months, and 12 between all biopsies. Majority of patients had Gleason 3+3 when started on active surveillance. 68.8% had a final Gleason of ≥3+4. 64.6% of initial biopsies were triggered by PSA, and 81.3% of treatment was triggered by biopsy results, i.e. Gleason progression or volume changes.

Conclusions:

The Manitoba Prostate Centre treatment data of Active surveillance is consistent with what is found in the literature. The data collected represents a significant cohort of patients relative to available literature.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):385.

P61: NaF PET/CT Scan Is More Accurate To Detect Bone Metastases in Advanced Prostate Cancer

Ilija Aleksic ¹, Christopher M Pieczonka ², Vladimir Mouraviev ², Peter Iannotta ², Herbert I James III ², David M Albala ¹

Abstract

Background:

The current standard for imaging CRPC is aimed to detect metastatic disease in bones as early as possible. Clinicians have identified bone metastasis predominantly through bone scintigraphy for the past few years. Recent studies have shown the NaF PET/CT Scans are significantly more sensitive and accurate in detecting bone lesions. This study conducted retrospective analysis to compare the competence of these two methods for identifying bone metastasis.

Methods:

Out of the 614 patients with advanced prostate cancer being treated with androgen deprivation therapy (ADT) in this particular bone clinic database, 34 patients received a NaF PET Scan. Of the 34 our study included all male patients ranging from 52–89 years of age (median 75.5 years).

Results:

Of these patients, 3 (8.8%) were determined to have metastasis with bone scintigraphy alone while 17 (50%) were determined to have metastasis with NaF Scan (p<0.005). Five patients had equivocal findings on Bone Scintigraphy. NaF Scan determined three of these as having no metastasis and two as having metastasis. NaF scan itself reported three patients as having equivocal findings for metastatic disease, requiring clinical correlation. In addition, in two cases we noticed the lysis of bone deposits from some bones after treatment with Sipuleucin-T.

Conclusions:

NaF PET/CT scan are feasible option for CRPC for detecting bone metastases, decreasing the dose, cost and imaging time. With coverage of this procedure by Medicare patients have more sensitive and specific tool to early diagnose and monitor a treatment of CRPC.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):385.

P62: Use of Rectal Swab Culture Before Prostate Biopsy yields positive results that can prevent Significant Risk Of Complication by administration of targeted antibiotics

Herbert I James III ¹, Christopher M Pieczonka ¹, Vladimir Mouraviev ¹, Yi Yang ¹, David M Albala ¹

Abstract

Background:

Trans-rectal ultrasound of prostate needle biopsy is the mainstay for diagnosing prostate cancer. Flouroquinolone antibiotics have typically been used to prevent infections prior to biopsy. In the community we have seen a rise in resistance to flouroquinolone leaving patients dealing with urosepsis. By swabbing for flouroquinolone resistant organisms, physicians are able to tailor their choice of antimicrobial agent used for infection prevention following biopsy.

Method:

Specimens were collected from the cohort of 701 patients using a BBL culture swab. The samples were labeled according to established protocol and transferred to the lab. Cultures were plated out against antibiotic disks to see if resistances developed against the flouroquinolones. Results were reported to the ordering physician - in cases in which resistances developed, further testing was done to determine sensitivities. In all cases, patients were placed on other appropriate antibiotics for infection prevention.

Results:

From January through April 2013, 701 rectal swab samples were obtained from patients. Of these patients, 72 cultures (10.3%) were noted to be positive for flouroquinolone-resistant flora. Below is the table by month regarding total positive cultures.

Conclusion:

In our community, the incidence of flouroquinolone-resistance in patients undergoing transrectal ultrasound guided prostate biopsy was over 10%. In these cases, antibiotic coverage was changed based on the sensitivities of the rectal swab culture results. In no cases, did these patients develop serious infections or complication after biopsy. This rectal swab program is easy and safely instituted in the community setting.

Table 1.

P62

2013	Total positive	Total tested	Percent positive
January	15	196	7.6%
February	17	160	10.6%
March	21	162	13.0%
April	19	183	10.4%
Total	72	701	10.3%

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Can Urol Assoc J. 2013 Sep-Oct;7(9-10):386.

P63: Five-year Outcomes after Prostate Brachytherapy with Cesium 131

Anne G Dudley ¹, Ryan P Smith ¹, Sushil Beriwal ¹, Ronald M Benoit ¹

Abstract

Background:

Cesium 131 is the newest isotope utilized for prostate brachytherapy. The current study reports oncologic outcomes achieved with this isotope.

Methods:

All patients who underwent prostate brachytherapy with Cesium 131 and had at least 24 months of follow up were included in this study. Patients with a Gleason score 3+4 or less and a PSA of 10 ng/mL were treated with external beam radiation and brachytherapy, and patients with a Gleason score ≥8 or a PSA >20 ng/mL were treated with external beam radiation, brachytherapy, and androgen deprivation therapy; although exceptions to these guidelines occurred. Patients were followed with PSA testing q 3 months for the first year, q 6 months until year 5, and then annually. The Phoenix definition was used to determine whether patients were biochemically free of disease (BFD).

Results:

A total of 408 patients have undergone prostate brachytherapy with Cesium 131 at our institution. Two hundred thirty two patients have at least 24 months of follow up (mean follow-up 39.8 months, range 24–72 months) and are included in this analysis. For the total cohort, 97.4% of patients remain disease free. Biochemically disease free rates are 98.9%, 96.4%, and 96.4% for men with low risk, intermediate risk, and high risk disease, respectively. Biochemically disease-free rates are 98.2%, 93.5%, and 95.8% for men who underwent prostate brachytherapy as monotherapy, who underwent combination therapy, and who underwent trimodal therapy, respectively. Mean PSA five years after the procedure was <0.1 ng/mL, and 71.4% of patients followed for five years had an undetectable PSA, while 91.4% of patients had a PSA of ≤0.1 ng/mL.

Conclusions:

Prostate brachytherapy with Cesium 131 appears to offer excellent cancer control for all risk categories at 5 years. We will continue to analyze outcomes to ensure that oncologic outcomes remain favorable as our cohort matures.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):386.

P64: The Effect of Steroids and Alpha-Blockade on the Severity and Duration of Urinary Morbidity after Prostate Brachytherapy

Anne G Dudley ¹, Ryan P Smith ¹, Sushil Beriwal ¹, Ronald M Benoit ¹

Abstract

Background:

Prostate brachytherapy is commonly associated with bothersome lower urinary tract symptoms after the procedure. The present study attempts to determine whether the severity and duration of these symptoms can be improved by the use of corticosteroids and alpha blockade in the perioperative period.

Methods:

Patients who were undergoing prostate brachytherapy as monotherapy were included in the study, and patients receiving androgen deprivation therapy were excluded. Patients received prednisone 5 mg q day for seven days, beginning one day prior to the procedure. Patients also received flomax 0.4 mg q day beginning one day prior to the procedure and continuing for at least 3 months after the procedure. All patients were asked to complete an AUA Symptom Index and EPIC urinary summary preoperatively and at 2 weeks, 3 months, and 6 months after the procedure. Patients were also asked by written instrument whether or not they had resumed their baseline voiding pattern. Outcomes in the patients who received prednisone and Flomax (treated cohort) were compared to consecutive patients who also underwent prostate brachytherapy as monotherapy but did not receive steroids or alpha-blockers in the peri-operative period (untreated cohort).

Results:

Twenty eight consecutive patients who comprised the treated cohort were compared to 28 consecutive patients who comprised the untreated cohort. By 2 weeks, 3 months, and 6 months after the procedure; 10.7%, 46.4%, and 75.0% of patients had resumed their baseline voiding pattern in the untreated cohort. In the treated cohort; 28.6%, 71.4%, and 78.8% of patients had resumed their baseline voiding pattern by 2 weeks, 3 months, and 6 months after the procedure. AUA symptom scores in the untreated cohort were 6.3, 20.8, 11.9, and 10.3 pre-operatively and at 2 weeks, 3 months, and 6 months after the procedure. AUA symptom scores in the treated cohort were 7.4, 18.2, 10.0, and 7.9 pre-operatively and at 2 weeks, 3 months, and 6 months after the procedure.

Conclusions:

In the present study, the use of corticosteroids and alpha-blockade in the perioperative period in men undergoing prostate brachy-therapy as monotherapy decreased the duration and severity of the bothersome lower urinary tract symptoms which commonly accompany this procedure.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):386.

P65: The History of BCG and Bladder Cancer: Ethical Considerations

Anees Fazili ¹, Jennifer Gordetsky ¹, Ronald Rabinowitz ¹

Abstract

Background:

In 1976, Morales et al first applied intravesical BCG, ushering in a new chapter in the treatment of bladder cancer. A review of the history of BCG use prior to that study raises some ethical questions about the design of this groundbreaking clinical trial.

Methods:

We performed a review of the literature regarding the use of BCG as an anti-neoplastic agent, with a focus on its application to bladder cancer.

Results:

In the 1950s BCG was shown to have anti-neoplastic qualities in mice. Experimentation on using BCG for human neoplasia began in the 1960s with work on acute lymphoblastic leukemia. By 1970, intra-lesional BCG injections had been reported for the treatment of melanoma. BCG’s anti-neoplastic properties came to the attention of urologists in the early 1970s when a trans-urethral, intra-tumoural BCG injection was reported to eradicate metastatic melanoma to the bladder. Two animal studies were then initiated, examining the effect of intravesical BCG, with the aim to better understand the safety and tolerability of this route of delivery. The clinical study by Morales et al utilizing intravesical BCG to treat human bladder cancer was begun before the authors had access to the results of these animal studies. This occurred in the days before the creation of Institutional Review Boards. Hence, despite being scientifi-cally sound and grounded in immunologic principles, there was a lack of appropriate pre-clinical and Phase 1 study data to support this study. Thus, study subjects could not have been appropriately counseled and informed regarding the risks and benefits of BCG therapy prior to study involvement.

Conclusions:

The initial clinical study of intravesical BCG for bladder cancer used human subjects at a time when other research groups were still undertaking the necessary preliminary animal experiments. The subsequent creation of Institutional Review Boards in 1978 and more stringent FDA approval processes would make it impossible to perform a similar trial without prior rigorous animal studies today.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):386–387.

P66: Lower Urinary Tract Symptoms after Prostate Brachytherapy with Cesium 131

Anne G Dudley ¹, Ryan P Smith ¹, Sushil Beriwal ¹, Ronald M Benoit ¹

Abstract

Background:

Cesium 131 is the newest isotope utilized for prostate brachytherapy, and is thought to be associated with a shorter duration of the bothersome lower urinary tract symptoms associated with the procedure. The present study updates our experience with Cesium 131.

Methods:

All patients who underwent prostate brachytherapy with Cesium 131 and had at least 12 months of follow up were included in this study. Patients completed an AUA symptom score and EPIC urinary survey pre-operatively; and at 2 weeks, 3 months, 6 months, 9 months, and 12 months after the procedure. Patients were also asked by written instrument at each post-operative interval whether they had resumed their baseline voiding pattern. Patients were considered back to baseline if their AUA symptom index was within 3 points of their pre-operative score, if their EPIC urinary summary was within 12 points of their pre-operative score, or if they answered yes to a written question inquiring whether they had resumed their baseline voiding pattern.

Results:

A total of 408 patients have undergone prostate brachytherapy with Cesium 131 at our institution. At 2 weeks, 3 months, and 6 months after the procedure; 23.2%, 62.3%, and 76.9% of patients had resumed their baseline voiding pattern. AUA symptom scores were 7.3, 18.6, 11.1, and 9.2 preoperatively and at 2 weeks, 3 months, and 6 months, respectively. EPIC urinary summary scores were 87.5, 58.4, 77.7, and 81.7 pre-operatively and at 2 weeks, 3 months, and 6 months, respectively.

Conclusions:

Prostate brachytherapy with Cesium 131 appears to offer a shorter duration of the bothersome lower urinary tract symptoms which commonly occur after the procedure when compared to the other isotopes utilized for this procedure.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):387.

P67: Surgeon Factors Affecting Treatment Decisions in The Management Of Small Renal Cancers

Alexandra Millman ¹, Kenneth Pace ¹, Michael Ordon ¹, Jason Y Lee ²

Abstract

Background:

The incidental detection of small renal masses (SRMs) has become much more common due to the increasing use of diagnostic imaging modalities. Management of SRMs can include a variety of options, ranging from surveillance to radical nephrectomy. However, there is incomplete evidence on the best treatment protocol for such tumours, and in lieu of strong evidence-based guidelines, surgeons may be more subject to subconscious biases when making treatment recommendations to their patients. The objective is to examine current practices in the management of SRMs and, in particular, to determine if there are any surgeon-specific factors (e.g., age, practice type, etc) that may influ-ence treatment choices.

Methods:

An online survey study was conducted among Canadian urologists currently registered with the Canadian Urological Association (n=632). The questionnaire was distributed, via email-blast, and involved the collection of demographic information, clinical practice details, and recommended treatments for 6 index cases involving theoretical patients of various ages (51–80years) with SRMs (<4 cm), medical comorbidities, and renal function (eGFR 57–96 mL/min/1.73 m²). Data was analyzed using SPSS software using Pearson and Spearman correlation for continuous and categorical data, respectively.

Results:

A total of 110 urologists responded (17% response rate) to the survey, although the email blast also included pediatric and retired urologists. While 51% of respondents were <45 years of age, 18% were >64 years old. Roughly half of participants (45%) were practicing in an academic setting and most participated in regularly scheduled “tumour” rounds (75%). Only 6% of respondents reported a personal history of cancer. Older age correlated with a non-academic practice (p<0.001), a personal history of cancer (p<0.001), and more aggressive management (surgical) for the 2 index cases involving elderly patients (∼80 years). A personal history of cancer also correlated with an increased likelihood of performing surgery on the same 2 elderly, index patients (p<0.04). Academic urologists were less likely to offer aggressive treatment (surgery) for these same elderly patients and when surgery was offered for any of the 6 index patients, they were more likely to utilize MIS techniques (p<0.005). For all 4 index cases where surgery could be considered the gold standard treatment, >50% of respondents reported, for each case, that they would utilize a MIS technique.

Conclusions:

There are various factors that influence the management options offered to patients with SRMs. The surgeon’s age, personal history of cancer, and other surgeon-specific variables may significantly influence treatments offered across Canada.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):387.

P68: Histologic Distribution of Metastatic RCC Shows a Difference Between N+ And M+ Disease: An Analysis of the SEER Database

Michael Daugherty ¹, Gennady Bratslavsky ¹

Abstract

Background:

Metastatic RCC occurs in approximately a third of all cases of patients diagnosed. The extent of metastasis and prognosis of the patient is dependent on Fuhrman grade and also histologic type. Some histologic types are more indolent and possess less metastatic potential. It is hypothesized that these differences in metastatic potential will manifest in different rates of nodal and distant metastasis for the various histologies.

Methods:

SEER-18 registries database was queried for all patients diagnosed with metastatic RCC between the years 2004 and 2010. Histologies selected were Clear Cell, Papillary, Chromophobe, Sarcomatoid and Collecting Duct. Patients were separated into two cohorts: those that had M+ disease (regardless of nodal status) and those that had N+ disease with an M0 status. There were 4135 and 645 patients with M+ and N+ disease, respectively. Histologic distribution between the cohorts was compared using a Chi-square analysis.

Results:

There were significant differences seen between the two cohorts in histologic distribution (p<0.0001, Fig. 1). There was a larger percentage of patients with papillary tumours in the N+ group (p<0.0001). In addition, there was a smaller percentage of patients with clear cell tumours in the N+ group (p<0.0001). However, there was no difference seen when comparing sarcomatoid tumours in both groups (p=0.161).

Conclusion:

The difference in histologic tumour rates is driven predominantly by the greater than three-fold increase in the number of papillary tumours in the N+ M0 cohort. This can be explained by either the early spread of papillary tumours to lymph nodes, preferential environment for papillary metastases within the lymph nodes, or the limited ability of papillary tumours to metastasize distantly. Further molecular studies are needed to analyze the predilection for preferential metastatic sites observed in different histologic RCC subtypes.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):387–388.

P69: The Metastatic Potential of Chromophobe RCC is Dependent on Tumour Size: Results from the SEER Database

Michael Daugherty ¹, Gennady Bratslavsky ¹

Abstract

Background:

Chromophobe RCC tends to be an indolent tumour with a lower propensity of metastasis. As a result, these tumours are often over treated especially when a radical nephrectomy is performed to remove the mass. We hypothesize that there is a difference in tumour size between localized and metastatic tumours and that larger tumours experience a higher rate of metastasis.

Methods:

SEER 18-registries database was queried for all patients age ≥20 years treated surgically for chromophobe RCC between 2000 and 2009. Tumours with unknown extension, grade, nodal status and size were excluded from analysis. In addition, patients with unknown race, sex and age were also excluded. Patients were divided into two cohorts based on metastatic status. There were a total of 1,740 patients with localized tumours and 59 patients with metastatic tumours. Patient demographics and tumour characteristics were compared using chi-square analysis. Tumour size was compared between the two groups using an unpaired t-test.

Results:

There were no differences in patient demographics between the groups, but there was a difference in tumour grade distribution (p<0.001). The mean localized tumour size was 5.9 cm (95% CI 5.7–6.0 cm), whereas the average metastatic tumour size was 11.7 cm (95% CI 10.4–13 cm). The interquartile range for tumour size was 3–8 cm and 8–14.5 cm, for localized and metastatic tumours respectively. The 2 groups were significantly different when comparing the tumour size distribution (p<0.001).

Conclusions:

Present SEER analysis reveals that the size of chromophobe RCC affects the metastatic potential of the tumour. These results can offer an alternative management strategy of patients found to have chromophobe RCC on needle biopsy. These patients may undergo active surveillance until the tumour reaches size of 8cm or larger, in order to avoid unnecessary surgery to remove cancers with limited metastatic potential.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):388.

P70: Histologic Distribution of RCC in Young Patients is Different from Older Patients: Results from the SEER Database

Michael Daugherty ¹, Stephen Blakely ¹, Oleg Shapiro ¹, Gennady Bratslavsky ¹

Abstract

Background:

Renal cell cancer incidence is relatively low in younger patients, encompassing 3–5% of all RCC tumours. While young patients often have bilateral multifocal tumours caused by known hereditary syndromes, some develop sporadic renal cancers without any family history or known genetic mutations. Our recent observations from clinical practice have led us to hypothesize that there is a difference in histologic distribution in the younger patients when compared to the older cohort.

Methods:

SEER 18-registries database was queried for all patients ≥20 years old that were surgically treated for renal cell carcinoma between the years 2001 and 2008. Patients with unknown race, grade, stage, histology and those with multiple tumours were excluded from the study. Histologies selected were clear cell, granular, papillary, chromophobe, sarcomatoid and collecting duct. Granular tumours were combined with clear cell during analysis as they are now considered one histologic entity. Three cohorts were created with the ages 20–44, 45–64 and ≥65 year olds that contained 3,514, 15,368, and 10,445 patients respectively. Chi-square analysis was used to compare the histologic distributions between the cohorts.

Results:

There was no difference in the incidence of clear cell RCC between the three cohorts (p=0.50). The histology distribution was not different in the 45–64 year olds compared to those ≥65 (p=0.44). The non-clear cell histologies were different between the 3 age groups (p <0.001). There were a larger percentage of patients in the younger patients that had chromophobe tumours compared to all non-clear cell histologies (p<0.001, Fig. 1).

Conclusion:

The difference in the non-clear cell histologic distribution between the groups may be due to genetic mutations predisposing these patients to chromophobe RCC. There has been limited data on HRCs, due in large part to its low incidence. Although the HRCs are known to have a most common histology, it is likely that this information is incomplete, as younger patients have undiagnosed genetic mutations that led to development of chromophobe tumours.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):388.

P71: Contemporary Series of Recurrent Superficial Bladder Cancer Treated with Intravesical Thiotepa

Kevin J Rycyna ¹, Tara Nikonow ¹, Ronald Hrebinko ¹, Benjamin J Davies ¹

Abstract

Background:

Intravesical thiotepa is an infrequently utilized therapy for superficial bladder cancer, with few reports in the current literature. We report our institution’s experience with this treatment over the previous 10 years.

Methods:

After obtaining IRB approval, we retrospectively searched our institution’s clinical CPT coding for thiotepa use. Over the previous 10 years, there were 18 patients with thiotepa use recorded in their chart. These charts were then reviewed for pertinent information related to their bladder cancer management. Of the 18 patients initially collected, we excluded two from analysis due to incompleteness of the medical record, one for lack of a true recurrence before thiotepa, and one for having never received thiotepa. The remaining 14 patients all had a history of recurrent superficial urothelial carcinoma of the bladder and received at least one 6 week course of intravesical thiotepa.

Results:

Nine out of fourteen (64%) were given thiotepa for recurrent low grade disease while the remaining five (36%) had recurrent superficial high grade disease. In the low grade group, five (55%) developed a high grade recurrence, one (11%) developed another low grade recurrence, and three (33%) did not recur after thiotepa. Median time to recurrence was 12.5 months (95% CI 3.4–84.6). In the high grade group, two (40%) had another high grade recurrence and two (40%) had no further recurrences after thiotepa. One patient with high grade disease was lost to follow up after receiving thiotepa. Median time to recurrence was 13.5 months (95% CI 7 to 20). There was no significant difference in time to recurrence between the low and high grade groups (p=0.87). Seven of the fourteen patients were given thiotepa as a second or third line intravesical therapy. Three of these patients (43%) had no further recurrences following treatment. In the low grade group, there was no difference in time to recurrence between the four patients who received thiotepa as a primary intravesical therapy and the two patients who received it as second line (p=0.64).

Conclusions:

Recurrent superficial bladder cancer can be a difficult entity to treat, despite the development of improved intravesical therapies over the last two decades. We report a contemporary series of intravesical thiotepa use, demonstrating a limited yet still relevant role for this therapy. Given the ongoing shortage of mitomycin C as well, thiotepa may become an increasingly useful second or third line agent for these challenging patients.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):388–389.

P72: Influence of Gender on Histologic Distribution and Stage at Presentation of Urethral Carcinomas

Ilija Aleksic ¹, Mickey Daugherty ¹, Gennady Bratslavsky ¹

Abstract

Background:

Urethral cancer is rare and histologically heterogeneous, and the literature on this topic is sparse. We aimed to evaluate the influence of gender on histologic distribution and stage at presentation of urethral carcinomas.

Methods:

The Surveillance, Epidemiology, and End Results (SEER) database was searched for all urethral cases between 2004 and 2010. The start of 2004 was chosen due to improved coding for histologic subtypes and staging. For the purpose of analysis, primary urethral carcinoma was sub-categorized as determined by specific ICD-O codes for histologic typing, mainly transitional cell carcinoma (TCC), squamous cell carcinoma (SCC), adenocarcinoma, and melanoma. The data was analyzed for distribution of histologic subtypes and stage at presentation based on the gender.

Results:

A total of 419 patients with primary urethral carcinoma were identified in 250 males and 169 females. In males, the most common histology was TCC (134 of 250; 53.6%), followed by SCC (87 of 250; 34.8%). The distribution of urethral carcinoma for females varied from males, with adenocarcinoma being the most common (79 of 169; 46.7%), followed by SCC (43 of 169; 25.4%).

Adenocarcinoma accounted for the highest proportion of locally advanced (T3 and T4 tumours) in both genders (41%, in men and 65% in women). While the nodal and metastatic spread was more likely to occur with urethral SCC in men (37 and 15%, respectively), in women it was most commonly seen with urethral TCC (26 and 19%) (Fig. 1).

Conclusions:

Histologic types of urethral carcinoma, mode of presentation, and distant disease are different among men and women. Despite the same terminology, the behavior and aggressiveness of these tumours are indeed affected by gender. While embryologic origin likely regulate the histology and behavior of these tumours, knowledge of gender influence may dictate further work-up, treatment, and subsequent follow-up.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):389.

P73: Concomitant Inguinal Hernia Repair at the Time of Open Radical Prostatectomy

Robert M Turner II ¹, Benjamin T Ristau ¹, Jeffrey J Tomaszewski ¹, Elen Woldemichael ¹, Steven Evans ¹, Leonard E Evans ¹, Joel B Nelson ¹

Abstract

Background:

Inguinal hernia (IH) is a widely recognized complication of radical prostatectomy (RP) with most series demonstrating a 15–20% risk at 2 years postoperatively. Because of this, some have advocated for simultaneous herniorrhaphy at the time of RP in patients with IH identified intraoperatively. We sought to characterize risk factors for postoperative hernia development and to examine the efficacy of concomitant IH repair at the time of RP in patients with IH discovered on preoperative physical examination.

Methods:

Patients from a prospectively collected cohort who underwent open RP by a single surgeon and had at least 2-years of follow-up were included. Men identified on preoperative physical examination to have an IH underwent hernia repair concomitantly with RP. Univariate and multivariate analyses were performed to identify factors that may predict postoperative inguinal hernia development.

Results:

2144 patients underwent open RP during the study period with a median follow-up of 71.5 months. 94 patients had 103 IH identified on preoperative physical examination and underwent concomitant hernia repair. 3/94 (3.2%) patients undergoing IH repair at the time of RP recurred during the follow-up period. 112/2050 (5.5%) patients who did not undergo IH repair developed IH postoperatively, 51 (45.5%) of whom required corrective surgery. There was no difference in operative time between the two groups (144m RP vs. 146m RP+IH, p=0.268). In those patients who did not undergo concomitant hernia repair, age, tobacco use, and bladder neck contracture were not risk factors for postoperative IH on univariate analysis. BMI was significantly lower in those patients who developed postoperative IH (26.8 vs. 28.0, p<0.001). Patients with a history of hernia were more likely to develop postoperative IH (8.1% vs. 4.7%, p=0.005, OR 1.77, 95% CI 1.18–2.67). On multivariate analysis, BMI and history of hernia remained significant (p=0.002 and 0.012, respectively).

Conclusion:

IH repair at the time of RP in patients does not add significant time to the operation and should be performed in patients with preoperative evidence of IH. The low rate of postoperative hernia in this series compared to other published cohorts may be due to directed pre-operative physical examination and surgical technique. Consistent with previously published series, BMI and history of a hernia are significant predictors of IH after RP.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):389.

P74: The Impact of the USPSTF PSA-Based Prostate Cancer Screening Recommendations on Academic Institution Referral Volume

Matthew C Ferroni ¹, Timothy D Lyon ¹, Tara N Nikonow ¹, Robert M Turner II ¹, Benjamin J Davies ¹

Abstract

Background:

In May 2012, the United States Preventative Services Task Force (USPSTF) published recommendations against PSA-based screening for prostate cancer in men in the general U.S. population. We aim to determine the immediate impact of the USPSTF screening recommendations on the referral volume for urologic evaluation of elevated PSA at a large, academic institution.

Methods:

We conducted a retrospective review of outpatient referrals to our urologic practice for evaluation of elevated PSA. Patients were categorized into two groups based on the date of referral. Group A represented the 10-month period prior to the recommendations initial appearance on the USPSTF website in October of 2011. Group B represented the 10-month period after the recommendations were published in print in May of 2012. Demographics collected included age and PSA value at the time of referral. Differences between mean age and PSA were calculated using t-tests and Mann-Whitney-U tests, respectively.

Results:

94 patients were referred for evaluation of elevated PSA during the study periods (52 in Group A and 42 in Group B). Subjects had a mean age of 62.4 ± 7.9 and mean PSA of 7.7±12.0 ng/dL. There was a 19.2% decrease in the number of referrals following release of the USPSTF recommendations. There was no significant difference between mean age of patients in groups A and B (62.8 vs. 61.9, p=0.57) or PSA (7.59 vs. 7.88, p=0.907).

Conclusions:

Our practice saw a modest decrease in referrals for evaluation of elevated PSA in the early period following the release of the new USPSTF recommendations for PSA-based prostate cancer screening. There was no significant change in the mean age or PSA of subjects referred.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):389–390.

P75: Preoperative Albumin Level as a Predictor of Immediate Postoperative Outcomes following Radical Cystectomy

Timothy D Lyon ¹, Thomas William Fuller ¹, Nicholas J Farber ², Jeffrey R Gingrich ¹, Tatum V Tarin ¹

Abstract

Background:

Low preoperative serum albumin, used as a marker for nutritional deficiency, has been associated with an increased risk of mortality within 90 days of cystectomy. We sought to investigate whether preoperative serum albumin had any predictive value on complication rates immediately following cystectomy.

Methods:

A retrospective chart review for all patients who underwent radical cystectomy for bladder cancer at our institution from 2011–2012 was performed. Serum albumin levels drawn within one month prior to surgery were included. The incidence and type of complications during the immediate postoperative hospitalization were recorded.

Results:

A total of 105 patients had data sufficient for analysis. Thirty-nine patients had low preoperative albumin levels (less than 3.5 g/dL) while 66 patients had normal levels. Patients with low albumin were older, had a higher American Society of Anesthesiologists (ASA) class, and were more likely to undergo ileal conduit diversion than their counterparts in the normal albumin group. Low serum albumin was a statistically significant predictor of increased length of stay (10.3 vs. 7.2 days, p=0.002) and increased incidence of complications during the immediate postoperative hospital course (56% vs. 35%, p=0.031). These effects remained statistically significant after an analysis of covariance to control for the effects of differences in age and ASA class.

Conclusions:

This retrospective, single-institution study demonstrates serum albumin to be a significant predictor of increased length of stay and increased risk of complications following cystectomy. In an age where increasing importance is placed on delivering cost-effective care, serum albumin level may be a potentially modifiable preoperative risk factor.

Table 1.

P75. Patient characteristics and outcomes

	Low albumin n=39 (%)	Normal albumin n=66 (%)	p value
Average age	71.8	66.4	0.008

Gender
Male	28 (72)	52 (79)	0.416
Female	11 (28)	14 (21)	0.416

BMI	27.3	26.1	0.372
Race (% white)	34 (87)	63 (95)	0.117

ASA class	3.21	2.83	0.003
Smoker	24 (62)	46 (70)	0.657

Neoadjuvant chemotherapy	4 (10)	7 (11)	0.974

Tumour stage and nodal status
T0	2 (5)	4 (6)	0.879 0.755
Tis	4 (10)	8 (12)
Ta	0	1 (2)
T1	3 (8)	6 (9)
T2	4 (10)	12 (18)
T3	13 (33)	23 (35)
T4	10 (26)	12 (18)
N0	20 (51)	47 (71)
N+	8 (21)	14 (21)

Diversion type
Conduit	34 (87)	39 (59)	0.000
Continent	3 (8)	27 (41)	0.000

Average length of stay (days)	10.3	7.2	0.002

Immediate complications	22 (56)	23 (35)	0.031
Minor (Clavien 1–2)	15 (39)	11 (17)	0.012
Major (Clavien 3–5)	7 (18)	11 (17)	0.863

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BMI: body mass index; ASA: American Society of Anesthesiologists.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):391.

P76: The First Experience with a Transurethral Suprapubic Endo-cystostomy (T-SPeC^®) as a Novel Suprapubic Catheter Insertion Device

David M Albala ¹, Lawrence Karsh ², Blair Egerdie ³, Brian Flynn ⁴, Braian Murphy ⁵, Peter Rimington ⁶, Abbay Rane ⁷, Andreas Kunit ⁸, Vladimir Mouraviev ¹

Abstract

Background:

The conventional percutaneous suprapubic cystostomy under direct cystoscopy vision or ultrasound guidance remains a blind procedure associated with high rate of complications (15–20%) and even mortality (0.5–1.8%). In order to define a precise localization of bladder and decrease morbidity and mortality of procedure, a novel new surgical system T-SPeC^® (Swan Valley Medical, Bigfork, MT) was developed. The device has been approved for use worldwide (Europe, Canada, Australia) and just recently in the United States. The T-SPeC® Surgical System is available in two models, T7 and T14, allowing large morbidly obese patients to be treated. We present the results of our first experience with this system used for introducing a suprapubic catheter (18 Fr) via a retrourethral approach, with a 15 Fr. incision.

Methods:

Initially we evaluated a feasibility of the accurate insertion of suprapubic tube into the bladder using the T-SPeC® technique on 14 human cadavers. Male and female cadavers were used with a BMI range of 28 to 43. In all cases, a precise suprapubic catheter placement was achieved. Following this, 22 patients with a need for a suprapubic catheter placement were selected. The T-SPeC^® device was used under general anesthesia to place a suprapubic catheter.

Results:

In cadaver study, there was no injury to adjacent organs found at autopsy after procedure was completed. In the live cases with the T-SPeC Surgical System, all patients had successful suprapubic tube placement. No complications were encountered. The average surgical time of the procedures was 9.4 minutes, with a range of 7.6–13.1 minutes. In all cadaver and live clinical cases, accurate catheter placement into bladder was achieved. The estimated blood loss was negligible. All patients were discharged within hours of the procedure.

Conclusions:

The novel T-SPeC Surgical System facilitates a faster, safer, and more precise suprapubic catheter placement than techniques currently available. This device is a useful addition to the urologic armamentarium for patients requiring a suprapubic tube.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):391.

P77: The Utility of the CT Scan for Measurement of Prostate Volumes: A Comparison to Gross Specimen and TRUS, Triple Concordance Study

Mourad Abouelleil ¹, Cristina Fox ¹, Imad Nsouli ¹

Abstract

Background:

To date there are only two studies that compare TRUS prostate volume that of CT volume, generally concluding that CT volumes correlate well to those of TRUS. While these studies have traditionally supported the diagnostic precision of both TRUS and CT, they fail to evaluate the accuracy of these modalities in relation to gross specimen volume. In order for CT to be accepted as a viable option for prostate size measurements, our study evaluates both the diagnostic precision of CT in comparison to TRUS as well as its accuracy in relation to surgical specimen volumes.

Methods:

Using departmental surgical logs, we compiled an electronic list of all patients who underwent a radical prostatectomy between January 2008 and December 2012. Inclusion criteria included patients who underwent preoperative CT and TRUS studies as well as postoperative pathologic prostate specimen measurements. Volumes from all 3 studies were generated utilizing ellipsoid calculations based on a three dimensions. TRUS data was obtained from the study report, CT data was obtained by measurements of a blinded radiologist, and gross specimen data were obtained from the postoperative pathologic report.

Results:

The measured preoperative TRUS and CT volumes were independently evaluated in comparison to the gross specimen volume obtained from the surgical prostate specimen. Each value was then evaluated for diagnostic accuracy utilizing the parameters of mean, median, absolute percent difference. TRUS volumes ranged from 19 to 49 cc with median volume of 30.0 cc and a mean of 29.8 cc.

CT volumes ranged from 16.1 to 41.7 cc with a median volume of 27.7 cc and a mean of 29.5cc. Gross specimens ranged from 22.1 to 44.4 cc. In comparing the measured values it was determined that TRUS measurements varied by an average of 8.2 cc while CT measurements varied by 6.8 cc representing an absolute percent difference from the gross volume of 26% and 21%, respectively.

Conclusions:

This triple concordance study has shown that CT is equivalent to TRUS in estimating prostate volume. This is an important tool for urologists in this era of inflated medical expenses to estimate prostate volume to help surgical planning ( for example TURP) if a CT scan is already in the medical record for any other reason no need for addition TRUS.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):391–392.

P78: Psychosocial Predictors of Quality of Life and Dyadic Adjustment in Men with Peyronie’s Disease

Seth N P Davis ¹, Saskia Ferrar ², Yitzchak M Binik ², Serge Carrier ³

Abstract

Background:

Peyronie’s Disease (PD) is clinically recognized as being highly distressing for patients. It is assumed that PD has a negative impact on quality of life and relationship satisfaction. Unfortunately, many decisions for surgery use sexual interference as the marker for surgical intervention, without taking into account psychosocial variables. The aim of the present study was to determine the impact of PD, and assess what predicts quality of life and relationship outcomes.

Methods:

A preliminary analysis of 48 men with PD was conducted. Men were sent a questionnaire package inquiring about their quality of life, relationship satisfaction, PD symptoms, shame, body image, sexual function, catastrophizing, and partner responses to PD. Multiple regression analyses were conducted in order to determine the correlates and predictors of quality of life and dyadic adjustment.

Results:

As a group, quality of life was not below healthy norms. Less shame, less concern with appearance and less sexual interference were associated with higher quality of life. Less shame, and more solicitous and less negative partner responses were associated with higher levels of dyadic adjustment. However, body image was the only significant predictor of quality of life, not sexual interference. Shame and partner responses were the only significant predictors of relationship satisfaction.

Conclusions:

Although PD appears to be distressing, many men appear to cope well nonetheless. In men with lower quality of life, psychosocial factors, such as body image, shame, and partner responses appear to be the best predictors of lower quality of life and relationship satisfaction. These factors should be assessed in men with PD, as appropriate referral for individual or couple therapy may be appropriate. These should also be assessed before and after surgical treatment. Finally, over time, more awareness about PD may help reduce the shame that men with PD experience.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):392.

P79: Prevalence of Male Hypogonadism in Couples Presenting to a Reproductive Endocrinology Infertility Clinic

Ardalan E Ahmad ¹, Michael Lao ¹, Clay W Mechlin ¹, Marsha Forman ¹, Peter M Horvath ¹, Andrew R McCullough ¹

Abstract

Background:

Fifteen percent of couples in the United States are infertile and male factor infertility is the sole cause in 20% of infertile couples. Most couples with refractory infertility are evaluated by a reproductive endocrinologist (RE). Male infertility may be due to reversible causes such as hypogonadism. Early hypogonadism may not be associated with the clinical prodrome associated with hypogonadism (decreased sexual function, energy and libido. The reported prevalence of hypogonadism in men younger than 50 years old is <10%. As the endocrinopathy of hypogonadism may result in inexorable worsening symptomatology, early recognition is crucial. We sought to determine the prevalence of male hypogonadism in infertile couples presenting to RE.

Methods:

Beginning 2011, male partners of women referred to an academic RE were routinely evaluated. We retrospectively reviewed 191 consecutive couples. Male partners’ demographic, hormonal and SA variables on initial presentation to RE were recorded. Student T-test was used to compare groups.

Results:

171/191 (90%) with concomitant SA and hormonal profile were included. Mean male and female age at presentation was 37±6 and 33±4 respectively. Mean BMI, total T, T/E ratio and total motile sperm count was 30±6, 368±157ng/dL, 18±13 and 75±105 million. Seventy one men (42%) had a T<300 ng/dL with 42 (25%) demonstrating T<250 ng/dL. Twenty three percent of patients had a sperm concentration <15x106/mL. There was no difference in T levels, between men with concentrations above or below 15 million/mL.

Conclusion:

Male hypogonadism is common in couples referred for assisted reproductive therapy with 25% being profoundly hypogonadal (T<250 ng/dL). Thirty eight percent of men with normal sperm concentration and sperm count are hypogonadal. Hereby, a normal sperm count on SA does not eliminate the need to assess for underlying male hypogonadism. Assessment for male hypogonadism should be a crucial part of the evaluation of the infertile male. Appropriate identification, evaluation and treatment in this group have the potential to improve not only natural fertility but overall future male health.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):392.

P80: Repetative Percutaneous Epididymal Sperm Aspirations (PESAs) in a Rat Model Resulted in Immediate Asthenospermia and Significant Inflammatory Changes

Yachao Zhang ¹, Kazim Chohan ¹, Steve Landas ¹, Jay Reeder ¹, JC Trussell ¹

Abstract

Background:

In azoospermia, choosing a sperm retrieval method for intra-cytoplasmic sperm injection (ICSI) depends primarily on the preference and expertise of both the urologist and reproductive endocrinologist. There is insufficient evidence to suggest which method of sperm harvesting (PESA verses testis biopsy/aspiration) optimizes ICSI outcomes. Generally, PESA is attempted first. Not uncommonly, multiple PESA’s are necessary due to ICSI failure or, the desire for additional children. Since there is no study stratifying epididymal damage or effect on sperm parameters, we propose a rat model to prospectively evaluate PESA-related changes. This study aims to provide clinicians with an understanding of sperm parameter and histological changes resulting from repetitive PESA procedures.

Methods:

A cohort of 30 male Winstar rats of reproductive age (68–73 days) were divided into three groups of 10 (G1–3). After quarantine, all three groups underwent a left epididymal head PESA using a 25–3/8 gauge needle. The untouched right epididymis acted as the control. At 14 day intervals, G2 and G3 underwent a second and third PESA respectively. 14 days after the final PESA, both epdidymides and a 1-centimeter segment of both vas deferens were harvested for histological and coulter counter analyses. Statistics: Contingency analysis.

Results:

PESA resulted in significant granuloma formation .A drop in concentration and motility was noted after G1, but essentially unchanged between G2–3.

Conclusions:

In a prospective rat model, PESA causes significant epididymal inflammatory changes and a reduction in both sperm concentration and motility. The number of PESA’s did not correlate with severity of inflammation or lost motility.

Table 1.

P80. Repetitive percutaneous epididymal sperm aspirations

	G1	G2	G3
Epididymal granulomas	70%	100%	80%
Controls	0%	0%	0%
Vas segment concentration >0.5 M/cc	100%	22%	20%
Control	100%	56%	100%
Vas segment motility >10%	90%	22%	20%
Control	100%	100%	100%

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Can Urol Assoc J. 2013 Sep-Oct;7(9-10):392.

P81: Nearly all Surveyed Reproductive Urologists Feel a Prospective Variocelectomy Trial is Important and Worthwhile

JC Trussell ¹; NIH Reproductive Medicine Network²

Abstract

Background:

A federally sponsored prospective randomized trial involving varicocele repair recently failed due to insufficient patient recruitment. Upon critical review of this trial, the hypothesis that limited recruitment due to a lack of urologists’ interest was tested. For this reason, we surveyed United States of America (USA) members of the Society of Male Reproductive Urologist (SMRU) and Society of Reproductive Surgeons (SRS) to determine if a NIH funded varicocelectomy trial for the treatment of male infertility would be of significance to the field.

Methods:

A total of 100 USA SMRU and SRS members were surveyed (using a 10-question Survey Monkey survey) to determine if a prospective, randomized varicocelectomy trial was warranted. Support of the trial was considered to be a majority or super-majority, if either 51% or 66% of respondents affirmed importance.

Results:

A total of 48 urologists responded (48% response rate). Of the respondents 96% felt that a prospective varicocelectomy trial was important and should be implemented. All respondents were familiar with the AUA/ASRM varicocelectomy guidelines and the majority (83%) performs a microscopic inguinal varicocelectomy most of the time. None of the respondents would operate on subclinical varicoceles. When given a scenario of a patient with “normal” semen analysis, 56% would still offer a varicocelectomy.

Conclusion:

We negated the hypothesis that there was a lack of urology support for a prospective varicocelectomy trial. There is broad (super-majority) support for a prospective randomized controlled varicocelectomy trial among USA reproductive urologists. Nearly all respondents would recruit patients from their practices for such a trial. These respondents were aware of the AUA/ASRM guidelines, typically performed microscopic repairs, and did not operate on subclinical varicoceles.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):393.

P82: Pilot Study on the Effects of Implantable Testosterone Pellets on Penile Oxygenation in Clinically Hypogonadal Men

Charles Welliver ¹, Zachary Testo ¹, Jason Frankel ¹, Clay Mechlin ¹, Andrew McCullough ¹

Abstract

Background:

Erectile dysfunction (ED) has been associated with penile atrophy, smooth muscle apoptosis and increased interstitial collagen deposition in animal models and in the human. The corpora in the flaccid state have been demonstrated to be in a relative hypoxic state that becomes normoxic in the erectile state. The observed pathologic changes are postulated to occur in the setting of the chronic hypoxic state associated with ED. It has been demonstrated that men with ED have significantly lower resting corporal oxygen saturation then men without ED and that men with significant hypogonadism have fewer nocturnal erections. The association between hypogonadism and corporal hypoxia has not been demonstrated.

Methods:

Men were prospectively recruited from an academic andrology practice. Inclusion criteria were symptoms of hypogonadism and a baseline testosterone of less than 250 ng/dL. ED was not a prerequisite. Baseline studies included a hormonal panel, penile oximetry, ADAM, IIEF, and erection hardness score (EHS). All of these studies were repeated at 6 and 12 weeks. Penile oximetry was performed with the Vioptix ODISsey tissue oximeter at 4 sites (ear, thigh, corpora and glans).

Results:

Nineteen men were recruited. Thirteen men completed the study (Table 1).

Conclusion:

This small, pilot study demonstrates the clinical and physiologic benefit of testosterone supplementation. When compared to previous studies looking at penile oximetry, this cohort has the lowest baseline corporal value. This pilot study does provide a link between hypogonadism and corporal hypoxemia although the result was not recoverable over the short duration. While larger and longer duration studies are needed, this study provides a validation for testosterone replacement for penile and general health along with the symptoms of hypogonadism.

Table 1.

P82

Objective data
	Baseline	6 weeks	12 weeks	p value
Testosterone	165	600	384	<0.001
ADAM	31.1	34.5	34.7	0.007
IIEF	37.8	52.2	48.8	0.037
EHS	2.6	3.2	3.1	0.012
Oximetry
Ear	70.9	73.4	74.1	NS
Thigh	53.5	56.8	54.6	NS
Corpora	27.5	30.3	25.2	NS
Glans	60.1	65.0	65.4	NS

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ADAM: androgen decline in the aging male; IIEF: International Index of Erectile Function; EHS: erection hardness score.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):393.

P83: Robotic Microsurgical Vasectomy Reversal: Initial Experience and Short Term Outcomes from a Single Academic Centre

Clay Mechlin ¹, Andrew McCullough ¹

Abstract

Background:

The Robotic platform has emerged as a feasible alternative to the traditional microsurgical vasectomy reversal (MSVR) with the operating microscope. Several small series and one larger series at a private institution have reported their experiences and outcomes. Potential advantages of the robotic platform are enhanced visualization, increased surgeon autonomy (with the 4^th arm), lack of tremor, and improved ergonomics. We report our initial experience and outcomes

Methods:

We retrospectively reviewed surgical outcomes for a single surgeon at an academic centre from 2011 to 2013. All patients that underwent surgery were included in the study. Residents and fellows were involved in all procedures. All patients underwent vasectomy reversal with the DaVinci robotic platform with the dual console. Demographic information, operative times, and outcomes were recorded.

Results:

Results are shown in Table 1. 15 patients had their follow-up sperm check. 73% of all cases had a positive sperm check and 85% of vasectomy reversals without a prior reversal attempt had a positive sperm check.

Conclusions:

RMSVR is safe and effective with good initial success rates at short term follow up. In addition it provided stereotactic vision, improved ergonomics, and a unique more controlled training environment for residents and fellows to advance microsurgical and robotic skills.

Table 1.

Robotic microsurgical vasectomy reversal

Demographics
	No.	Mean (SD)	Range

Age	40	6.7	33–53
BMI	31.5	6.7	25.5–49.0
Years since vasectomy	8.4	5.5	3.0–22

Surgical outcomes
Procedure performed	Bilateral Vasovaso	Vasovaso and vasoepi	Bilateral vasoepi

Number (% total)	6 (40)	6 (40)	2 (13)
Total no.	15 (1 unilateral vasoepi)
Complications	No.	Percent of total

Hematoma	0	0
Persistent pain	0	0
Infection	0	0
High riding/fixed testis	1	7
Previous scrotal surgery	4	27
Postoperative semen analysis
No. with positive sperm: All cases (n)	11	73.3
No. with positive sperm:Vasectomy reversal (first attempt) (n)	11	85
Mean no. days since surgery to sperm check (SD)	92 (99)

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BMI: body mass index; SD: standard deviation.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):394.

P84: Anterograde and Retrograde Dilation of Corpora Accessed Via Second Ventral Incision is Required for Placement of Inflatable Penile Prosthesis Following T Shunt/Corporal Snake Management of Refractory Priapism

Christopher Zappavigna ¹, Rany Shamloul ¹, Matthew Roberts ¹, Anthony J Bella ¹

Abstract

Background:

Lue and Burnett have separately redefined management of refractory priapism by introducing the distal T-shunt/corporal snake maneuver. Accessing the corpora cavernosa via the glans, followed by instrumental dilation to the proximal corpora (entire corporal length) resolves priapism, and allows for potential erectile function return even after 24–72 hours of priapism. For patients not treated with immediate penile prosthesis insertion after resolution of the priapism, the likelihood remains that definitive management will include inflatable penile prosthesis (IPP) performed in a delayed fashion. We present cumulative experience of IPP placement in post-T shunt patients, specifically the need for adjunct surgical maneuvers secondary to distal corporal fibrosis.

Methods:

Seven patients post T-shunt required IPP placement due to refractory erectile dysfunction. Colour duplex ultrasound was performed prior to IPP by the operating surgeon in all cases.

Results:

IPP surgery utilizing penoscrotal access, at approximately 3 months post T-shunt, was complicated in all cases by dense distal fibrosis. A second small (<3 cm) distal ventral incision allowed for direct dissection into the corpora, Metzenbaum excision of non-dilatable scar tissue, and retrograde and anterograde dilation using the bladed Uramix instrument to establish continuum. The rate of second ventral corporotomy incision for non-priapism patients undergoing IPP (approximately 90–100 per annum), but including Peyronie’s disease in the practice is 6.6%. There were no device infections or second procedures, EHS scores were 4 at six months, and IIEF-5 increased over 16 patients (mean) from baseline. No erosions or early mechanical failures were noted in either group.

Conclusions:

Minimizing iatrogenic injuries, including urethral perforation, in these complex patients requires a second ventral distal incision allowing bilateral access to the corpora, and direct excision incision/dilation, requiring specialty dilators. Little time is added to surgery, and no additional morbidity was noted. Although distal tunica is compromised at distal T-shunt/corporal snake maneuver priapism management, no erosion was noted.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):394.

P85: Inflatable Penile Prosthesis Durability Does Not Appear to be Negatively Impacted by Peyronie’s Disease Erectile Dysfunction Primary Etiology Based on Revision-free Survival of Inflatable Penile Prostheses in 24914 Men

Anthony J Bella ¹, Angela M Ginkel ²

Abstract

Background:

Primary erectile dysfunction etiology may impact 3-piece inflatable penile prosthesis (IPP) device survival. Recently published reports suggest an increased rate of device-related complications for IPPs when used for combined treatment of erectile dysfunction (ED) and Peyronie’s disease (PD), although they are limited in part by small cohorts, are single institution, and may not accurately reflect current surgical practice or devices.

Methods:

A large database of patient information form (PIF) records for patients who had AMS 700 IPPs implanted between May 1, 2001 and December 31, 2008 was retrospectively reviewed. Patients with PD as single recorded etiology of ED vs. patients without PD were compared (n=24914). Kaplan-Meier life table survival analysis was used to estimate device survival from revisions for any reason, and due to infection, erosion, mechanical malfunction, fluid loss, and patient dissatisfaction. Device specific (CX vs. LGX/Ultrex cylinders) data was evaluated within the subgroup of men with PD. A p-value <0.05 was considered statistically significant.

Results:

No appreciable differences in device survival from revision for any reason were demonstrated for 1,882 men with PD vs. 23,032 with other recorded etiologies, including diabetes, post-prostatectomy, or others (p=0.3529). No significant differences were demonstrated in revision-free survival for any individual reason examined between men with PD and those without. Survival from revision for any reason in men with PD at up to 7.7 years of follow-up was 90.96% for CX implants, vs. 93.36% for LGX/Ultrex implants (p=0.2154). Revisions were reported at any time throughout follow-up for 113 (6.97%) of 1,621 CX cylinders, and for 5 (3.31%) of 151 LGX/Ultrex cylinders within the PD subgroup.

Conclusions:

This series of PD patients treated with modern IPPs, the largest reported to date, demonstrates that survival from device revision over more than 7 years post-implantation exceeds 90% and is not significantly different than in patients with non-PD primary causes of ED. Confirmatory data, including data for patients undergoing curvature correction procedures at the time of implantation, is awaited from the multi-institutional multi-year PROPPER study (Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration).

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):394.

P86: Etiology and erectile treatments prior to surgery: Results for 352 patients from the Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration (PROPPER)

Anthony J Bella ¹, Gerard Henry ², Edward Karpman ³, William O Brant ⁴, LeRoy Jones ⁵, Nelson Bennett ⁶, Bryan Kansas ⁷, Tobias Kohler ⁸, Mohit Khera ⁹

Abstract

Background:

PROPPER is designed to document outcomes for AMS 700 and AMS Ambicor inflatable penile prostheses (IPPs), and Spectra penile implants. Validated patient questionnaires and electronic data collection are used to record baseline patient characteristics and surgical implantation details, and to prospectively measure response to treatment annually to five years post-implantation including durability, complications, and effectiveness (functional, satisfaction and quality of life) outcomes. ED etiology and attempted pre-surgery erectile treatments are presented to better understand the patients’ pathway to surgical management.

Methods:

The PROPPER registry was initiated in June, 2011 and through November 7, 2012, 352 patients were implanted with AMS 700 series IPPs at a total of 9 study sites. Analyses based on primary ED etiologies and duration of ED and treatments prior to implantation were performed.

Results:

The four most common primary ED etiologies were post-radical prostatectomy (30.7%), cardiovascular disease (25.6%), diabetes (20.5%), and Peyronie’s disease (8.8%). Mean reported duration of ED for these patients was 5.7, 7.9, 8.0, and 3.3 years, respectively. Fourteen percent of patients had a previous penile implant. In the majority of cases, multiple ED therapies had been attempted prior to implant surgery. The use of combination therapies prior to surgery approached 10% across these four patient groups, likely reflecting changes in the understanding of underlying pathophysiologies and contemporary practice.

Conclusions:

Analyses support IPPs as definitive treatment for ED of varying etiologies. In contemporary patient goal-oriented ED practice, pre-surgery treatment differences may reflect duration of ED, underlying root causes (neural, endothelial, smooth muscle, tunical disease or combination) or patient preference.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):395.

P87: AMS 700 Conceal Reservoir submuscular placement: results for 50 patients from the Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration (PROPPER)

Edward Karpman ¹, Gerard Henry ², William O Brant ³, LeRoy Jones ⁴, Bryan Kansas ⁵, Mohit Khera ⁶, Tobias Kohler ⁷, Nelson Bennett ⁸, Anthony J Bella ⁹

Abstract

Background:

Data from the PROPPER study (Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration) were examined to determine surgical implantation use patterns for the Conceal^™ Low Profile reservoir. Given the clinical interest for ectopic reservoir placement in patients undergoing three-piece inflatable penile prosthesis (IPP) surgery, initial submuscular placement data were examined.

Methods:

Multicentre clinical data were reviewed. Surgical implantation locations were recorded and reviewed for initial AMS 700 implants. Patient characteristics and complications reported were reviewed for the first 50 study patients consecutively implanted with Conceal reservoirs placed sub-muscularly, all with a minimum of 2 months of post-implant follow-up.

Results:

The study population consisted of 352 patients implanted with an AMS 700 IPP across 9 study sites (standard spherical or Conceal placement n=275, submuscular Conceal n=57, submuscular spherical n=14, other n=6). Forty-eight percent of the first 50 implants with sub-muscular Conceal placement were in men post-radical prostatectomy. After a mean of 14 months (median 15 months, range 8.0–20.3 months) post-surgery, complications were reported in 4 submuscular Conceal patients consisting of 2 reservoir herniations, a mechanical complication of a concurrently implanted artificial urinary sphincter, and device fluid loss, all within 6 weeks of implantation. There were no bladder, bowel or blood vessel complications. Results were comparable to historical outcomes in men with standard reservoir placement.

Conclusions:

Conceal reservoir placement in the submuscular location in post-radical prostatectomy patients appears safe, and further study continues on this option for 3 piece IPP placement. Submuscular placement avoids potential injury to bladder, bowel and blood vessels, and may be especially useful in patients with previous pelvic surgery.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):395.

P88: Prospective Randomized Evaluation Of Razor Types For Preoperative Hair Removal On The Male External Genitalia

Daniel FG Costa ¹, Christopher Zappavigna ¹, Darren J DeSantis ¹, Susan Maggs ¹, Anthony J Bella ¹

Abstract

Background:

Grober et al. recently published a prospective randomized trial suggesting that preoperative hair removal on the scrotal skin using a razor results in less skin trauma and improved overall shave quality with no apparent increased risk of surgical site infections (J Sex Med 2013 Feb;10(2):589–94). Based on these findings, institutional support was obtained for use of razors (versus clippers) for preoperative preparation of the male genitalia for Peyronie’s repair and penile prosthesis surgeries. Two single blade razor types were available - serrated (SER) and smooth (SM). Initial observations suggested use of SER resulted in greater degrees of skin trauma, therefore we proceeded to objectively evaluate shave quality and the degree of skin trauma.

Methods:

Patients undergoing Peyronie’s or penile implant surgery were randomized to hair removal using SM (left blade) or SER (right) (Fig. 1). Grober’s experimental design was followed. Primary outcomes were blinded global ratings of preoperative hair removal completeness within the surgical field and degree of skin trauma following hair removal. Immediately following hair removal, a standardized digital photograph was taken of the male genitalia. All digital photos were evaluated in a blinded fashion. Skin trauma was scored on a five point scale, and the incidence of SSI was monitored for three months after surgery.

Results:

Sixty consecutive patients (n=30 each group) were evaluated. SER resulted in significantly more skin trauma (p<0.05), and there were 3 SSI vs. zero for SM.

Conclusions:

Given the physical characteristics of the scrotum, and previously published findings, evidence-based surgical site preparation of the scrotum for surgery includes the use of a razor for hair removal. It appears to be in the patient’s best interest to utilize a straight-edge single razor, in comparison to a single serrated blade. Intra-institutional quality control studies such as these benefit patient care as they influence practice based on accurate data accrual.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):395–396.

P89: Robotic Microsurgical Varicocele Repair: Initial Experience and Surgical Outcomes From a Single Academic Center

Clay Mechlin ¹, Andrew McCullough ²

Abstract

Background:

The Robotic platform has emerged as a feasible alternative to the traditional microsurgical subinguinal varicocelectomy (MSV) with the operating microscope. Several small series and one larger one at a private institution have reported comparable outcomes to the operating microscope. Potential advantages of the robotic platform are enhanced visualization, increased surgeon autonomy (with the 4^th arm), lack of tremor, and improved ergonomics. We report our initial experience and outcomes for robotic microsurgical varicocelectomy (RMSV).

Methods:

We retrospectively reviewed surgical outcomes for a single surgeon at an academic centre from 2011 to 2012. All patients that underwent surgery were included in the study. Residents and fellows were involved in all procedures. Patients either underwent repair with the operating microscope or the DaVinci robotic platform with a dual console. Demographic information, operative times, and outcomes at the initial postoperative visit were recorded. Statistical analysis was performed with a one-way ANOVA test.

Results:

Results are shown in Table 1. There was no significant difference in operative times between the 2 groups. A small learning curve was seen.

Conclusions:

RMSV is safe and effective with no significant increase in operative times or complications. In addition it provided improved visualization, ergonomics, and a unique more controlled training environment for residents and fellows to advance microsurgical and robotic skills.

Table 1.

P89. Robotic microsurgical vasectomy reversal

Demographics
	No.	Mean (SD)	Range

Age	40	6.7	33–53
BMI	31.5	6.7	25.5–49.0
Years since vasectomy	8.4	5.5	3.0–22
Surgical outcomes
Procedure performed	Bilateral vasovaso	Vasovaso and vasoepi	Bilateral vasoepi

No. (% Total)	6 (40)	6 (40)	2 (13)
Total no.	15 (1 unilateral vasoepi)
Complications	No.	Percent of total

Hematoma	0	0
Persistant pain	0	0
Infection	0	0
High riding/fixed testis	1	7
Previous scrotal surgery	4	27
Postoperative semen analysis
No. with positive sperm: All cases (n)	11	73.3
No. with positive sperm: Vasectomy reversal (1st attempt) (n)	11	85
Mean no. days since surgery to sperm check (SD)		92 (99)

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BMI: body mass index; SD: standard deviation.

Can Urol Assoc J. 2013 Sep-Oct;7(9-10):396.

P90: Prospective Evaluation of Glove Perforation Supports Double Gloving for Penile Prosthesis Surgeries

Paul Hartman ¹, Christopher Zappavigna ¹, Rany Shamloul ¹, Anthony J Bella ¹

Abstract

Background:

Device infection in the setting of inflatable penile prosthesis implantation (IPP) is a catastrophic complication, requiring secondary surgeries, conferring morbidity to the patient, and adding significant financial burden to the health care system. Gloves are a barrier to potential surgical site infection, as well as offering protection to the surgeon. Double gloving has not undergone rigorous prospective evaluation in this surgical setting. Fry et al (J Am Coll Surg. 2010 Mar;210(3):325–30) did not demonstrate a substantial impact on manual dexterity or tactile sensitivity when compared with no gloves or single-gloving. We evaluated 50 consecutive cases for inner and outer glove perforation, resulting in change-of-practice behavior.

Methods:

For 50 consecutive IPP cases over a 6 month period in 2012, frequency of significant glove perforation for the primary surgeon and first assistant (resident or fellow) gloves was assessed using the hydrosufflation technique. If perforation was suspected intraoperatively, gloves were removed, and all sets utilized were evaluated.

Results:

51 primary surgeon (PS) and 54 assistant sets (AS) of gloves were evaluable. All inner and outer sets comprised the study cohort. Identified outer glove perforations requiring intraoperative glove change occurred in 0/1 PS and 2/4 AS sets removed during surgery, while inner gloves remained intact. End of surgery evaluation yielded outer perforations in 1 PS and 3 AS gloves, with inner glove perforation in 1 AS instance. All patients are enrolled in a prospective registry and have been followed to one year with no devices removed due to infection to date (www.ClinicalTrials.gov Identifier: NCT01383018).

Conclusions:

Outer glove perforation rate was 2 and 10% for PS and AS, while inner perforation occurred in one AS case. Glove perforation is not accurately identified intraoperatively. Rates compared favorably to previous open urological procedure reports (Feng et al.Can J Urol. 2011 Apr;18(2):5615–8). Given these findings, double gloving should be standard operating procedure for all IPP procedures.

PERMALINK

2013 NS-AUA Abstracts

P1: R.E.N.A.L Nephrometry Scores Are Associated With Perioperative Outcomes Following Partial Nephrectomy

Abhijith D Mally

Zeyad Schwen

Julie Riley

Li Wang

Ronald Hrebinko

Stephen V Jackman

Abstract

Background:

Methods:

Results:

Conclusions:

Table 1.

P2: Renal Lesions With High R.E.N.A.L Nephrometry Score Are Associated With More Aggressive Renal Cell Carcinomas

Abhijith D Mally

Zeyad Schwen

Julie Riley

Li Wang

Ronald Hrebinko

Stephen V Jackman

Abstract

Background:

Methods:

Results:

Conclusions:

Table 1.

P3: The CCP Score: A Novel Genetic Test for Prostate Cancer

Michael Brawer

Jack Cuzick

Matthew Cooperberg

Greg Swanson

Stephen Freedland

Julia Reid

Gabrielle Fisher

Jerry Lanchbury

Alexander Gutin

Steven Stone

Peter Carroll

Abstract

Background:

Methods:

Results:

Conclusions:

P4: Process of Care Variables Explaining the Influence of Surgical Volumes in Bladder Cancer Outcomes: A Population-Based Study

D Robert Siemens

Gavin Li

William Mackillop

Chris Booth

Abstract

Background:

Methods:

Results:

Conclusions:

P5: Pathological Features of Surgically Managed Small Renal Lesions: Analysis of Contemporary Series

Andres F Correa

Bishoy A Gayed

Milon Amin

Amir Toussi

Jodi K Maranchie

Abstract

Background:

Methods:

Results:

Conclusions:

Table 1.

P6: The First National Experience Of Intravesical Injection Of The TraceIT™ Tissue Marker Under A Local Anesthesia For Imaging Visualization Of Muscle-invasive Bladder Cancer For The Targeted Imrt

Joel Bass

Neil Mariados

Po Lam

Christopher Pieczonka

Patrick Campbell

David M Albala

Howard Williams

Vladimir Mouraviev

Abstract

Background:

Methods:

Results: